Heath, Fitness & Exercise Information

Fitness Report
What’s All The Rage?

A comprehensive study of
global fitness industry behavior.

Image courtesy of Encore, Moscow, Russia Lounge McFIT_© McFIT JOHN_REED_Gesundbrunnen_Cardio © JOHN REED
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2018 International Fitness Industry Trend Report - What’s All The Rage?
A comprehensive study of global fitness industry behavior

Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
General Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Study Methodology, Disclaimer and Report Flow & Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Chapter 1: Trend Wisdom...The How, What, Who and Why of Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chapter 2: Overarching Insights in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Chapter 3: Fitness Equipment Trends in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Chapter 4: Fitness Facility Trends in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Chapter 5: Fitness Program and Training Trends in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Chapter 6: Fitness Technology Trends in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Chapter 7: Respondent Profile in 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Appendices:
A. About Our Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
B. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
C. About ClubIntel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
D. Trend Adoption Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
E. Club Photos From Around the World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Copyright 2018 © ClubIntel.
All rights reserved. No part of this report may be reprinted, reproduced, stored in a retrieval system, or transmitted
in any form by any means – electronic, mechanical, or otherwise – without the express written consent of ClubIntel.
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2018 International Fitness Industry Trend Report - What’s All The Rage?
A comprehensive study of global fitness industry behavior.

In prior years, the report has looked at trends on a consolidated
global basis. What we’ve observed over the past few years of
conducting this study, and which was very evident in this year’s
study, is that trends are heavily influenced by geographic region
(e.g., cultural and economic influences), business model (e.g.,
boutique studio, budget club, luxury club, non-profit, etc.), and
to a lesser degree, the scale of the business (e.g., one club or
200 clubs). Attempting to generically quantify trends on a global
basis by providing an overarching consolidated perspective
does an injustice to what is actually occurring in the marketplace. Therefore, for 2018, the global trends are being presented
not as a consolidated model but instead by geographic region,
business model and business scale. We believe doing this will
provide owners and operators relevant trend patterns specific to
their business model and geographic location. In addition, it will
allow operators to benchmark trends across these segments
and help them identify opportunities they can exploit within their
given region or business segment.
We hope you find this report insightful, and more importantly,
beneficial in your efforts to remain a relevant and powerful force
in the global fitness industry.

Stephen Tharrett and Mark Williamson
Co-founders and Principals
ClubIntel
Introduction
“We are moving toward a global economy. One way of
approaching that is to pull the covers over our head. Another is
to say: It may be more complicated – but that’s the world I am
going to live in, I might as well be good at it.”
-Phil Condit, Former Chairman and CEO of Boeing
ClubIntel welcomes you to the 4th Annual International Fitness
Industry Trend Report – What’s All the Rage?. Our goal in
conducting this trend study is to shed light on what equipment,
facility spaces, programs/services and technology practices
are being adopted by industry operators around the globe.
Josh Linkner, the founder of ePrize, and author of Disciplined
Dreaming said, “Instead of being heads down, we should be
heads up so we can spot trends.” Well, our goal is to help you
stay heads up, eyes wide open and focused on the future.
In 2015, we first launched the International Fitness Industry
Trend Report – What’s All the Rage. The report was the health/
fitness industry’s first ever data-based trend report focused on
behavioral outcomes – the practices fitness industry operators
were adopting and how those adoption rates were changing
over time. In 2018, we solicited data from a host of U.S. and
international operators, uncovering subtle and not so subtle
trends in fitness industry practices. Consequently, the insights
in this report provide a wealth of information about what is all
the rage in the global fitness facility industry and the impact
these trends have across the various segments of the fitness
industry in shaping the business of today and in the future.

provided permission for us to use photos from their business.
Each of these individuals and organizations is recognized as a
health/fitness industry authority and passionate champion for
the vision and future of the industry. It is with great respect and
appreciation that we acknowledge our partners in this endeavor.
To learn more about our global partners and their service to the
global fitness industry, please refer to the first section of the
Appendices where we share their stories (See Pages 82 - 84).
General Acknowledgements
ClubIntel wants to acknowledge and recognize the numerous
individuals and organizations that partnered with and assisted
us in developing and promoting the 2018 International Fitness
Industry Trend Study. Our global partners, each highlighted below,
were indispensable. This year, in addition to promoting and
distributing the survey to fitness operators around the globe,
our partners provided assistance with translating the survey
into six different languages. This allowed fitness operators to
respond in their native language. Lastly, many of these partners

Active Management, Australia
www.activemgmt.com.au
ACAD, Brazil
www.acadbrasil.com.br
AGAP, Portugal
www.agap.pt
Association of Fitness Studios, U.S.
www.afsfitness.com
Canfitpro, Canada
www.canfitpro.com
ChinaFit, China
www.chinafit.com
Club Industry
www.clubindustry.com
Club Insider
www.clubinsideronline.com
Club Spa & Fitness Association, U.S.
www.csfassociation.com
Encore Fitness, Russia
www.encorefitness.ru
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Europe Active, Europe
www.europeactive.eu
fitness MANAGEMENT, Germany
www.fitnessmanagement.de
Gym Factory, Spain
www.gymfactory.net
Health Club Management, U.K.
www.healthclubmanagement.co.uk
JCC of North America, U.S. & Canada
www.jcca.org
Leisure DB, U.K.
www.leisuredb.com
Mercado Fitness, Argentina
www.mercadofitness.com
MSC Muench Solutions Consulting
www.hans-muench.com
Armando Moreira
AM
Image courtesy of Bodytech, Columbia www.bodytech.com.co
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Disclaimer
The statistical information contained in this report is representative of the individuals responding to the survey. All
reasonable efforts were taken by ClubIntel to assure data
comparability within the scope and limitations of the reporting
process. However, the data contained in this report is not
necessarily based on third-party audited data and the statistical
validity of any given number varies depending upon sample
sizes and the amount of consistency among responses for that
particular data point.
ClubIntel, therefore, makes no representations or warranties
with respect to the results of this study and shall not be liable
to clients or anyone else for any information inaccuracies,
errors or omissions in content, regardless of the cause of such
inaccuracy, error or omission. In no event shall ClubIntel be
liable for any consequential damages.

Study Methodology
In the third quarter of 2018, ClubIntel sponsored the 4th
Annual International Fitness Industry Trend Study – What’s
All the Rage? among global fitness professionals. The study
measured trend adoption rates from 2018 across multiple fitness
categories, including: equipment, facilities, programs/services/
training approaches and technology.

The study survey was translated into the following languages:
English, French, German, Mandarin, Portuguese, Russian and
Spanish. The study collected responses via an online survey
among the following fitness professional audiences: club/studio
owners, club/studio CEOs, club/studio managers, club/studiobased fitness directors, club/studio-based fitness/wellness
professionals and independent fitness/wellness professionals.
ClubIntel managed and administered the study itself, and the
survey was distributed via email blasts, email invitations and a
variety of digital platforms. In all, 1,374 usable responses were
collected representing approximately 19,000 health/fitness
facilities worldwide, including many of the largest operators
in the world. Collectively, these responses provided a strong
representation of fitness facility leaders from around the globe.
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A comprehensive study of global fitness industry behavior

Trends Yet to Jump the Chasm. These tend to be the trends
with the lowest levels of adoption, and concurrently, they have
the greatest potential for growth. These are the trends that
are confronting the proverbial chasm, a position where the
trend either remains a niche offering (innovation stage or early
adoption stage) or takes the leap into the mainstream.
In the final chapter, Chapter Seven, we provide a profile of the
survey respondents.

The report also contains an extensive appendix that includes:
data tables displaying adoption levels for every trend across
categories by global region, business model and size of the
business, definitions of the various trends, trend categories
and terms used in the report, as well as profiles of our global
partners, and finally, the story of ClubIntel.
Report Flow & Format
This year’s report begins with a chapter on trend wisdom,
which describes what trends are, why they are important to
understand and how industries and businesses can evaluate
the efficacy of a trend using the Trend Adoption Curve. Our
second chapter, entitled Overarching Insights, offers readers a
high-level interpretation of the various trends occurring in the
fitness industry. Starting with Chapter Three and continuing on
through Chapter Six, we take a deep dive into the trends by
trend category: equipment, facilities, programs/services and
technology. In each of these chapters, we explore the trends by
global region, business model and size and scope of the business.
In each instance, we look at the trends from two perspectives:
Trendsetters. Trendsetters are those who are innovators or
early adopters of equipment trends. Once a trend enters the
mainstream, these are the players likely to display the highest
level of adoption for a trend, having embraced it early on.

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Chapter 1
Trend Wisdom...The How, What, Who and Why of Trends
“Change is not a threat, it’s an opportunity. Survival is not the goal, transformative success is.”
- Seth Godin
Photo Credit: Image courtesy of MINDBODY, the world’s leading technology platform for the wellness industry
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need to focus on if they wish to build a successful business
going forward.
The Importance of Using Trends to
Drive Business Success

The value of observing, understanding, exploiting or even
setting trends cannot be overstated. In an online article entitled,
Six Hot Reasons to Follow Trends Around Your Business,
that appeared on the website entrepreneurshipinabox.com,
the authors offered six reasons why business leaders should
observe trends around their business. According to the authors,
these six “hot” reasons are:

■Understanding trends will allow you to be a better forecaster.
The ability to predict the future with a reasonable degree of
certainty can be a great enabler of future success.
■By following trends, you will know what is happening presently
and what is most likely going to occur tomorrow.
■By following trends, it will establish you as a leader, not a
follower. Steve Jobs spoke of this when he said, “Innovation
distinguishes between a leader and a follower.”
■Trend knowledge is essential to generating ideas and
innovations that can propel your business forward during
periods of hyper-competition.

Introduction
Trends are one of the quintessential truths of mankind and
one of the enduring truths of capitalism. Trends influence how
we think, what we want to believe or not believe, how we act
and how we react. John Henry, an American businessman
and investor said about trends, “Man’s expectations manifest
in trends.”

Business, as well as cultural trends, can inform us of where the
market is headed, what competitors are doing, what consumers
are embracing, what business leaders are thinking and what
opportunities there are for the taking. The health/fitness
industry may be one of the most fickle industries, along with
fashion design and food, when it comes to the impact trends
can have on the way players do business. In this era of the
4th Industrial Revolution, change often occurs at warp speed,
especially in the realm of technology. Against this backdrop of
hastened business disruption, trends can very often become
the accelerant for informed or misinformed strategy.

The Definition of a Trend
Trends are events that evolve into movements. Trends have
the ability to gain momentum and create long-term societal
and business impact. Trends have vitality, often ingraining
themselves within the cultural roots of society, whether it is
a social trend or a business trend. The power of a trend can
manifest itself in the attitudes, values and behaviors of its
audience. Trends are the truths that help shape our future and
the journey we take. Trends are truths that business leaders
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future prosperity for their business.
Trendsetting. The final element is framed by this quote from
Frank Capra, “Don’t follow trends, start trends.” What he meant
was: be an innovator by building value propositions that uniquely
capture the attention and purchase intent of consumers. Steve
Jobs expanded on this by saying, “Innovation distinguishes
between a leader and a follower.” What both of these successful
professionals were saying is that success in business often
requires a focus on innovation or the introduction of disruptive
and game changing trends.
The Trend Adoption Curve
Trends begin as ideas, then through execution, evolve into
innovations, and finally, trends. How businesses respond to an
industry innovation, and whether that trend finds itself becoming
an industry mainstay or a niche phenomenon, lay at the heart
of the Trend Adoption Curve (Based on Rogers Adoption
Curve as put forward by Everett Rogers in his book Diffusion
of Innovations). This adoption curve can be applied to any
industry’s or business’s adoption and acceptance of a trend.
Understanding the implications of the adoption curve can
inform leaders where their business stands in respect to others
in the industry when it comes to the adoption of trends. In
addition, understanding the adoption curve of a trend can tell
you if it’s a niche innovation or one bound to monopolize an
industry’s ecosystem.

Innovation Stage. This represents 2.5% of businesses and
■Following trends will enable you to identify important early
warning signals regarding disruptive change.
■By understanding trends, it will guide you on what must improve in your organization, and also, what needs to be extricated.

How do fitness industry leaders use the previous advice on the
importance of trends to propel their operations in the future? By
taking the three steps presented below:

Become a trend observer. A leader’s failure to recognize
trends can result in a downward spiral for their business.
History is littered with businesses whose leaders either failed
to observe or identify trends, or worse, ignored them, believing
their business was not subject to the capitalistic disruptions that
trends generate. While observing trends is critical to business
success, understanding what they are and how they can impact
your business is just as important. Unless you understand the
significance of a particular trend, you will never be able to build
a strategy around it. Matthew Tokaki expressed his perspective
when it comes to the impact of not understanding trends, “If you
are not on top of understanding trends – you’re not on top.”
Trend Exploitation. This element is captured in the following
quote from Dick Clark, “I don’t set trends. I just find out what they
are and exploit them.” The inference is that, if you are a keen
observer of trends, you can take that knowledge and exploit it to
your business’s advantage. Steve Jobs was quoted as saying,
“We’ve always been shameless about stealing great ideas.”
Like Dick Clark, Steve Jobs understood that leaders who are
keen observers of trends can often exploit those trends to foster
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for the marketplace.

Once they have proof it works (their
competitors are having success with it), then these organizations
proceed to adopt it. Organizations in this realm are constantly
chasing the leaders. Fortunately for them, they have joined
the bandwagon early enough not to become irrelevant in the
competitive landscape. Once a trend reaches the stage where
the Early Majority assumes ownership of it, the trend is no
longer a niche offering, but instead a mainstream product in
the industry.

The Late Majority State. 50% of an industry has to adopt a
trend before these organizations will even consider it. When
a trend is adopted at this stage, it is typically the result of an
internal culture of complacency and apprehension to change.
Businesses who adopt trends at this stage do so out of business
necessity, not a desire to get ahead. Unfortunately, 34% of
organizations find themselves in this stage. If your business
is here, beware. By the time a product or experiential trend
is adopted by this group, it’s become standard practice for an
industry, as now, between 50% and 84% of businesses have
already adopted it. This is an example of karaoke capitalism
at work. Once a trend or practice falls into this stage, it means
that over 84% of businesses have adopted it, making it an
industry-must.

The Laggard Stage. This represents the final 16% of
organizations. These are firms that, for some reason, are full-on
skeptics of a trend, complacent to the point of being comfortably
numb. These are businesses or industries whose future is
potentially very short.

speaks to innovators, industry revolutionaries, game changers
and risk takers. These are the few who take the lead when
introducing or adopting a trend within an industry and creating a
distinct competitive advantage. These organizations, by way of
their entrepreneurial nature, either find themselves the darling
of an industry or simply a niche player with a unique product.
Apple is a great example in mainstream business that regularly
finds itself as one of the first to introduce and adopt innovative
technology trends.
Early Adoption Stage. This represents 13.5% of organizations,
a group that is composed of revolutionaries, change agents
and visionaries. While these organizations may not introduce
trends, or are the very first to embrace them, they are the ones
who quickly envision the opportunity of an emerging trend and
use it to gain a competitive advantage.

The Chasm. (The chasm is not part of the original Rogers
Adoption Curve and was proposed by Geoffrey Moore in his
book Crossing the Chasm.) This is not a stage but a barrier/
hurdle that all trends face in light of an industry’s unwillingness
to change. If a trend can’t leap this chasm, especially if it’s been
around for a few years, chances are it remains a niche offering,
providing a competitive niche for those who adopt it. Jump
the chasm and trends pick up steam, eventually becoming an
important part of an industry’s business practices.
Early Majority State. This transformation point is achieved
once 16% of an industry adopts a trend and represents trends
that have achieved between 16% and 50% adoption. These
organizations are pragmatists; they see the value in adopting a
trend but only when sufficient proof exists to verify its suitability See Figure 1.1 on the Next Page

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The Trend Adoption Curve
Based on the five stages of the Rogers Adoption Curve as put forward by Everett Rogers in his book Diffusion of Innovations.
Innovators
Early Adopters
Early Majority
Late Majority
Laggards

Adoption Rates
Stage:
Cumulative:
2.5% 13.5% 34% 34% 16%
2.5% 16% 50% 84% 100%
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Mainstream trends are those that make it over the chasm within
a few years of their introduction. Once a trend has traversed the
chasm and gains acceptance by the early majority it is on its
way to becoming an industry mainstay. A mainstream offering
is an example of what Jonas Ridderstrale and Kjell Nordstrom
referenced in the book Karaoke Capitalism, where industry
players copy each other rather than innovate. In the fitness
industry HIIT training is a great example. For a few years HIIT
lay in the domain of a few hardy studio operators, but before
long, HIIT studios were popping up everywhere and traditional
clubs were introducing it as part of their program portfolio.
A Word about Niche Trends and

Mainstream Trends
As demonstrated in the previous section, an innovation goes
through five stages of adoption, interceded by the chasm after
the early adoption stage. Frequently, a trend fails to achieve
the momentum needed to hurdle this adoption chasm. When a
trend remains mired in the innovation or early adoption stage
for a period of time, it is a niche offering. Niche offerings never
achieve the critical mass to become an industry mainstay, but
at the same time they can be great differentiators in a crowded
marketplace. Niche offerings appeal to small, passionate
and well-defined audiences. They can exert disruption by
the mere fact they attract these audiences away from more
mainstream offerings.

Image courtesy of Encore, Moscow, Russia
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Chapter 2
Overarching Insights & Adoption Curves
“The key to growth is the introduction of higher dimensions into our awareness.”
-Lao Tzu
Photo Credit: Image courtesy of Another Space, London
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respondent).

What we identified was that the business model a
fitness business pursues and the global region in which it conducts
business are the two primary influences in respect to how well
a trend is adopted. The following are some examples specific to
various regions and business segments:

■U.S. operators are significantly more inclined to adopt
programs such as Pickleball, personal training, fee-based small
group training, sports courts and pools than other regions.
We can infer from this that, at least from a programming
perspective, U.S. operators are more inclined to program
around sports activities than their international colleagues and
lean more heavily on internal programming that monetizes the
member experience.

■European operators are more inclined to adopt facility
spaces such as saunas, steam rooms and cold plunges than
their counterparts in other regions. We can infer from this
that European operators are more inclined than operators in
other regions to adopt heat and wet therapy spaces into their
business models.

■Budget clubs are more likely than other business models to offer
virtual self-directed training platforms and streaming/on-demand
virtual group exercise programs members can use away from
the club. Budget clubs are also more likely to leverage internet
advertising than other business models. This might be a reflection
of their business model being highly self-directed and requires
high volume membership sales.

Introduction
A daunting challenge for any business professional involves
identifying important trends as they emerge, understanding how
these trends could potentially impact their business and then
exploiting the trend to create a competitive advantage.
In this chapter, we showcase five key insights with respect to
industry trends, along with the presentation of some key adoption
curves by global region and business model.

Five Overarching Insights
1. Trends Don’t Adhere to One Universal Pattern. There is
a tendency for fitness professionals to view trends as “one size
applies to all.” Well, like everything in today’s society, trends appear
to have cultural, economic and tribal influences that prevent one
from universally applying assumptions regarding how a specific
trend might apply to a given business model, size of business or
international market. The data clearly shows that many industry
trends, no matter their category (e.g., equipment, facility, program/
services and technology) have unique fingerprints that are specific
to the economic, cultural and even tribal influences of the local
marketplace and the business’ value proposition. Consequently,
operators need to be sensitive to and considerate of these
influences when determining whether to introduce a trend, continue
with a trend or even eliminate a trend from their value proposition.

2. Business Model and Region are the Two Greatest Influences
on Trend Adoption. We evaluated the trends across a variety of
filters (region, business model, size of the business and role of
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use of EFT for collection of payments for ancillary services (44%).

■Russian operators have the highest level of adoption when it
comes to the use of social media (88%) and internet banner ads
(78%), having a mobile app (58%) and offering online scheduling
and registration (56%).

■Budget clubs have the highest adoption levels when it comes
to the use of digital payment gateways (31%), digital platforms
for distributing virtual group exercise content to members
when they are not in the club (21%) and are among the
leaders when it comes to offering in-club virtual group exercise
experiences (24%).

■Luxury clubs have the highest adoption levels when it comes to
incorporating a mobile app (61%), online member portal (43%),
acceptance of mobile wallets (25%) and online scheduling and
registration tools (57%) and health/wellness blog (46%).

■Boutique group exercise studios are leaders in the adoption
of social media (84%), online pricing of memberships/services
(66%), use of internet advertising (64%) and online registration
and scheduling (57%). Boutique group exercise studios are also
among the top two business models in respect to engaging with
digital middlemen (20%) and accepting customer payments via
mobile wallets (18%) and digital gateways (36%).

■Private clubs (e.g., member-owned athletic clubs and country
clubs) are the least tech savvy among all the business models
when it comes to leveraging technology.
3. Programming and Technology are Impacted the Most
by Business Model and Geographic Region. Programming
activities and technology adoption are the two trend categories that
appear the most heavily influenced by business model and region.
While facility spaces and equipment are influenced by these two
variables, it is the realm of programming and technology where the
greatest distinction is seen. Some examples of how technology is
impacted by region and business model follow.

Technology:
■Latin American operators have a significant edge when it comes
to adopting digital middlemen (30%) than any other geographic
region. Furthermore, Latin American operators are among the
top two globally when it comes to the use of social media (80%),
internet advertising (61%) and digital payment gateways (18%).

■European operators lead the way from a technology perspective
when it comes to online registration and scheduling (41%), delivery
of virtual group classes within the club setting (19%), use of artificial
intelligence to enhance the member experience (16%) and providing
streaming/on-demand virtual content members can use when not
in the club (12%). European operators are among the top two in
technology when it comes to the adoption of EFT for payment of
ancillary services (44%), introduction of a mobile app (40%), online
purchase of memberships (36%) and engagement with a digital
middleman (16%).

■U.S. operators are among the least likely of all the regions to adopt
technology as a means to enhance their business. They are more
likely to adopt platforms for distributing virtual self-directed coaching
(18%) and are also among the top two when it comes to adopting
in-club, on-demand virtual group exercise content (16%) and the
See Figure 2.1 on the Next Page
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Club-based Social Media Site
Internet Banner Ads
Club-based Mobile Application
Cloud-based Class Registration
Online Pricing of Memberships/Services
Cloud-based Appointment Registration
Accept Mobile Wallet
Use Fitness Wearables to Support Client Efforts
Cloud-based Member Portals
Online Purchase of Memberships
Accept Payments Via Digital Payment Gateways
Monthly EFT for Ancillary Services
Health/Wellness Member Blog
Engaged With Internet Middleman
Use AI to Enhance Member Experience
Virtual Group Exercise Classes (On-Site)
Virtual Group Exercise Classes (Off-Site)
Virtual Self-directed Fitness Programs
Augmented and/or Virtual Reality Training Systems
*

Innovators Early Adopters Early Majority Late Majority
18 2018 International Fitness Industry Trend Report - What’s All The Rage?
A comprehensive study of global fitness industry behavior
highest level of adoption for equipment-based group classes (46%).

■Latin American operators lead the way in respect to low intensity
interval training (LIIT) at 31%.

■Luxury clubs are industry leaders when it comes to the adoption
of personal training (93%), HIIT group classes (82%), HIIT small
group training (75%), Pilates (individual and group at 71%),
physical therapy services (65%), barre classes (54%), youth
personal training (50%) and a few other program formats. Luxury
clubs appear to be positioned as having the highest adoption
levels for many personal and fee-based services and also group
exercise programs.

■YMCAs/YWCAs/JCCs have among the highest adoption levels
for functional resistance training (90%), traditional yoga (88%),
group cycling classes (88%), senior fitness programs (88%),
aquatic exercise classes (81%), youth fitness programs (69%),
dance-related classes (52%), mind-body-based martial arts
(48%) and pickleball (45%). This industry segment appears
to be positioned to provide both fitness and recreational
activities across all generations. The YMCAs/YWCAs/JCCs,
and to a lesser degree non-profits, are more inclined than any
other segment to address the programming needs of a broad
consumer segment.

■Boutique fitness studios and boutique group exercise studios,
because of their specialization, do not occupy the top tiers of
program adoption when measured against other market segments.
This may be because of the variety of specialized offerings
boutiques offer.

Programming:
■The U.S. is the global leader by a wide margin when it comes
to barre, where 56% of U.S. operators report offering it; in other
regions, adoption levels are in the high teens. U.S. operators are
also the leaders in adopting personal training (90%), HIIT smallgroup training (65%), boot camp-style classes (74%), senior fitness
programming (72%), fusion style-group exercise classes (60%),
traditional yoga (67%), youth fitness programs (56%), suspension
training classes (63%) and health coaching (46%). Generally
speaking, the U.S. is the clear leader when it comes to setting and
adopting most program and service trends, particularly those that
have reached the mainstream level in most regions of the globe.

■European operators are among the leaders when it comes to
the adoption of EMS training (13%), whole body vibration training
(9%) and equipment-based exercise classes (43%).

■Russian operators have the highest levels of adoption for
programs such as group cycling (63%), youth personal training
(61%), dance-related classes (59%), suspended yoga (53%),
physical therapy services (45%), martial arts training (44%),
exotic dance-oriented classes (31%), medical spa services (19%)
and EMS training (17%). Russian operators may be the second
most progressive region of the globe when it comes to adopting
programming trends and appear to be clear leaders in respect
to some program and service formats that have yet to enter the
mainstream in other parts of the world.

■Australia is among the top three globally when it comes to the
adoption of free weight training in groups (79%), HIIT group classes
(75%), senior fitness programs (60%), HIIT small group training (54%)
and medical-based fitness programs (33%). Australia also has the See Figure 2.2 on the Next Page
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Free Weight Training (individual or small group)
Boot Camp-style Conditioning Classes
Senior Fitness/Active Aging Programs
Dance-related Classes (e.g. Latin, Hip Hop, etc.)
Fusion-style Group Exercise Classes
Pre-choreographed Group Exercise Classes
Group Cycling Classes (e.g., RPM, Spinning)
Functional Resistance Training
Barre Classes
HIIT Small Group Training (six or fewer individuals)
Equipment-based Exercise Classes
HIIT Group Exercise Classes (more than six individuals)
Youth Fitness Programs
Youth Personal Training
Traditional yoga (e.g., Ashtanga, Hatha, Ivengar)
Personal Training (individual private training)
LIIT (Low Intensity Interval Training)
Mind/Body-based Martial Arts
Nutritional Counseling and Coaching
Exotic Dance-oriented Group Exercise Classes
*

Russia and United States are within the Laggard Stage for Personal Training *
Australia
Canada
Europe
Latin America
Russia
United States
Innovators Early Adopters Early Majority Late Majority
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Physical Therapy Services
Pilates (groups with equipment)
Aquatic Exercise Classes
Hot Yoga
Holistic Health Services (e.g., Acupuncture)
Event-style Group Exercise Classes (e.g., chocolate and yoga)
Non-traditional/Adventure Training Programs (e.g., Ninja Warrior)
Traditional Endurance Training Programs (e.g., marathons, etc.)
Health Coaching/Wellness Coaching
Sports-specific Performance Training
MMA/Kickboxing (e.g., classes or small group)
Small Group Fee-based Personal Training (six or fewer individuals)
Suspension Training Classes (e.g., TRX, Jungle Gym, etc.)
EMS Training (Electric Muscle Stimulation Training)
Medical Spa Services (e.g., Botox, microdermabrasion, etc.)
Medical Fitness-based Programs
Restorative/Recovery Training
Pilates (individual with equipment)
Suspended Yoga (e.g., wall, aerial, etc.)
Pickleball
Whole body vibration training
Chiropractic services
Australia
Canada
Europe
Latin America
Russia
United States
Innovators Early Adopters Early Majority Late Majority
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■YMCAs/YWCAs/JCCs and non-profits offer a lot of programs
that appeal to its youth and senior populations. They are also
more inclined to provide recreational programming such as
basketball, racquet sports, etc.

■Medical fitness centers, in turn, offer programming that serves
older adults and those with physical limitations while being less
inclined to offer programming targeting Millennials.

■Luxury clubs offer a very diverse array of programs compared
to other segments, and in particular they are more likely to
deliver programs that monetize the member experience.

4. Technology is the Industry’s Achilles’ Heel. According to the
principle of Digital Darwinism, businesses will always be behind
the advances in technology and how consumers use them.
That is even truer in the health/fitness industry. Other than the
use of social media, which is highly adopted across regions and
business models, most of the technology practices measured in
this study lay in the early adoption stage for the fitness industry.
There are some business models, such as luxury clubs and
boutique group exercise studios, that are embracing technology
more wholeheartedly than other business segments. Likewise,
regions, such as Europe and Russia, seem more inclined to
incorporate technology than other regions of the globe.

5. Programming is the Ultimate Differentiator in Respect
to Business Segment. Segmentation in the health/fitness
industry speaks to the business principle that, in order for a
value proposition to stand out and generate appeal among
consumers, it has to be different, or as Dr. Seuss said, “You have
to be odd to be number one.” Our research, and that of others,
shows it is not so much the tangibles, such as facilities and
equipment, that generate great oddity but instead the intangible
things, such as emotional connections, emotional highs and
tribal preferences. Well, programming has significantly more
influence on the intangibles than equipment, facilities, and to
a lesser degree, technology (mobile apps and social media
are incredibly influential on the intangibles). Consequently,
programming, and to a lesser degree, technology are the tools
of differentiation, and it’s reflected in what we see when we look
at business segments. Each business segment speaks to a
very unique programming profile.

For example:
Image courtesy of MINDBODY, the world’s leading technology platform for the wellness industry
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Chapter 3
Fitness Equipment Trends in 2018
“When future archeologists dig up the remains of California, they’re going to find all those gyms, their
scary-looking equipment, and they’re going to assume that we were a culture obsessed with torture.”
-Douglas Copeland
Photo Credit: Cardiovacular Area -JOHN_REED_Gesundbrunnen_Cardio © JOHN REED
23 Fitness exercise
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and Europe are the three most influential trendsetters when it
comes to equipment.

Specifically:

■The U.S. is the global leader in respect to the adoption of
equipment trends by capturing the number one rank for 60%
of the measured equipment trends. Russia and Australia both
follow capturing the top rank for 14% of the equipment trends.

■When considering the countries that rank among the top three
for each equipment adoption trend, the U.S. market ranks
in the top three on 81% of the equipment adoption levels,
Europe captures 60%, Australia captures 50% and Russia
captures 45%.

■The U.S. holds a dominant position with respect to the
adoption of AEDs (69% and a 28-point advantage); Flexibility
and mobility equipment (86% and a 15-point advantage)
and Non-traditional functional fitness equipment (81% and a
8-point advantage).

■Russia has the highest level of adoption for selectorized
resistance equipment (77% and 16-point advantage) and Electric
Muscle Stimulation or EMS (17% and 6-point advantage).

■Other than these significant leadership positions, adoption
levels for the remaining equipment are minor from a
percentage perspective.

Introduction
The fitness industry is highly dependent upon equipment to
deliver its value proposition to the consumer. If you were to
think of the fitness experience as a carefully crafted theatrical
production, then equipment would be the necessary props to
bring the story to life. Without the right props there is no story
to tell. Consequently, the equipment fitness operators adopt
speaks to the types of programs and training they seek to
deliver to members. Fitness equipment, like the other attributes
measured in this study, is subject to the influence of trends. Our
goal in this chapter is to bring forward the story behind 22 global
fitness equipment trends based on their level of adoption by
operators in 2018. Rather than explore these equipment trends
from a singular perspective, we will delve into them based on
geographic regions, business models and size of the business
operation. We believe this will provide valuable benchmarks for
operators everywhere.

The Influence of Geographic Location and
Culture on Equipment Trends
Geographic location and their accompanying cultural influences
determine to a large degree the types of equipment operators
around the world adopt. While the 22 equipment trends
measured in this study appear in clubs and studios across the
globe, their level of adoption is often specific to a region (Asia,
Australia/New Zealand, Canada, Europe, Latin America, Russia
and the U.S.). In this section we look at adoption levels for each
of the aforementioned regions.
Trendsetters - As reflected in Figure 3.1, the U.S., Russia
See Figure 3.1 on the Next Page
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Trend Leadership in Equipment for 2018
Number of Equipment Trends at the Top for Industry Adoption
Australia Canada Europe Latin America Russia United States
Number of Equipment Trends in the Top Three for Industry Adoption
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In Figure 3.2, we compare adoption levels for the five leading
equipment trends in the fitness industry for 2018. As the
figure reflects, when it comes to five most dominant trends in
equipment, the U.S. holds or shares the dominant stake for
all five, while Australia holds or shares the dominant position
for two equipment trends. The two trends that Australia and
the U.S. seem to take the lead on are with flexibility/mobility
equipment and traditional functional fitness equipment.

Figure 3.2
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■Metabolic testing equipment. On a regional level it remains in
the early adoption stage with Russia and the U.S. having the
highest adoption levels at 13% and 12% respectively.

■Digital fitness assessment tools. While this equipment remains
mired in the innovation or early adoption stage across all regions,
Latin America and Europe appear to be reaching levels where
they will soon become adopted by the early majority.

■3D Body Scanners have been adopted by 10% or less of
facilities in all regions.
Trends Yet to Jump the Chasm - In Figure 3.3, the five least
adopted equipment trends for each of the global regions are
represented. These niche equipment trends are:

■EMS training equipment. Russia and Europe are the only
regions whose level of acceptance of this type of equipment
exceeds 10%.

■Whole body vibration equipment. This equipment remains in
the innovation and early adoption stage for every market.
Figure 3.3
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a category, while only five of the business segments have an
adoption level that ranks number one for an equipment trend.
In Figure 3.5, we compare adoption levels across each
business segment for the five leading equipment trends in the
fitness industry for 2018. As the figure reflects, adoption levels
vary widely. Insights from Figure 3.5, as well as some of the
lesser adopted pieces of equipment include:

■Mid-market clubs have the highest adoption levels for traditional
functional fitness equipment, non-traditional functional fitness
equipment, elliptical trainers and suspension training equipment.
It appears that equipment comprises an important element of
the mid-market club value proposition.

■YMCAs/YWCAs/JCCS have the highest adoption levels for
treadmills, flexibility and mobility equipment, upright bicycles
and upper body ergometers. Like mid-market clubs, equipment
appears to play an important role in the value proposition of
these facilities.

■Luxury clubs have the second highest adoption levels for
three of the five leading equipment categories. This might be
a reflection of their serving an affluent and more demanding
membership base.

■Surprisingly, Private Clubs display fairly low adoption levels
for the key equipment trends.
The Influence of Business Segment on

Equipment Trends
The fitness industry of today is highly segmented reflecting
operators’ efforts to build and sustain a competitive advantage
through differentiation of their value proposition. The manner in
which a fitness business establishes differentiation often speaks
to the type of consumer it wants to attract, and the experience
they want the member to have. Furthermore, segmentation
influences the type of equipment a fitness operation offers. In this
section we look at adoption levels for each of the 22 equipment
trends for the following industry segments: Non-profits, YMCA/
YWCA/JCC’s, private clubs, budget clubs, mid-market clubs,
premium clubs, luxury clubs, boutique fitness studios, boutique
group exercise studios and medical fitness centers.
Trendsetters - As Figure 3.4 indicates, trend leadership does
not sit with just one business segment but is spread across the
various business segments, specifically:

■Premium clubs hold the top spot for 45% of the measured
equipment trends followed by YMCAs/YWCA/JCC’s at 23%
and mid-market clubs at 18%.

■95% of luxury clubs have equipment adoption levels that
fall among the top three globally, while approximately 60% of
YMCA/YWCA/JCC’s have equipment adoption levels that fall
among the top three. This insight would seem to indicate that
luxury clubs, possibly as a result of their positioning and price
points, are able to secure the various types of equipment with
less consternation than those in other business segments.

■Of the 12 business segments, seven have two or more
equipment adoption patterns that fall within the top three for
See Figures 3.4 & 3.5 on the Following Pages
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3.4
Trend Leadership in Equipment for 2018
Number of Equipment Trends at the Top for Industry Adoption
Number of Equipment Trends in the Top Three for Industry Adoption
Luxury Clubs
12
Luxury Clubs
22
YMCA/
YWCA/JCC
5
Mid-Market
Clubs
4
Medical Fitness
Centers
2
Premium Clubs
1
0
Non-Profits
Private Clubs
Budget Clubs
Boutique Fitness Studios
Boutique GX Studios
Independent Fitness Pro
YMCA/
YWCA/JCC
13
Mid-Market
Clubs
11
Medical Fitness
Centers
9
Premium Clubs
8
Non-Profits
4
Budget Clubs
2
0
Private Clubs
Boutique Fitness Studios
Boutique GX Studios
Independent Fitness Pro
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Figure
3.5
Figure 3.5
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■Cryotherapy equipment. Similar to the trends witnessed for
metabolic testing equipment, only luxury clubs and medical
fitness centers have adoption levels that exceed the early
adoption stage.

■3D Body Scanners. 3D body scanners have adoption levels
below 5% across all but one industry segment; luxury clubs
have adoption levels at 14%. None the less, this new technology
remains a niche product at the moment.

■Electronic stimulation equipment. Across every business
segment EMS equipment remains a niche product. Luxury
clubs lead the way with an adoption level of 14%.
Trends Yet to Jump the Chasm - In Figure 3.6, the five least
adopted equipment trends for each of the different business
segments are represented. These include:

■Whole body vibration equipment. While this piece of equipment
has garnered less than 10% adoption among the majority
of business segments, budget clubs and luxury clubs have
adopted this equipment at levels of 17% and 32% respectively.

■Metabolic testing equipment. While nine of the ten business
segments have adoption levels for this equipment of under
10%, 25% of luxury clubs and 12% of medical fitness centers
have adopted this equipment.

Figure 3.6
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levels for elliptical trainers (86% with 15-point advantage) and
recumbent bicycles (73% with 11-point advantage).

■Firms with 51 to 100 units are far more likely than any
other segment to adopt Pilates’ equipment (30% with 7-point
advantage) and metabolic testing equipment (21% with
9-point advantage).

■For nearly every type of fitness equipment, the larger unit
operators have higher levels of adoption.
In Figure 3.8, we compare adoption levels for the five leading
equipment trends in the fitness industry for 2018. As the figure
reflects, when it comes to the five most dominant trends in
equipment, firms with more than 11 units hold a considerable
adoption level advantage over their smaller competitors.

For example:

■Firms with 101 or more units hold an edge in respect to the
adoption of treadmills, suspension training equipment, foam
rollers and flexibility and mobility equipment.

■Firms with either 11 to 50 units or 51 to 100 units have
a slight adoption edge in respect to traditional functional
training equipment.
The Influence of Business Size on
Equipment Trends
The size of a fitness business (number of units it oversees)
often plays a role in the types of equipment operators around
the world adopt. The larger a business, the more capital it has
access to and the easier it becomes to acquire the newest
equipment when it is introduced to the market. While the 22
equipment trends measured in this study appear in clubs and
studios across the globe, their level of adoption is frequently
influenced by the size and scope of the business (single club,
2 to 10 clubs, 11 to 50 clubs, 51 to 100 clubs and greater than
101 clubs). In this section we look at adoption levels for each of
the aforementioned size of businesses.
Trendsetters - As reflected in Figure 3.7, the larger the business
(more units it operates), the more likely it is to be a trendsetter
who leads adoption levels, specifically:

■Companies with over 101 units hold the top spot for 45% of
the measured equipment trends followed by companies with 51
to 100 units at 27%.

■95% of the firms with over 101 units have adoption levels that
fall among the top three globally, while 100% of those with 11
to 50 units and 82% of those with 51 to 100 units do the same.

■It is evident that firms with 10 or fewer units do not have nearly
the same levels of equipment adoption as the larger operators.

■Firms with over 101 units have significantly higher adoption
See Figures 3.7 & 3.8 on the Following Pages
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3.7
Trend Leadership in Equipment for 2018
Number of Equipment Trends at the Top by Scale of Business
Number of Equipment Trends in the Top Three by Scale of Business
22
11 to 50 Clubs
21
101+ Clubs
18
51 to 100 Clubs
4
One Club
3
2 to 10 Clubs
4
Independent Professional
10
101+ Clubs
6
51 to 100 Clubs
4
11 to 50 Clubs
0
2 to 10 Clubs
0
One Club
0
Independent Professional
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Figure
3.8
Figure 3.8
34 2018 International Fitness Industry Trend Report - What’s All The Rage?
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■Cryotherapy equipment. Cryotherapy equipment has adoption
levels below 6% across all business sizes.

■3D Body Scanners. Across the different size of businesses, 3D
Body Scanners have adoption levels below 7% except among
clubs with 11 to 50 units where adoption levels are at 12%.

■Electronic stimulation equipment. EMS equipment has adoption
levels below 6% except in club chains of 51 to 100 units where
adoption levels have achieved 12%. Even at this level, EMS
remains a niche offering across the different business sizes.
Trends Yet to Jump the Chasm - In Figure 3.9, the five
least adopted equipment trends for each of the different size
businesses are represented. These include:

■Whole body vibration equipment. The two business segments
that have achieved greater than 10% adoption for this equipment
are firms with 51 to 100 units and firms with over 101 units.

■Metabolic testing equipment. Businesses with 51 to 100 and
greater than 101 units are the only segments to have adoption
levels in excess of 12%.
Figure 3.9
2018 International Fitness Industry Trend Report - What’s All The Rage?
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Chapter 4
Fitness Facility Trends in 2018
“A great building must begin with the unmeasurable, must go through measurable means when it is
being designed and in the end must be unmeasurable.”
-Louis Kahn, Architect
Photo Credit: Image courtesy of Another Space, London
36 2018 International Fitness Industry Trend Report - What’s All The Rage?
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look at adoption levels for each of the aforementioned regions.
Trendsetters - As reflected in Figure 4.1, the U.S. and Russia
are the two most influential trendsetters when it comes to
facilities, followed by Europe, specifically:

■Russia holds the top spot for 45% of the measured facility
trends followed by the U.S. at 41%. The margins in respect to
the percentage adoption for some of these trends are slight. This
may be a great example of the one region being an innovator
and the other an early adopter; in both instances they have
achieved very similar levels of leadership.

■86% of the U.S. market’s facility adoption levels fall among the
top three globally, while 68% of Russia and 59% of Europe do
the same.

■The U.S. holds a dominant position with respect to the adoption
of Pickleball courts (35% and an 18-point advantage); indoor
sports facilities (39% and an 18-point advantage) and pools (same
level of adoption as Russia at 56% and 19-point advantage).

■Russia has the highest level of adoption for saunas
(56% and 14-point advantage) and Day Spas (44% and
16-point advantage).

■The U.S. profile appears to offer not only a focus on fitness
in general, but also more of a focus on sports activity-oriented
spaces, indoor sports courts, Pickleball courts and pools.
Introduction
In the theatrical production of delivering the fitness club
experience, our facilities represent the stage. The type of
facilities a club or studio offers is a direct reflection of its value
proposition and the experience it plans to deliver. In many
instances, a tangible attribute of the business, the facility and
the spaces it offers are positioned as a competitive differentiator
intended to appeal to particular group of consumers; sometimes
a small niche audience and in other instances a very broad
demographic group. Fitness facility spaces like the other
attributes measured in this study, is subject to the influence
of trends. Our goal in this chapter is to bring forward insights
regarding these 22 global facility trends based on their level
of adoption by operators in 2018. Rather than explore these
facility trends from a singular perspective, again we will delve
into them based on a geographic region, business model and
size of the business operation. We believe this will provide
valuable benchmarks for operators everywhere.
The Influence of Geographic Location and

Culture on Facility Trends
Geographic location and their accompanying cultural influences
often determine the types of fitness facilities, and in particular
the areas within those facilities that operators around the world
adopt. While the 22 facility trends measured in this study appear
in clubs and studios across the globe, their level of adoption is
often specific to a region (Asia, Australia/New Zealand, Canada,
Europe, Latin America, Russia and the U.S.). In this section we
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4.1
Trend Leadership in Facility Spaces for 2018
Number of Facility Trends at the Top for Industry Adoption
Australia Canada Europe Latin America Russia United States
Number of Facility Trends in the Top Three for Industry Adoption
= 0
= 0
= 10
= 9
= 1
= 1
= 19
= 5
= 3
= 15
= 13
= 3

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compared to less than 5% in any other region.
In Figure 4.2, we compare adoption levels for the five leading
facility trends in the fitness industry for 2018. As the figure reflects,
when it comes to five most dominant facility trends, the U.S.
holds or shares the dominant stake for all five, while Russia holds
or shares the dominant position for three of these facility trends.

■Europe and Russia facilities are more likely to incorporate
wet therapy and heat therapy amenities (e.g., sauna, steam
and cold plunge) than their regional counterparts. In addition,
Europe and Russia have embraced free-standing group cycling
studios more than their regional counterparts.

■Yoga walls have been adopted by 11% of Russian operators,

Figure 4.2
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plunges and yoga walls in Russia. Their destiny in the other
regions seems to be as niche facility spaces. The others,
climbing walls, high altitude training rooms and whole body
cryotherapy rooms seem destined to remain niche spaces for
the foreseeable future.
Trends Yet to Jump the Chasm - In Figure 4.3, the five
least adopted facility trends for each of the global regions are
represented. None of which have achieved the 16% adoption
level that would move it from niche or early adoption to early
majority and mainstream. The niche facility trends that seem
destined to become main stream at some juncture are cold
Figure 4.3
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six of these business segments capture the top adoption level
of a facility category.
In Figure 4.5, we compare adoption levels across each
business segment for the five leading facility trends in the
fitness industry for 2018. As the figure reflects, when it comes
to the five most dominant facility trends, adoption leadership
varies. For example:

■Mid-market clubs appear to have the highest adoption levels for
stretching zones, functional training zones and cycling studios.

■YMCAs/YWCAs/JCCS have the highest adoption levels for
pools, group cycling studios and racquet courts and are a close
second in respect to their adoption of mind body studios and
children’s areas. This profile speaks to facilities positioned for
family-oriented activities.

■Medical fitness centers have either the highest or second
highest level of adoption for sports performance centers,
therapeutic pools, stretching zones and functional training areas.
These spaces align closely with the intent of a fitness center
offering medical-oriented activities and serving customers with
physical limitations.
The Influence of Business Segment on

Facility Trends
The fitness industry of today is highly segmented, reflecting
operators’ efforts to build and sustain a competitive advantage
through differentiation of their value proposition. The manner in
which a fitness business establishes differentiation often speaks
to the type of consumer it wants to attract, and the experience
they want the member to have. Furthermore, segmentation
influences the type of facility, size of the facility, scope of the
facility and finish level of the facility. In this section we look at
adoption levels for each of the 22 facility trends for the following
industry segments: Non-profits, YMCA/YWCA/JCC’s, private
clubs, budget clubs, mid-market clubs, premium clubs, luxury
clubs, boutique fitness studios, boutique group exercise studios
and medical fitness centers.

Trendsetters - As Figure 4.4 indicates, trend leadership does
not sit with just one business segment but is spread across the
various business segments, specifically:

■Luxury clubs are significantly more likely to have adoption
levels for the various facility trends that are either number one
in their category (36%) or fall within the top three (100%).

■YMCAs/YWCAs/JCCs are second only to luxury clubs when it
comes to having facility adoption levels that are either number
one in their category (27%) or fall within the top three (68%).

■Of the 12 business segments, seven have at least one fitness
adoption level that falls within the top three for their category;
See Figures 4.4 & 4.5 on the Following Pages
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Trend Leadership in Facilities for 2018
Number of Facility Trends at the Top for Industry Adoption
Number of Facility Trends in the Top Three for Industry Adoption
Luxury Clubs
8
Luxury Clubs
22
YMCA/
YWCA/JCC
6
Medical Fitness
Centers
4
Non-Profits
1
Mid-Market
Clubs
1
Premium Clubs
1
0
Private Clubs
Budget Clubs
Boutique Fitness Studios
Boutique GX Studios
Independent Fitness Pro
YMCA/
YWCA/JCC
15
Premium Clubs
12
Medical Fitness
Centers
8
Non-Profits
5
Mid-Market
Clubs
4
Budget Clubs
1
0
Private Clubs
Boutique Fitness Studios
Boutique GX Studios
Independent Fitness Pro
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Figure 4.5
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of operators with the exception of luxury clubs where they have
achieved 14% adoption.

■Hot yoga studio. These studios are primarily a niche offering
with the exception of luxury clubs where 29% of operators
have adopted them. It appears that luxury clubs have a distinct
advantage when it comes to offering more esoteric yoga
programs as a result of having considerably higher adoption
levels for yoga walls and hot yoga studios.

■Cold plunge. Cold plunges have been adopted by premium,
luxury and medical clubs (10%, 11% and 12%, respectively). In
other segments, adoption levels are less than 5%.
Trends Yet to Jump the Chasm - In Figure 4.6, the five
least adopted facility trends for each of the different business
segments are represented. These include:

■Whole body cryotherapy room. These spaces have received
4% or less adoption across the various segments, indicating
they are primarily in the innovation stage and an extremely
niche space.

■High Altitude training rooms. These rooms have a nearly
identical profile to cryotherapy rooms.

■Yoga walls. Yoga walls have been adopted by less than 10%
Figure 4.6
44 2018 International Fitness Industry Trend Report - What’s All The Rage?
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studios (33% with 21-point advantage).

■Firms with 51 to 100 units are far more likely than any other
segment to adopt Mind Body Studios (58% with 10-point
advantage) and pools (56% with 10-point advantage).

■For nearly every fitness space, the larger unit operators have
higher adoption levels for most facility spaces.
In Figure 4.8, we compare adoption levels for the five leading
facility spaces. As the figure reflects, when it comes to the
most dominant trends, firms with more than 11 units hold
a considerable adoption level advantage over their smaller
competitors. For example:

■Firms with 51 to 100 units are the most likely to offer mind
body studios and stretching zones.

■Group cycling studios are the most prevalent in firms with over
101 units.
■Stand-alone clubs tend to have the lowest levels of adoption
for most facility spaces, possibly the result of differentiation and
trying to serve a defined niche.
The Influence of Business Size on

Facility Trends
The size of a fitness business (number of units it oversees) often
plays a role in the facility offerings operators around the world
adopt. The larger a business, the more capital it is likely to have
and the easier it becomes to renovate and expand their facilities.
While the 22 facility trends measured in this study appear in
clubs and studios across the globe, their level of adoption is
often influenced by the size and scope of the business (single
club, 2 to 10 clubs, 11 to 50 clubs; 51 to 100 clubs and greater
than 101 clubs). In this section we look at adoption levels for
each of the aforementioned sized businesses.
Trendsetters - As reflected in Figure 4.7, the larger the
business the more likely it is to lead in adoption levels and be a
trendsetter, specifically:

■Companies with over 11 to 50 units hold the top spot for 45%
of the measured facility trends followed by companies with 51
to 100 units and 101 or more units at 27%.

■91% of the firms with over 101 units have adoption levels that
fall among the top three globally, while 86% of those with 11 to
50 units and 81% of those with 51 to 100 units do the same.

■It is evident that firms with 10 or fewer units do not have the
same levels of adoption for fitness spaces as the larger operators.

■Firms with over 101 units have significantly higher adoption
levels for saunas (64% with 20-point advantage) and hot yoga
See Figures 4.7 & 4.8 on the Following Pages
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4.7
Trend Leadership in Facilities for 2018
Number of Facility Trends at the Top by Scale of Business
Number of Facility Trends in the Top Three by Scale of Business
20
101+ Clubs
19
11 to 50 Clubs
18
51 to 100 Clubs
7
2 to 10 Clubs
3
One Club
1
Independent Professional
10
11 to 50 Clubs
6
101+ Clubs
6
51 to 100 Clubs
1
2 to 10 Clubs
0
One Club
0

Independent Professional
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4.8
Figure 4.8
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■Yoga walls. When accounted for simply by the scale of the
business yoga walls fall in the innovation stage.

■High altitude training rooms. When accounted for simply
by the scale of a business these specialty spaces lay in the
innovation stage.

■Whole body cryotherapy rooms. When accounted for
simply by the scale of a business these spaces lay in the
innovation stage.
Trends Yet to Jump the Chasm - In Figure 4.9, the five least
adopted facility trends for each of the different size businesses
are represented, a list of which follows:

■Cold plunges. The level of adoption across business segments
is below 6%, a clear indicator that cold plunges are a niche
facility offering.
■Climbing walls. The level of adoption across business
segments are all below 7%.
Figure 4.9
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Chapter 5
Program, Service and Training Trends for 2018
“A club without programming is like a smart phone that can’t access the internet and has no apps; it
may look cool and sound cool, but it can’t connect you to the world.”
-Stephen Tharrett
Photo Credit: Functional Training -JOHN REED_Training_Functional © JOHN REED
49 Fitness exercise

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important role. While the 42 programming trends measured in
this study appear in clubs and studios across the globe, their
level of adoption is often specific to a region (Asia, Australia/
New Zealand, Canada, Europe, Latin America, Russia and the
U.S.). In this section we look at adoption levels for each of the
aforementioned regions.

Trendsetters - As reflected in Figure 5.1, the U.S., Russia
and Europe are the three most influential trendsetters when it
comes to programming, specifically:

■The U.S. holds the top spot for 60% of the measured
programming trends followed by Russia at 31%. The margins in
respect to the percentage adoption for some of these trends are
slight. This graph shows that the U.S. is an important influencer
of global industry trends in respect to programming. Russia and
Europe are definitely important trendsetters; just not as likely to
have the highest rates of adoption in the industry.

■79% of the U.S. market’s program adoption levels fall among
the top three globally, while 59% of Russia and 55% of Europe
do the same.

■The U.S. holds a much stronger position with respect to the
adoption of barre (56% and a 25-point advantage) and boot
camp classes (74% and a 31-point advantage).

■Russia has a much stronger position with adoption levels for
suspended yoga (53% and a 50-point advantage), exotic dance
Introduction
Again, using the analogy of a theatrical production as an
engineered club experience, programming serves as the
script for how operators can engage the bodies and emotions
of their members. Programming engages members in the
facility experience, creating opportunities for members to
become actively involved. The approach operators take to
programming speaks to how they plan to engage and connect
with their members and customers. Programming, because
of its ability to speak directly to different audiences, is one of
the most important tools facility operators have for fostering
tribes, whether it’s a singular tribe in a fitness studio or a group
of tribes in a multipurpose fitness facility. Programming and
training practices, more so than any of the other attributes
measured in this study, is heavily influenced by demographic
and cultural trends. Our goal in this chapter is to bring forward
insights regarding these 42 global programming trends based
on their level of adoption by operators in 2018. As with the
previous chapters, rather than explore these programming
trends from a singular perspective, we will delve into them
based on a geographic region, business model and size of the
business operation.

The Influence of Geographic Location and
Culture on Programming Trends
Geographic location and their accompanying cultural influences
play an important role in how club and/or studio operators
program their facility. Since programming speaks to the bodies
and emotions of the audience, regional influences play an

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5.1
Trend Leadership in Programming for 2018
Number of Program Trends at the Top for Industry Adoption
Australia Canada Europe Latin America Russia United States
Number of Program Trends in the Top Three for Industry Adoption
= 25 = 13
= 2
= 2
= 0
= 0
= 11
= 10
= 9
= 33
= 25
= 23
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choreographed classes.

■Australia leads the world in respect to the adoption of HIIT
group exercise classes and is just behind the U.S. in the adoption
of functional resistance training and free weight training.
In Figure 5.2, we compare adoption levels for the five leading
programming trends in the fitness industry for 2018. As the
figure reflects, when it comes to five most dominant trends in
programming, the U.S. holds or shares the dominant stake for
all five, while Russia and Australia are not far behind.
classes (31% and 16-point advantage) and youth personal
training (61% with 12-point advantage).

■The U.S. profile includes high adoption rates for many of
the new boutique-style classes such as barre and HIIT, and
fee-based programs such as personal training and small
group training.

■Russian operators seem to lead the way in respect to some
of the more esoteric forms of group exercise, as well as some
of the traditional approaches such as group cycling and preFigure 5.2

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majority stage where it could possibly become a mainstream
offering in these two regions. Lastly, whole body vibration in
Europe and Latin America appears to be growing with the
potential to soon move out of the early adoption stage and enter
the mainstream programming mindset for these markets.
Trends Yet to Jump the Chasm - In Figure 5.3, the five least
adopted programming trends for each of the global regions are
represented, only one (Pickleball in the U.S.) of which exceeded
the 16% adoption level, thus becoming part of the early majority
stage. EMS training in Europe and Russia appears perched to
jump the chasm and go from the early adoption stage to the early

Figure 5.3
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industry for 2018. As the figure reflects, when it comes to the
five most dominant trends in programming, adoption leadership
varies. For example:

■A majority of the leading program trends fall within the late
majority stage or even laggard stage of the adoption cycle.
This indicates that most of these programs are well established
within their market segment. This is considerably different than
it is for some of the other trend categories such as equipment
and technology.

■YMCAs/YWCAs/JCCs have the highest adoption levels for
boot camp-style classes, free weight training, senior fitness,
pre-choreographed classes, group cycling classes and aquatic
exercise classes.

■Luxury clubs lead the way when it comes to the adoption of
personal training, HIIT classes, sports specific training, private
Pilates training, hot yoga, functional resistance training and
medical spa services.

■Mid-market clubs demonstrate similar levels of program
adoption to luxury clubs in respect to the five leading
programming trends.

■Medical fitness centers have either the highest or second
highest level of adoption when it comes to stretching zones,
senior fitness programming, and functional training areas.
The Influence of Business Segment on

Programming Trends
How a fitness operator programs their business speaks to a
variety of elements; including the audience they are targeting
(age, gender, income level, generation), the experience they
want to create, the price they wish to charge customers, the
level of member engagement they wish to deliver, and the level
of differentiation they want to generate. In this section we look
at adoption levels for each of the 42 programming trends for the
following industry segments: Non-profits, YMCA/YWCA/JCC’s,
private clubs, budget clubs, mid-market clubs, premium clubs,
luxury clubs, boutique fitness studios, boutique group exercise
studios and medical fitness centers.
Trendsetters - As Figure 5.4 indicates, trend leadership does
not sit with just one business segment but is spread across the
various business segments, specifically:

■Luxury clubs are significantly more likely to have programming
adoption levels that are either number one in their category
(48%) or fall within the top three (83%).

■YMCAs/YWCAs/JCCs are second only to luxury clubs when it
comes to program adoption levels that are either number one in
their category (36%) or fall within the top three (64%).

■Of the 12 business segments, nine have at least one fitness
adoption level that falls within the top three for their category;
six of these business segments have an adoption level that
ranks number one for a programming category.
In Figure 5.5, we compare adoption levels across each business
segment for the five leading programming trends in the fitness
See Figures 5.4 & 5.5 on the Following Pages
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5.4
Trend Leadership in Programming for 2018
Number of Programming Trends at the Top for Industry Adoption
Number of Programming Trends in the Top Three for Industry Adoption
Luxury Clubs
20
Luxury Clubs
35
0
Private Clubs
Boutique Fitness Studios
Boutique GX Studios
Independent Fitness Pro
YMCA/
YWCA/JCC
15
Premium Clubs
4
Medical Fitness
Centers
3
Budget Clubs
2
Mid-Market
Clubs
1
YMCA/
YWCA/JCC
27
Premium Clubs
19
Mid-Market
Clubs
16
Medical Fitness
Centers
13
Non-Profits
10
Boutique GX
Studios
7
Budget Clubs
6
Boutique Fitness
Studios
3
0 - Private Clubs, 0 - Independent Fitness Pro
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Figure
5.5
Figure 5.5
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■Whole Body Vibration Training. While a niche program for
most business segments, budget clubs and luxury clubs appear
to have adopted it to the level that it approaches what is defined
as being in the early majority stage.

■Chiropractic services. These services are the most popular
in premium clubs, having achieved adoption levels of 18%, but
for the other segments chiropractic services achieve less than
12% adoption.

■Suspended yoga. Luxury clubs (25%) and premium clubs
(23%) have significantly higher adoption levels for suspended
yoga than the other business segments.
Trends Yet to Jump the Chasm - In Figure 5.6, the five least
adopted programming trends for each of the different business
segments are represented. These include:

■Medical spa services. While these services fall below 10% for
most facility segments, 30% of luxury clubs offer these services.
This service is a niche offering for every other business segment.
The dominance of luxury clubs in respect to this service may
speak to the fact that these services are expensive and more
likely to appeal to those who can afford them.
■EMS training. Premium and luxury clubs are the only segments
to achieve greater than 10% adoption for these services.
Figure 5.6
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leaders; quite different than it is for equipment and facilities.
■Firms with over 101 units have significantly higher adoption
levels for hot yoga (33% with 21-point advantage) and
pre-choreographed group exercise classes (73% with
18-point margin).
■Firms with 51 to 100 units are far more likely than any other
segment to adopt Pilates (36% with 7-point margin) and boot
camp classes (73% with 9-point margin).
■Health coaching is significantly more prominent in stand-alone
clubs where 40% report offering this service.
In Figure 5.8, we compare adoption levels for the five leading
programming trends in the fitness industry for 2018. As the
figure reflects, when it comes to five most dominant trends in
programming, firms with more than 11 units influence trends
with group exercise classes, however, single-unit owners play a
role influencing the trends related to functional, free weight and
personal training programs.
The Influence of Business Size on
Programming Trends
The size of a fitness business (number of units it oversees)
often plays a role in the programming offerings operators
around the world adopt. While the 42 programming trends
measured in this study appear in clubs and studios across the
globe, their level of adoption is often influenced by the size and
scope of the business (single club, 2 to 10 clubs, 11 to 50 clubs;
51 to 100 clubs and greater than 101 clubs). In this section
we look at adoption levels for each of the aforementioned
sized businesses.
Trendsetters - As reflected in Figure 5.7, larger scale
businesses (operate more than ten units) are more likely to be
a trendsetter (lead in adoption levels), specifically:
■Firms with 11 to 50 units have adoption levels that fall within
the top three globally for 95% of the programming trends, while
86% of firms with 101 or more units hold a top three position in
regard to the programming trends. It is interesting to note that
48% of the programs independent fitness professionals deliver
fall within the top three, giving credence to the idea that individual
entrepreneurs play a role in the industry’s programming trends.
■Firms with 2 to 10 units occupy the top spot in respect to the
adoption of programming trends, while firms with over 101 units
occupy the top spot for 33% of industry programming trends.
■From a programming perspective, firms with a smaller unit
count are as capable as the largest companies of being trend
See Figures 5.7 & 5.8 on the Following Pages
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F
i
g
u
r
e
5.7
Trend Leadership in Programming for 2018
Number of Programming Trends at the Top by Scale of Business
Number of Programming Trends in the Top Three by Scale of Business
40
11 to 50 Clubs
36
101+ Clubs
26
51 to 100 Clubs
20
One Club
4
2 to 10 Clubs
3
Independent Professional
19
11 to 50 Clubs
14
101+ Clubs
10
51 to 100 Clubs
2
One Club
0
2 to 10 Clubs
0
Independent Professional
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Figure
5.8
Figure 5.8
60 2018 International Fitness Industry Trend Report - What’s All The Rage?
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with adoption levels below 8%.
■Suspended yoga. The adoption levels for this program don’t
seem to be materially impacted by business size.
■Holistic health services. The adoption levels for this program
don’t seem to be materially impacted by business size.
■Medical spa services. This service has some of the lowest
adoption levels of any program function.
Trends Yet to Jump the Chasm - In Figure 5.9, the five least
adopted programming trends for each of the different size
businesses are represented. These include:
■Whole body vibration training. This unique form of training
has adoption levels of under 10% when accounted for by
business size.
■Electric Muscle Stimulation (EMS). With the exception of
chains with 2 to 10 clubs, EMS remains a very niche offering
Figure 5.9
2018 International Fitness Industry Trend Report - What’s All The Rage?
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Chapter 6
Technology Trends of 2018
“Each business is a victim of Digital Darwinism, the evolution of consumer behavior when society
and technology evolve faster than businesses are able to exploit it. Digital Darwinism does not
discriminate. Every business is threatened.”
-Brian Solis
Photo Credit: CYBEROBICS Cycling_© CYBEROBICS -virtual fitness
62 2018 International Fitness Industry Trend Report - What’s All The Rage?

A comprehensive study of global fitness industry behavior
in clubs and studios across the globe, their level of adoption is
often specific to a region (Asia, Australia/New Zealand, Canada,
Europe, Latin America, Russia and the U.S.). In this section, we
look at adoption levels for each of the aforementioned regions.
Trendsetters - As reflected in Figure 6.1, Europe and Russia
are clear trendsetters and early adopters. The U.S. lays fourth
in respect to its leadership role in adopting technology (based on
number of technology trends among the top three for industry
adoption) for purposes of enhancing the fitness experience for
members, specifically:

■Russia holds the top spot for 42% of the measured technology
trends followed by Europe at 31%. The margins in respect to the
percentage adoption for some of these trends are slight. Figure 6.1
shows that Europe and Russia are definitely important trendsetters
both in the early adoption of technology trends and the acceptance
of these trends into the mainstream.

■79% of the European market’s technology adoption levels have
at least a top-three ranking among all categories, while 68% of
Russia and 58% of Australia do the same.
■European operators have significantly higher levels of adoption
in respect to AI (16% with 3-point advantage); VR (12% with
4-point advantage) and online blogs at 35% with a 10-point
advantage. While the percentages for AI and VR indicate they are
in the early adoption stage, both seem ready to make the leap
to the early majority stage and become a part of the mainstream
technology offering in this market. European operators seem ready
to embrace the positive aspects of technology as drivers of the
member experience.

Introduction
The fitness industry finds itself immersed in the disruption and chaos
of the 4th Industrial Revolution where the fusion of technologies
is blurring the lines between the physical, biological and digital
spheres; a period many authorities believe will fundamentally
change how we live, work and relate to each other. One of the
consequences of this tumultuous 4th Industrial Revolution is the
emergence of Digital Darwinism; a period in which the changes in
technology and consumers use of them is growing faster than most
businesses can adopt them. The fitness industry, more than most,
has been an industry that has yet to fully embrace technology,
and as a result, finds itself at high risk to the destructive forces
of Digital Darwinism. Our goal in this chapter is to bring forward
insights regarding 19 global technology trends; trends reflective
of the pressure of Digital Darwinism. We will explore the level
of adoption in 2018 for each of these trends birthed by the 4th
Industrial Revolution. Rather than explore these technology
trends from a singular perspective we will delve into them based
on a geographic region, business model and size of the business
operation. We believe this will provide valuable benchmarks for
operators everywhere.

The Influence of Geographic Location and
Culture on Technology Trends
Geographic location and their accompanying cultural influences
play an important role in how club and/or studio operators leverage
technology. For example, in Asia and Russia nearly everyone has
access to a smart phone, but only a small percentage has access
to a laptop or desktop computer. In some cultures, technology
is embraced and others, shunned with a degree of skepticism.
While the 19 programming trends measured in this study appear
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6.1
Trend Leadership in Technology for 2018
Number of Technology Trends at the Top for Industry Adoption
Number of Technology Trends in the Top Three for Industry Adoption
= 0
= 8
= 6
= 3
= 2
= 1
Australia Canada Europe Latin America Russia United States
= 15
= 13
= 11
= 9
= 6 = 0
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■One technology trend in which Latin America holds a
distinctive advantage is in respect to digital middlemen where
32% of operators have indicated they are engaged with
digital middlemen.
■Canada tends to lag well behind the other regions in respect
to using social media and mobile apps.
In Figure 6.2, we compare adoption levels for the five leading
programming trends in the fitness industry for 2018. As the
figure reflects, when it comes to five most dominant trends in
technology, Australia, Europe, Latin America and Russia are
the most likely to embrace these technologies.
■Russian operators have a commanding lead when it
comes to the use of mobile wallets (34% with 19-point
advantage) and online registration and scheduling (56% with
17-point advantage).
■Australia, the number three adopter of technology, holds the top
spot with respect to online pricing (59% with 8-point advantage)
and online purchasing of memberships and services (43% with
7-point advantage).
■Australia, Europe and Russia, have embraced the challenges
of today’s newest technologies to enhance the member
experience considerably more than their counterparts on the
other side of the Atlantic.
Figure 6.2
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■Virtual group exercise classes such as Fitness on Demand and
Wexer have entered the early majority stage in Asia, Europe
and is about to do so in the U.S.
■The use of AI has achieved 16% adoption in Europe, meaning
it is likely to become a mainstream technology in the near future.
Australia and Russia are not far behind in this respect.
Trends Yet to Jump the Chasm - In Figure 6.3, the five least
adopted technology trends for each of the global region are
represented. Some insights regarding what this figure shows:
■In the case of virtual self-directed fitness coaching, this
technology is no longer a niche technology in Australia, having
leaped the 16% mark and entered the early majority stage. This
technology platform is also close to changing stages in Europe.
Figure 6.3
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■Boutique group exercise studios, like luxury clubs, have
high adoption levels for technology. They have adoption rates
exceeding 50% for online scheduling and registration, online
pricing, the use of internet ads and leveraging social media.
■Private clubs appear to be the least savvy business segment
when it comes to technology. In general, adoption levels for this
segment are the lowest in the industry.
■Budget clubs and mid-market clubs are well represented
when it comes to assuming a leadership role in the adoption
of technology. Budget clubs are the most likely to offer a virtual
fitness platform that members can stream live or on-demand
when not in the club. In some regards this seems counter
intuitive as one would expect business models with a higher
price point to lead in this regard.
In Figure 6.5, we compare adoption levels across each business
segment for the five leading technology trends in the fitness
industry for 2018. As the figure reflects, when it comes to the
five most dominant trends in technology, adoption leadership
varies. For example:
■Social media is the most widely adopted technology trend
across business segments. Mid-market clubs, luxury clubs and
boutique group exercise studios have the highest adoption
levels for this particular category.
The Influence of Business Segment on
Technology Trends
As we learned at the beginning of this chapter, most businesses
find themselves struggling with the challenges of Digital
Darwinism. In this section we look at adoption levels for each
of the 19 technology trends for the following industry segments:
Non-profits, YMCA/YWCA/JCC’s, private clubs, budget clubs,
mid-market clubs, premium clubs, luxury clubs, boutique
fitness studios, boutique group exercise studios and medical
fitness centers.
Trendsetters - As Figure 6.4 indicates, trend leadership does
not sit with just one business segment but is spread across the
various business segments, specifically:
■Of the 12 business segments, eight have at least one adoption
level that falls within the top three for their technology category,
while only four of these business segments have an adoption
level that falls at the top of a technology category.
■Luxury clubs are significantly more likely to have technology
adoption levels that are either number one in their category
(53%) or fall within the top three (74%). Luxury clubs have
adoption rates of over 50% in categories such as internet banner
ads, online pricing, mobile apps and over 80% in respect to
the use of social media. This might indicate that the affluent
consumers who use luxury operations place greater value on
these technology offerings which in turn creates demand for
operators to provide them.
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See Figures 6.4 & 6.5 on the Following Pages
■The use of internet banner ads is the second most widely
adopted technology trend across business segments, with the
highest adoption levels seen in budget clubs, mid-market clubs
and boutique group exercise studios. One might assume the
reason they lead in this technology category is related to their
need to drive higher levels of consumer traffic than the other
business segments.
■Online pricing of memberships garners the third highest level of
technology adoption, yet only five of the 12 business segments
have achieved 50% or higher adoption for this technology.
In this day and age, one would expect adoption levels in this
category to be considerably higher.
■Online sale of memberships had the fifth highest level of
adoption across all business segments, yet none of the
segments was able to gain 50% adoption. Budget clubs and
boutique group exercise studios had the highest levels of
adoption for online sales.
Image courtesy of MINDBODY, the world’s leading technology platform
for the wellness industry
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6.4
Trend Leadership in Technology for 2018
Number of Technology Trends at the Top for Industry Adoption
Number of Technology Trends in the Top Three for Industry Adoption
Luxury Clubs
10
Luxury Clubs
14
0
Non-Profits
YMCA/YWCA/JCC
Private Clubs
Premium Clubs
Boutique Fitness Studios
Medical Fitness Centers
Independent Fitness Pro
Boutique GX
Studio
4
Budget Clubs
3
Mid-Market
Clubs
3
Mid-Market
Clubs
12
Budget Clubs
10
Boutique GX
Studios
10
Premium Clubs
9
Boutique Fitness
Studios
3
Medical Fitness
Centers
3
Non-Profits
1
0 - YMCA/YWCA/JCC, 0 - Private Clubs, 0 - Independent Fitness Pro
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Figure
6.5
Figure 6.5
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C
clubs are at approximately 14%, the only two segments that
have jumped the chasm in respect to the implementation of
virtual delivery content to members when they aren’t in the club.
■Engaged with a digital middleman. While primarily a niche trend
across business segments, boutique group exercise studios at
20% adoption and luxury clubs at 25% adoption seem to be
embracing this new and disruptive technology.
■Acceptance of mobile wallets. Similar to engagement with
digital middlemen, boutique group exercise studios and
luxury clubs have the highest level of adoption for this niche
technology. They are the only segments with 16% or greater
adoption, meaning these segments have jumped the chasm.
Trends Yet to Jump the Chasm - In Figure 6.6, the five least
adopted technology trends for each of the different business
segments are represented. These include:
■Use of AR/VR systems. On average this technology has been
adopted by 5% or less of the business segments making it a
niche technology. In all but boutique group exercise studios it is
mired in the innovation stage.
■Use of AI. Over 20% of medical fitness centers have adopted
AI technology, while the other 11 segments have adoption levels
below 10%.
■Virtual group exercise members can stream while away from
the club. Budget clubs have just over 20% adoption and premium
Figure 6.6
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and fitness wearables (52% with a 22-point margin.).
■Firms with 51 to 100 units are far more likely than any other
segment to adopt online pricing (64% with 18-point margin);
online registration (45% with 15-point margin) and mobile
wallets (21% with 9-point margin).
In Figure 6.8, we compare adoption levels for the five leading
technology trends in the fitness industry for 2018. As the figure
reflects, when it comes to five most dominant trends in facility
spaces, firms with more than 11 units hold an adoption level
advantage over their smaller competitors. Interestingly, it is
club chains with 51 to 100 units that have the highest levels of
adoption for three of the top five trends while smaller operations
(11 to 50 clubs and stand-alone clubs) take the top spots for
two of the five leading trends. The most intriguing insight from
this figure is that stand–alone clubs are just as likely to have a
strong social media presence as chains with over 101 clubs.
The Influence of Business Size on
Technology Trends
The size of a fitness business (number of units it oversees)
often plays a role in how it uses technology to serve its clients
and benefit business operations. The larger a business,
presumably the more capital it has the easier it becomes to
introduce new and upgraded technology platforms. While the
19 technology trends measured in this study appear in clubs
and studios across the globe, their level of adoption is often
influenced by the size and scope of the business (single club,
2 to 10 clubs, 11 to 50 clubs; 51 to 100 clubs and greater than
101 clubs). In this section we look at adoption levels for each of
the aforementioned sized businesses.
Trendsetters - As reflected in Figure 6.7, the larger the business
(more units it operates) the more likely it is to be a trendsetter
(lead in adoption levels), specifically:
■Firms with 51 to 100 units have adoption levels that fall within
the top three globally for 89% of the technology trends, while
84% of firms with 11 to 50 units hold a top three position in
regard to the technology trends.
■Firms with 51 to 100 units occupy 53% of the top spots in
respect to the adoption of technology trends, while firms
with over 101 units occupy the top spot for 42% of industry
technology trends.
■Firms with over 101 units have significant higher adoption
levels for virtual group exercise (53% with 26-point advantage)
See Figures 6.7 & 6.8 on the Following Pages
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6.7
Trend Leadership in Technology for 2018
Number of Technology Trends at the Top by Scale of Business
Number of Technology Trends in the Top Three by Scale of Business
17
51 to 100 Clubs
16
11 to 50 Clubs
14
101+ Clubs
6
One Club
1
2 to 10 Clubs
1
Independent Professional
10
51 to 100 Clubs
8
101+ Clubs
3
11 to 50 Clubs
1
One Club
0
2 to 10 Clubs
0
Independent Professional
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Figure
6.8
Figure 6.8
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It should be noted that while on average these five technology
applications have the lowest overall levels of adoption, and in
most instances are in the innovation or early adoption stage,
the use of virtual group exercise classes that members can
view outside the club, the acceptance of mobile wallets and
engagement with digital middlemen have leaped the chasm for
the operators of 51 to 100 clubs, which for this segment are now
part of the early majority. A sign they are becoming part of the
mainstream portfolio.
Trends Yet to Jump the Chasm - In Figure 6.9, the five
least adopted technology trends for each of the different size
businesses are represented. These include:
■Virtual group exercise classes offered outside the club. Only
the larger club operations appear to take advantage of this
technology as both segments of 51 to 100 and 101 or more
have adoption levels above 15%.
■Mobile wallets. The majority of business segments have very
low adoption levels for mobile wallets. The operators with 51 to
100 clubs appear to be the key driver for use of this technology
with 21% adoption; however, single unit operators have made
inroads with 12% adoption.
■Relationship with a digital middleman. Similar to mobile wallets,
the operators with 51 to 100 clubs are the driving force behind
the use of Internet middlemen (18% adoption). Operators with
11 to 50 units and those with one club each have 11% adoption.
■Incorporation of AI into the business. Business size is not a
strong predictor for the use of AI as the adoption levels are very
low across all categories.
■Use of augmented or virtual reality has yet to push past the
innovation stage for the various industry segments.
See Figure 6.9 on the Following Page
Image courtesy of Fit Reserve
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Figure
6.9
Figure 6.9
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Chapter 7
Respondent Profile
“Diversity in the world is a basic characteristic of human society, and also the key condition for a
lively and dynamic world as we see today.”
-Jintau Hu
Photo Credits: Image courtesy of Alta Fitness, Canterbury, Australia; Image courtesy of Goodlife Fitness Canada; Image courtesy of Fiter Clubs, Argentina
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Geographic Region of Origin
As reflected in Figure 7.1, 86% of respondents who completed
this question operated a fitness business outside the U.S.
Canada had the largest representation of individuals, but
when accounting for the total number of clubs represented it
approximates the response rates from Europe, Latin America
and the U.S.. Behind the Canadian contingent were the U.S. at
14%, Latin America at 10% and Australia/New Zealand at 8%.
This year’s profile is well balanced with larger representation
from Australia/New Zealand, Canada, Europe, Latin America
and Russia than the previous three studies. Many of the largest
club operators by unit size came from Europe, Canada and
Latin America. This geographic profile generated statistically
reliable sample sizes for segmentation work thereby allowing
for comparison of trends across global regions.

Introduction
As indicated in the methodology section, a survey invitation
was sent to health/fitness professionals around the globe in
cooperation with our partners in Asia, Australia, Canada, England,
Europe, Latin America and the U.S. Our goal in reaching out to
these international operators was to capitalize on the incredible
value gained by having a broad understanding of the trends
affecting the industry from markets around the world. A quote of
Muslim origin says, “A lot of different flowers make a bouquet.”
We believe that in 2018, more than in previous years, we have
attracted a more appealing bouquet of club operators. This
year, we had 1,374 individual responses of which approximately
300 did not complete the demographic questions. As a result,
the respondent profile presented in this section is based on
approximately 1,100 respondents who provided profile details
on their organization, market and role. This demographic
profile may vary by a few percentages points from the actual
profile due to not every respondent completing the profile
questions. The profile that follows portrays their geographic
region of origin, business model they work within, size and
scope of their business and their position/role in the industry.
See Figure 7.1 on the Following Page

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Figure 7.1
Distribution of Respondents by Geographic Region
Based on those who responded to this question
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e
data by business segment, providing a reasonably accurate
picture of the trends being adopted by the various segments
of the fitness industry, including boutique fitness studios
and nonprofits.
Business Model Within the Fitness Industry
Figure 7.2 provides a profile of survey respondents based on
the fitness industry business segment they work in. While 75%
of respondents worked at one of 10 different business models,
25% of the respondents were independent fitness professionals.
The distribution of business models allowed us to segment trend
Figure 7.2
Distribution of Respondents by Business Model & Segment
Based on those who responded to this question
Independent
Fitness Pro
25%
Mid-Market
Clubs
18%
Private Clubs
13%
Non-Profits
13%
Boutique Fitness
Studios
9%
Premium Clubs
7%
Boutique GX
Studios
4%
YMCA/
YWCA/JCC
4%
Luxury Clubs
3%
Budget Cluba
3%
Medical Fitness
Centers
2%
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units (7%). This dynamic allowed us to better understand what
influences company size has on the adoption of industry trends.
Position/Role in the Health/Fitness Industry
Figure 7.4 portrays the distribution of respondents based on
their specific role in the industry. Of interest, 25% of respondents
owned the business, while another 13% were either CEOs or
COOs of the business. This means that 38% of the respondents
were in ownership or C-Suite positions.

Size and Scope of the
Respective Fitness Businesses
Figure 7.3 provides a general profile of respondents based
on the number of units in their business. The largest segment,
representing 38% of respondents were single stand-alone
facilities, while 46% worked in one of the various multiple unit
businesses and 16% were independent fitness professionals.
Compared to previous years, we had a larger response rate
from firms operating 101 or more units (12%) and 11 to 50

Figure 7.3 Figure 7.4
Distribution of Respondents by Number of Facilities
Based on those who responded to this question
Distribution of Respondents Based on Professional Role
Based on those who responded to this question
Photo Credit: Image courtesy of Solinca Health and Fitness, Portugal
2018 International Fitness Industry Trend Report - What’s All The Rage?
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Appendices
Photo Credit: Image courtesy of Solinca Health and Fitness, Portugal
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Appendix A - About Our Partners
Our global partners, who are each highlighted below, were
indispensable. This year, in addition to promoting and
distributing the survey to fitness operators around the globe,
our partners provided assistance with translating the survey
into six different languages. Each of these individuals and
organizations is recognized as a fitness industry authority and
passionate champion for the vision and future of the industry. It
is with great respect and appreciation that we acknowledge our
partners in this endeavor:
Active Management (www.activemgmt.com.au)
An International fitness business consulting company that helps owners, managers and fitness business entrepreneurs develop
their business. With strength in bringing outside industry knowledge to your marketing, retention and culture we can help you lead
your business and your industry. Active Management also hosts the Fitness Business Podcast (www.fitnessBusinessPodcast.
com), the number one podcast on the planet for fitness business owners, managers and staff. A weekly 30-minute show
where they interview guests from within the industry and outside of the industry to help you run your business more efficiently
and profitably.
Armando Moreira
Armando is a well-respected authority on the fitness industry throughout Europe, and in particular in his home country of Portugal.
Associacao Brasileira De Academias - ACAD (www.acadbrasil.com.br)
ACAD is the Brazilian association of health clubs whose mission is to grow and protect the Brazilian fitness industry, working
intensely on public policy issues throughout the country. ACAD has represented the Brazilian fitness industry for approximately 20
years and presently has 1,000 member clubs.
AGAP - Associacao de Empresas de Ginasios e Academias de Portugal - AGAP (www.agap.pt)
AGAP is a professional trade association representing health and fitness facility operators in Portugal. AGAP provides its members
with a variety of support services including: legal advice and legislative support, insurance, district and regional meetings and a
variety of industry reports and publications.
Association of Fitness Studios - AFS (www.afsfitness.com)
AFS is the only trade association that provides business-specific products, services, and benefits to studio owners (500-10,000
sq. ft.) and entrepreneurial fitness professionals, supporting their efforts and giving them the platform to effectively manage and
grow their businesses.
Canfitpro (www.canfitpro.com)
Canfitpro is the largest provider of education in the Canadian fitness industry. Founded in 1993, canfitpro delivers accessible,
quality education, certifications, conferences, trade shows, and membership services. canfitpro’s over 100,000 members include
some of the world’s finest fitness professionals, health club operators, industry suppliers, and fitness consumers.
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ChinaFit (www.chinafit.com)
ChinaFit Fitness Network is a news platform for management information and industry news for practitioners and general managers
of China’s commercial fitness industry. ChinaFit publishes ChinaFit Business, a semi-annual business manual for health club
industry professionals in China and also hosts domestic and international education events for fitness professionals in China.
Club Industry (www.clubindustry.com)
Club Industry covers the news and trends of the fitness industry, helping to educate owners, operators and staff of commercial
clubs, studios, nonprofits, university rec, hospital wellness, parks and recreation and others through a website, newsletters,
special reports, webinars and the annual Club Industry Show.
Club Insider (www.clubinsideronline.com)
Celebrating 25 Years of Trust as the Pulse of the Health and Fitness Club Industry, Club Insider’s mission is “To help the owners
and operators of health, racquet, and sports clubs professionalize their clubs and gain the trust and business of their community.”
Club Spa and Fitness Association - CSFA (www.csfassociation.com)
The Club Spa & Fitness Association (CSFA) was established in January 2007 to provide support for fitness, spa, and wellness
professionals in the club industry. CSFA is committed to providing educational and networking opportunities to help members
advance their careers.
Encore Fitness (www.encorefitness.ru)
Encore Fitness presently operates two fitness clubs positioned in the premium segment of fitness industry in Russia. Encore
Fitness’s mission is to be Russia’s fitness industry leader in the adoption and use of new programs and technologies. The
company’s first was opened in 2016 and has since earned recognition from AD magazine for its unique and cutting-edge design.
The company’s second club opened in May of 2017 with additional clubs planned in the future.
Europe Active (www.europeactive.eu)
Europe Active is the European Association that provides the unique voice for the fitness, physical activity, and wellbeing sector at
the EU level in Brussels, with the aim to get more people, more active, more often.
fitness MANAGEMENT (www.fitnessmanagement.de)
fitness MANAGEMENT operates one of the leading magazines for club operators and fitness professionals. The publication fitness
MANAGEMENT international (fMi), first published in 1994, is distributed to 20,000 readers in the German-speaking health and
fitness industry. The magazines owners and editorial staff aspire to make a sustainable impact on the health and fitness industry.
Gym Factory (www.gymfactory.net)
Gym Factory is a bimonthly publication with a triple focus (managers, coaches and wellness) distributed in fitness centers in Spain
and Portugal and has authentic references of the sector among its authors.
Health Club Management (www.healthclubmanagement.co.uk)
Health Club Management is a leading publication for the global fitness, health and physical activity industry, covering the latest
news, research, trends and interviews with thought leaders from across the sector.
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JCC of North America (www.jcca.org)
JCC Association of North America strengthens and leads JCCs, YM-YWHAs and camps throughout North America. As the convening
organization, JCC Association partners with JCCs to bring together the collective power and knowledge of the JCC Movement.
JCC Association offers services and resources to increase the effectiveness of JCCs as they provide community engagement
and educational, cultural, social, recreational, and Jewish identity building programs to enhance Jewish life throughout North
America. By supporting the 25,000 Jewish communal professionals who connect with two million JCC participants each year, JCC
Association encourages engaged lives of purpose and meaning.
Leisure DB (www.leisuredb.com)
At Leisure DB, we’re passionate about leisure market intelligence because we know that an understanding of a business target
market enables good decision making, better investments and happier customers. We work with leisure operators to help them
understand who their customers are and identify where there is still demand for fitness in their area. With our unique database
of fitness facilities and Mosaic, the industry standard demographic system, we analyse customer data alongside catchment
demographics to provide a total market assessment. This provides clients a comprehensive analysis of their current customers,
existing and future competitors & potential demand. Our database holds extensive details of UK sports & fitness facilities and is the
leading source for leisure operators, suppliers and industry bodies. Each year, we compile the State of the UK Fitness & Swimming
Industry Reports which contain key statistics on the industry.
Mercado Fitness (www.mercadofitness.com)
Mercado Fitness is a leading publication for the fitness, health and physical activity industry in Latin America, covering the latest
news, research, trends and interviews with thought leaders from across the region.
MSC Muench Solutions Consulting (www.hans-muench.com)
MSC provides consulting and related supportive services to club groups and industry suppliers seeking international expansion.
Company founder, Hans Muench was formerly the European Director for IHRSA and presently serves on the faculty for the
Germany University of Fitness, Health and Prevention. He is an acclaimed fitness industry leader and writes articles for various
fitness industry publications in Europe.
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Digital Fitness Assessment Tools - These are devices that allow
individuals to assess their basic levels of fitness (e.g., posture, body
fat level, muscular strength, etc.) using digital platforms involving
basic artificial intelligence (e.g., TRX Maps or Fit Quest).
Digital Payment Gateways - These are cloud-based payment
platforms that allow operators to collect fees and customers to make
payments without using EFT, wire transfers, credit cards are debit
cards (e.g., PayPal and Stripe).

Electrical Muscle Stimulation (EMS) - A recently introduced training
apparatus that applies electrical stimulation to various muscle groups
while the individual performs exercise movements.
Event-Style Classes - Group exercise classes that are staged
around a specific theme such as Chocolate and Yoga, Wine and Yoga
or Wine and Pilates.

Exotic-dance Oriented Group Exercise Classes - Group exercise
classes built around specialty dance practices such as Belly Dancing,
Pole Dancing or other cultural dance techniques.
Flexibility/Mobility Equipment - Specialized fitness equipment and
accessories such as foam rollers, trigger point sticks, myofascial
release devices and stretch trainers.
Functional Training Zones - Physical spaces in a club/facility
designated for conducting functional training movements using either
traditional or non-traditional fitness equipment and exercises.
Fusion-style Group Exercise Classes - Group exercise classes
that blend two distinctly different styles or regimens of exercise such
as boxing and Pilates, yoga and cycling and HIIT and Tai Chi.
Appendix B - Definitions
We understand that some of the descriptors used to identify the
practices monitored in this study may be unfamiliar to many of those
reading this report. The following definitions are intended to provide
greater clarity of those descriptors and terms readers may be less
familiar with:

Artificial Intelligence (AI) Systems - These are digital platforms that
leverage AI (machine learning and deep learning) to pride insight and
direction to operators and members around the fitness experience
and equipment (e.g., Halo by Life Fitness, My Wellness Cloud by
Technogym, etc.).

Augmented/Virtual Reality (AR/VR) - New digital training tools that
use sophisticated digital systems to either superimpose graphics and
data in one’s real world (AR) or provides a virtual world to inspire
exercise performance (Blackbox, Holodia and Icaros).
Cloud-based Member Portals - Virtual platforms (e.g., website) that
are password protected allowing members/clients of a club/facility to
access personal account information, including paying bills.
Club-based Mobile Application - Application for use with members’
smart phones that allows them access to critical club information
and tools.

Dance-related Classes - Group exercise classes leveraging danceoriented movements such as hip hop, Latin dancing and ballroom
dancing. An example of a pre-choreographed dance-related class
would be Zumba.
Cryotherapy Equipment - Equipment that applies cold treatment to
assist in physical recovery.
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conducting medical-related fitness routines such as an area for
cardiac rehabilitation or physical therapy.
Medical Spa Services - Spa services and cosmetic related
treatments that must be overseen by a physician such as Botox,
collagen injections and microdermabrasion.
Medical-based Fitness Programs - Fitness programs intended to
address specific physical and medical conditions such as arthritis,
diabetes, COPD, heart disease and obesity.

Metabolic Testing Equipment - Specialized equipment for
measuring an individual’s resting metabolism and/or exerciseinduced metabolism. Examples include devices that measure oxygen
consumption at rest and during exercise such as metabolic carts.
Mind Body-based Marital Arts - Activities such as Tai Chi and Qi Kung.
Mobile Wallet - Digital payment solutions that replace a credit card,
check or cash (e.g., Apple Pay, Android Pay or Samsung Pay).
Non-traditional Functional Training Equipment - Fitness
equipment and accessories such as battle ropes, kettlebells, Indian
Clubs, sandbags, sand bells and tires.
Pickleball - A paddle sport that combines elements of badminton and
tennis. The game is played on a court with dimensions of 44 feet by
20 feet and is played with a paddle and plastic ball.
Online Cloud-based Registering and Reserving Space in Class -
An online platform or portal that allows members/clients to register
and reserve a space in a class at their club/studio.
Online Cloud-based Registration and Scheduling Services - An
online platform or portal that allows members/clients to register and
Health Coaching/Wellness Coaching - Individual coaching and
guidance offered by professionals to help individuals address health
and wellness related issues.

High Altitude/Hypoxic Training Room - A physical space that can
simulate the environmental conditions of training at high altitude (i.e.
lower Oxygen partial pressure).

HIIT Group Exercise Classes - Group exercise classes composed of
more than six individuals that use the principles of metabolic training
where bouts of high intensity exercise are blended with bouts of low
intensity exercise.

HIIT Small Group Training - Small group training involving six or
fewer individuals that use the principles of metabolic training where
bouts of high intensity exercise are blended with bouts of low
intensity exercise.

Holistic Health Services - Health services that leverage what are
often defined as alternative and complementary medicine approaches
such as acupuncture, acupressure, homeopathy, naturopathy, etc.
Hot Yoga - Traditional or non-traditional yoga classes taught in a high
temperature environment, typically above 85 degrees Fahrenheit and
often above 100 degrees Fahrenheit.
Hot Yoga Studio - A studio specifically designed for conducting hot
yoga classes and comprised of customized heat generation and
retention elements.
LIIT - Stands for low intensity interval training. Rather than using bouts
of high-intensity training as the centerpiece of the training approach
low intensity activities are used instead.
Medical Exercise Area - Physical spaces designed specific for
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intended to improve athletic/sports performance and focused on
developing one or more elements associated with enhanced sports
performance such as agility, power and speed.
Suspended Yoga - Yoga classes using props to assist in supporting
one’s bodyweight. Examples include the use of a yoga wall or
other apparatus suspended from the celling using names such as
aerial yoga.
Suspension Training Classes - Group fitness classes or
sessions using bodyweight suspension equipment such as TRX or
Jungle Gym.
Therapeutic Exercise Pool - A pool designed specifically for
conducting preventative and rehabilitative exercises and maintained
at a higher than normal temperature.
Traditional Functional Fitness Equipment and Accessories -
Fitness equipment and accessories such as bands, balance boards,
Bosu balls, medicine balls, stability balls and tubes.
3D Body Scanners - High tech digital devices that allow a threedimension image to be created of an individual. The devices also
calculate body density and percentage of body fat.
Whole Body Cryotherapy Room - A physical space that can
simulate lower temperatures and enhance physical recovery after
strenuous exercise.

Whole Body Vibration Equipment - Equipment used specifically to
provide whole body vibration training to individuals.
Whole Body Vibration Training - A training methodology that uses
whole body vibration equipment accompanied by different body
movements to stimulate muscular growth.

schedule services (e.g., classes and personal training).
Restorative/Recovery Training - These are activities designed to
assist individual recovery from higher intensity workouts and include
cryotherapy, infrared therapy and myofascial release.
Virtual Group Exercise Classes Broadcast in the Club - Digital
platforms such as Fitness On-Demand, Les Mills and Wexer.
Virtual Group Exercise Classes Members Can Stream or Get
On-Demand - An online platform or portal that members/clients can
access and download or stream group exercise content to follow
on their digital devices (e.g., Beach Body on Demand, Daily Burn,
fitcloud connect, Forte).

Virtual Self-Directed Fitness Programs (e.g. on-demand and
streaming personal training & coaching for members) - An online
platform or portal that allows members/clients to access coaching
and instruction from club/studio staff either on-demand or streaming.
Pre-choreographed Group Exercise Classes - Group exercise
classes that have been choreographed and programmed by a
provider for resale to health and fitness facilities. Examples include
Les Mills, Zumba, Mossa and Jazzercise.

Small Group Fee-based Personal Training - Fee-based personal
training sessions lead by an instructor/trainer and composed of six or
fewer clients.
Sports Performance Center - A physical space or zone dedicated
to sports performance-training activities. Often comprised of an open
turf area, court surface and equipment designed to enhance sports
performance.

Sports Specific Performance Training - Fitness training programs
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We also offer strategic and actionable advice and coaching to
assist businesses achieve long-term success. Our co-founders
have a combined 60 plus years of experience spanning
consumer and customer insights, branding, club operations and
people development.

Appendix C - About ClubIntel
ClubIntel is a member and brand insights firm founded by
Stephen Tharrett and Mark Williamson. The company is
primarily focused on helping clubs understand, appreciate and
leverage the needs, wants and personal journeys of consumers,
employees and members. At ClubIntel we help clubs and studios
understand the position and voice of their brand in the market.
Stephen Tharrett, Co-founder and Principal
Stephen has been a thought leader and fitness industry advocate for nearly 40, having worked both domestically
and internationally across nearly every industry segment, including health, fitness, golf and country clubs both
public and private. From 2008 to 2010 Stephen served as the Chief Executive Officer for the Russian Fitness
Group, a privately held health/fitness club company that was at the time the largest in Russia. He spent 20 years
with ClubCorp, a billion-dollar private club company based in Dallas, Texas where he was a vice president of
operations. Stephen is also the owner and president of U.S.-based Club Industry Consulting, a global consulting
practice serving the club Industry since 2006, and is a former president of the International Health, Racquet
and Sportsclub Association, having served as president of the international association from 1996-1997 and
presently serves on the advisory board for the Association of Fitness Studios, Club Industry Magazine and
Southern Methodist University’s Digital Accelerator Program.
Mark Williamson, Co-founder and Principal
Mark has more than 20 years’ experience in market research, and consumer insights, including 17 years within
the club and hospitality industry at ClubCorp USA, which comprises an elite collection of private golf, country,
business, sports and alumni clubs. He also led Consumer Insights teams for industry-leading restaurant brands
such as Applebee’s, Chili’s, Maggiano’s, On The Border, Romano’s Macaroni Grill, and Corner Bakery. Outside
of the hospitality industry, Mark led the consumer insight team at match.com. He is a guest lecturer at national
conferences and frequent panelist on a series of webinars.
89 Fitness exercise
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AppendixD-AdoptionTables

Appendix D - Trend Adoption Tables
Regions ■Equipment Adoption Table ■Facility Adoption Table ■Programming Adoption Table ■Technology Adoption Table
Business Model ■Equipment Adoption Table ■Facility Adoption Table ■Programming Adoption Table ■Technology Adoption Table
Business Size (Unit Count) ■Equipment Adoption Table ■Facility Adoption Table ■Programming Adoption Table ■Technology Adoption Table
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Regions - Equipment Adoption Table
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Regions - Facility Adoption Table
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Regions - Programming Adoption Table
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AppendixD-AdoptionTables
Regions - Technology Adoption Table
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Business Model - Equipment Adoption Table
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Business Model - Facility Adoption Table
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Business Model - Programming Adoption Table
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Business Model - Technology Adoption Table
Fitness exercise
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Business Size - Equipment Adoption Table
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Business Size - Programming Adoption Table
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Business Size - Technology Adoption Table
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Club Photos From Around the World
Image courtesy of Alta Fitness, Canterbury, Australia Image courtesy of Encore, Moscow, Russia
Europe - Lounge McFIT_© McFIT
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Image courtesy of VillaSport, United States Image courtesy of Encore, Moscow, Russia
Image courtesy of Goodlife Fitness Canada
104 2018 International Fitness Industry Trend Report - What’s All The Rage?
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Club Photos From Around the World
Image courtesy of Solinca Health and Fitness, Portugal
Images courtesy of Bodytech, Columbia www.bodytech.com.co
Image courtesy of Fiter Clubs, Argentina
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Image courtesy of Fiter Clubs, Argentina
Image courtesy of Fitness Hut, Portugal
Image courtesy of Goodlife Fitness Canada
fitness exercise

Chapter One
The Physiology of Exercise
by Roger M. Glaser, PhD; Thomas W.J. Janssen, PhD ; Agaram G. Suryaprasad, MD;
Satyendra C . Gupta, MD; and Thomas Mathews, MD
Dr. Glaser is Director of the Institute for Rehabilitation Research and Medicine, Wright State University School of Medicine in
Dayton, Ohio and Dr. Janssen is Associate Director . Drs. Suryaprasad, Gupta, and Mathews are Chiefs of Cardiology, Noninvasive
Cardiology, and Neurology, respectively at the Dayton VA Medical Center, Dayton, Ohio.
INTRODUCTION
Knowledge of exercise physiology is essential for
implementing strategies to develop optimal physical
performance among individuals with lower limb paralysis
due to spinal cord injury (SCI) . Since there can be
marked neuromuscular changes, it is necessary to take
into consideration specific deficits in neuromuscular,
cardiovascular, and respiratory function . Indeed, physiologic
responses to arm exercise performed by individuals
with SCI can be quite different from those for either
arm or leg exercise by individuals who are nondisabled,
and exercise activities need to be designed to reflect
these differences.
Individuals with lower limb paralysis due to SCI
typically use their arms for wheelchair locomotion and
other activities of daily living (ADL), as well as for
exercise training and sports activities . However, several
physiologic factors, including the relatively small
muscle mass that is under voluntary control, deficient
cardiovascular reflex responses, as well as inactivity of
the skeletal muscle pump of the legs (potentially
resulting in a slowing down of circulation), can
This material is based on work supported by the Department of
Veterans Affairs, Rehabilitation Research and Development Service,
Washington, DC .
markedly reduce the capacity for arm activity (1–3).
Muscular weakness and the early onset of fatigue can
discourage an active lifestyle, since activities of daily
living become relatively more stressful to perform and
limit the development of cardiopulmonary (aerobic)
fitness . A sedentary lifestyle aggravates this situation,
since muscle strength and cardiopulmonary fitness
progressively decrease, leading to a debilitative cycle
that can be difficult to arrest or reverse (1,2,4) . In
addition, a number of secondary medical complications
that can cause much suffering and greatly increase the
cost of medical care, tend to become more prevalent
(5,6) . However, studies on wheelchair users with SCI
indicated that those who maintain a more active lifestyle
by regularly participating in exercise and sports programs
can increase their muscle strength, cardiopulmonary
fitness, and physical performance to levels
well above those of their inactive peers (2,4,7–10) . In
addition to fitness gains, habitual physical activity may
also elicit improvements in health, psychosocial status,
rehabilitation potential, functional independence, and
quality of life (10-13). Therefore, a major focus of our
VA-supported research effort has been to apply exercise
physiology principles to develop specialized exercise
testing and training techniques for individuals with
SCI, and to gain a better understanding of how their

RRDS Physical Fitness : A Guide for Individuals with Spinal Cord Injury
muscular, metabolic, and cardiopulmonary responses to
various exercise modes differ from those elicited from
individuals who are nondisabled . This information may
help clarify how physical performance of individuals
with paraplegia and quadriplegia can be improved, and
how risks for secondary medical complications can be
reduced.
Arm exercise modes have traditionally been used
for the testing and training of wheelchair users.
However, physiologic responses to arm exercise performed
by individuals with SCI can be quite different
from those for either arm or leg exercise by nondisabled
peers . Our research is related to physical capability and
physiologic responses to exercise of wheelchair users
with SCI, the use of the arm exercise techniques for
physical fitness testing and training, and the use of
recently developed training techniques that incorporate
functional electrical stimulation (FES)-induced exercise
of paralyzed leg muscles . Although most of the subjects
who participated in the described research had SCI,
many of the techniques and data presented may also be
applicable to wheelchair users with other neuromuscular
disorders (e.g ., head trauma, stroke, multiple sclerosis).

Causes of SCI
SCI is a disorder that can cause paraplegia or
quadriplegia (tetraplegia) due to lesions that interrupt
the transmission of nerve signals (i .e ., action potentials)
between the brain and periphery . Major causes are
motor vehicle accidents (over 38 percent), accidents that
occur during sports or physical activities, falls, and
trauma during violent crimes (14) . It has been estimated
that there are more than 200,000 individuals with SCI
(48 percent paraplegia, 52 percent quadriplegia) in the
United States, and there are approximately 8,000 new
cases of SCI each year that survive to join this
population (14,15) . Prior to World War II, 80 percent of
victims with SCI died within 3 years of the injury (16),
primarily due to kidney and pulmonary infections (17).
However, with the advent of antibiotic drugs and
advances in surgical techniques, individuals with
paraplegia can have a near normal life expectancy,
whereas those with quadriplegia tend to have a life
expectancy that is about 10 percent lower than
nondisabled individuals (17) . Generally, the higher the
age at the time of SCI, the higher the lesion level, and
the greater the extent of the lesion, the lower will be the
life expectancy (18,19) . Currently, the prevalent causes
of death with long-term SCI appear to be related to a
variety of cardiovascular and respiratory disorders
(14,20–22).

Pathophysiology of SCI and Exercise Limitations
This section provides a brief overview of how
skeletal muscles are controlled by the central nervous
system (CNS ; brain and spinal cord) and how SCI
impairs this control and limits exercise capability.
Figure 1 is a diagram illustrating efferent (i .e ., motor)
and afferent (i .e., sensory) pathways which normally
permit precise control of skeletal muscle contractions
(1). To initiate skeletal muscle contractions voluntarily,
action potentials arise in the motor cortex of the brain
and are propagated down the spinal cord along upper
motoneurons that eventually synapse onto the lower
motoneurons (a motoneurons) . Axons of the lower
motoneurons leave the CNS and provide motor signals
to particular groups of skeletal muscle fibers via
neuromuscular junctions . Lower motoneurons and the
particular muscle fibers they innervate are called motor
units, of which there are about one-half million in the
body. Of course, an interruption of the efferent motor
pathway would lead to paralysis of the particular
skeletal muscle fibers involved . In addition to inducing
contractions, the CNS normally monitors performance
of the muscles. For this, sensory receptors located in
muscles, tendons, and joints (in conjunction with
afferent neurons), send feedback information, such as
action potentials, to the CNS concerning muscle length,
limb position, rate of movement, and contraction
tension.

This permits stimulation to the muscles to be
continuously and appropriately modified so that the
actual performance closely matches the intended performance,
and motor learning can take place . Of course, an
interruption of this afferent sensory pathway can result
in a loss of kinesthetic sense, as well as skin sensations
below the lesion level.
Figure 2 diagrammatically illustrates the CNS with
outflow levels of the somatic nervous system, which
innervates skeletal muscles, and the autonomic nervous
system, which innervates internal organs (1) . The higher
the level and more extensive the spinal cord lesion, the
more widespread will be the loss of somatic and
autonomic nervous system function.

Somatic Nervous System Dysfunction
With respect to somatic function, lesions in the
thoracic and lumbar regions typically result in paraplegia
with lower limb and partial trunk muscle involve5
Chapter One: The Physiology of Exercise
Upper Motoneurons
Interneurons
Efferent Motor
Signals
Lower Motoneurons
(cc- motoneuron)
Afferent Sensory
Information
(from receptors)
Figure 2.
Diagram of the central nervous system, and the neural outflows from
the somatic nervous system (innervating skeletal muscles) and
autonomic nervous system (innervating internal organs) . General
innervations from each spinal cord level are indicated.
Autonomic
Nervous System
Parasympathetic
(Cranial)
Heart
Gastrointestinal
Sympathetic
(1 horaco-lumbar)
Cardiovascular
Lungs
Gastrointestinal
Kidney
Sweat glands
Upper Extremity
Upper Arm (C5-C8)
Forearm (C6-C8)
Hand (C7-T1)
Lower Extremity
Thigh (L2-S2)
Lower Leg (L4-S2)
Foot (L4-S2)
Figure 1.
Diagram of the central nervous system with efferent (motor) and
afferent (sensory) pathways for controlling skeletal muscle contractions
(l).

ment. Lesions in the cervical region typically result in
quadriplegia with lower limb, trunk, and upper limb
muscle involvement. Usually, the greater the skeletal
muscle mass that is paralyzed, the lower will be the
voluntary exercise capability and functional independence,
and the lower will be the absolute
cardiopulmonary (aerobic) fitness level that may be
achieved through exercise training . The extent of the
paralysis can also be directly related to the incidence of
secondary medical complications . Paralysis commonly
results in marked disuse, atrophy (weakening or wasting
away) of the muscles involved, and osteoporosis
(brittleness) of the bones . Inactivity of the skeletal
muscle pump of the lower limbs can precipitate venous
stasis, blood pooling and edema (swelling), and reduce
venous return. This may increase the risk for deep
venous thrombosis and subsequent pulmonary embolism
(blood clot in the lung) . Decubitus ulcers (pressure sores
on the skin) frequently occur due to prolonged pressure
on supporting tissues and inadequate local circulation.
In individuals with higher level SCI, paralysis of
intercostal (chest) and abdominal muscles can severely
limit pulmonary ventilation, which can further reduce
aerobic exercise capability and lead to pulmonary (lung)
complications due to diminished ability to cough.
Sympathetic Nervous System Dysfunction
In addition to skeletal muscle paralysis, aerobic
exercise capability of individuals with SCI can be
limited by diminished sympathetic outflow (Figure 2),
since sympathetic stimulation is required for normal
cardiovascular reflex responses to exercise . These reflexes
normally augment blood flow to metabolically
active skeletal muscles to provide more oxygen and fuel
substrates, while increasing the rate of metabolic
end-product removal . Such responses include: vaso
constriction in relatively inactive tissues (e .g., gut,
kidneys, skin) ; vasodilation of skeletal muscle
arterioles ; venoconstriction (which facilitates venous
return) ; and increases in heart rate, myocardial contrac6
RRDS Physical Fitness : A Guide for Individuals with Spinal Cord Injury
tility, stroke volume, and cardiac output (1,2,23–25).
Although these reflexes are absent to varying degrees in
most individuals with SCI, those with lesions above Ti
would have interruption of all sympathetic nerves that
innervate the heart (from T1 to T4), which would
markedly limit cardioacceleration, myocardial contractility,
stroke volume, and cardiac output (26) . With this
condition, any cardioacceleration that occurs with exercise
may be primarily due to withdrawal of vagal
parasympathetic tone to the S-A node . As a result,
persons with complete quadriplegia usually have a peak
exercise heart rate (e .g., 100–125 beats/min) that is well
below the age-predicted maximal . In addition, the
combination of reduced venous return and deficient
myocardial contractility decreases the stroke work (i .e .,
stroke volume x mean arterial blood pressure) of the
heart, which can ultimately lead to loss of left
ventricular muscle mass. This is especially prevalent in
quadriplegia (27) . It is also likely that reduced sympathetic
outflow with SCI will impair thermoregulatory
capacity due to inappropriate blood flow distribution
and insufficient sweating response below the lesion
level (28).

Exercise Consequences
The loss of functional skeletal muscle mass with
SCI and inactivity of the skeletal muscle pump in the
lower limbs are compounded with diminished or
nonexistent cardiovascular reflexes during exercise.
This can cause high fatigability of active arm muscles
due to their relatively small mass, inadequate blood
flow due to hypokinetic circulation, and limited aerobic
energy supply, as well as a greater component of
anaerobiosis (living in an oxygen-free atmosphere) and
the accumulation of metabolites in the muscles
(1–3,29). High fatigability of arm muscles during
wheelchair locomotion and exercise training can discourage
many wheelchair users from leading active
lives . Unfortunately, a sedentary lifestyle can lead to a
further decrement of physical fitness and an even
greater reduction of physical capability . Aging further
decreases cardiovascular, pulmonary, and muscular
function, which can eventually lead to a loss of
independence and an increase in medical complications
(19) . An active lifestyle, which incorporates specific
exercise training and/or sports programs, is needed to
break this debilitating cycle of sedentary lifestyle/loss of
fitness and to enhance one's functional independence
and quality of life (1,2,4) .

Exercise Precautions and Considerations for
Persons with SCI
Individuals with SCI who perform strenuous exercise
are exposed to the usual risks known for
nondisabled individuals, as well as additional risks due
to their CNS damage and the resulting motor, sensory,
and autonomic dysfunction. Generally, exercise guidelines
recommended by the American College of Sports
Medicine should be followed (30) . In addition, since
there can be numerous health risks, it is prudent for
wheelchair users to have a thorough medical examination
(including an EKG) prior to beginning a strenuous
exercise program . This is especially true for older
individuals who have been sedentary for many years.
Unique risks that should be anticipated for individuals
with SCI during exercise include trunk instability,
exercise hypotension, orthostatic hypotension, autonomic
dysreflexia, pressure sores, muscle spasms, and
thermoregulatory problems (31-36) .

Therefore, it is
recommended that individuals with SCI, health care
professionals, and athletic trainers, be aware of known
exercise risks and take appropriate precautions to derive
optimal benefits in a safe manner such as:
Appropriate Body Support. Where necessary, a
security belt should be placed around the individual's
upper trunk during arm exercise to prevent malalignment
and falls due to trunk instability and poor sitting
balance . In addition, it is absolutely essential that
measures be taken to minimize pressure on weightbearing
tissues to prevent decubitus ulcers . Therefore, it
is important to place effective cushions under the ischial
tuberosities and other weight-bearing areas, as well as to
perform periodic pressure relief (i .e., raising the body
off the cushion every 20–30 minutes for 30–60 sec
pushups).

Blood Pressure Responses . Exercise may elicit
blood pressure (BP) responses from individuals with
SCI that can be quite different and inconsistent in
comparison to those from nondisabled individuals . This
is particularly true for persons with high-level SCI who
can exhibit a paradoxical drop in blood pressure as
exercise progresses (29,34,35,37) . This so-called exercise
hypotension is apparently due to a lowering of total
peripheral resistance, as blood vessels in active muscles
dilate in response to hypoxia and increased concentrations
of local metabolites (e.g., CO2 , lactic acid, heat),
without a corresponding increase in cardiac output . As
indicated above, cardiac output can be limited by
inadequate venous return due to inactivity of the
skeletal muscle pump and deficient sympathetically

Chapter One: The Physiology of Exercise
mediated redistribution of blood . Exercise in the upright
posture can exacerbate this situation, since it can result
in blood pooling in the lower body and orthostatic
hypotension due to gravitational effects . The combined
effects of exercise hypotension and orthostatic hypotension
concurrent with reductions in cardiac output and
cerebral blood flow can cause nausea/vomiting, dizziness,
or possible loss of consciousness . If symptoms
occur either during or following exercise, the individual
should be immediately placed in a reclining position to
facilitate venous return to elevate cardiac output and
blood pressure . Hypotension risk may be reduced by
elevating the legs during exercise, regular orthostatic
training (e.g., head-up tilt, standing via tilt table,
orthotic ambulation), proper hydration, compression
stockings, abdominal binder, and physical conditioning.
Occasionally, some individuals with high-level SCI
may exhibit a sudden and inappropriate episode of
extremely high blood pressure (hypertension) due to
autonomic dysreflexia (hyperreflexia) . This is caused by
loss of central control (i .e ., inhibition) of spinal reflexes
causing exaggeration of some sympathetic responses
(increase in noradrenaline) to noxious afferent stimuli
such as skin tissue trauma, bladder overdistension, and
bowel impaction (31,38). Autonomic dysreflexia can be
quite hazardous and possibly lead to fatality if it is not
corrected immediately (39–41) . To help avoid this
condition, it is important that the individual follow
proper health practices to eliminate noxious stimuli, and
seek medical treatment where appropriate . It is, therefore,
recommended that the bladder be emptied just
prior to exercise and during prolonged exercise bouts,
and that blood pressure be monitored at regular
intervals—at least during initial exercise sessions (32).
Of course, if extreme hypertension occurs, exercise
should be immediately discontinued, and an upright
posture should be maintained until the blood pressure
returns to normal.

Muscle Spasms. Many individuals with SCI experience
occasional spasms in the paralyzed lower limb
muscles, ranging from mild to severe in intensity . This
is due to a loss of inhibitory drive to motor neurons
which makes them hyperexcitable to sensory input. Care
must be taken to avoid damage to the lower limbs in the
event of strong spasms and rapid limb movements.
Pharmacotherapy is often employed to help control for
muscle spasms . This treatment may involve the use of
oral antispasmodic and muscle relaxant drugs . However,
these drugs may further limit exercise capability by not
only reducing excitability of the paralyzed muscles, but
also of the non-paralyzed muscles. In addition, there can
be detrimental side effects including dizziness, ataxia
(irregularity of muscular action), and depression (17).
Thermal Stress. Careful consideration should also
be given to ambient temperature, relative humidity, type
of clothing worn, exercise intensity, and duration in order
to prevent hyperthermia or hypothermia .

Since
many individuals with SCI have limited thermoregulatory
capacity due to inadequate secretion by sweat
glands and inappropriate distribution of blood due to
impaired cardiovascular system control, it is possible
that overheating can occur more easily in this population
than for nondisabled individuals (28,42–44) . This is
especially true in a hot, humid environment where prolonged
strenuous exercise can cause severe dehydration,
dangerously elevated body temperature, and possibly
heat stroke and circulatory collapse. Under these conditions,
frequent and adequate fluid replacement is essential.
Exercise in cold environments may result in excessive
heat loss from the body, also exacerbated by impaired
cardiovascular system control . Therefore, if there
are symptoms of hyperthermia or hypothermia, exercise
should be discontinued, and clothing and environmental
conditions should be appropriately adjusted.
Role of Exercise and Wheelchair Sports in

SCI Rehabilitation
Trauma-induced SCI usually results in sudden and
drastic changes in lifestyle where there is a marked
decrease in physical activity . It has been found that
physical activity in individuals with SCI tended to be
lower with higher chronological age and shorter time
since injury (45) . These variables were also related to a
less rewarding life and a decline in psychological
adjustments . Sedentary lifestyle can be a major factor
leading to consequential degenerative changes in the
cardiovascular system (2,46,47) . This may help explain
the 228 percent higher death rate reported for an
experimental group with SCI compared to the age- and
gender-matched nondisabled control group in the same
study (21). Higher coronary heart disease risk for
sedentary individuals with SCI had been indicated by
findings of significantly lower blood high-density
lipoprotein-cholesterol (HDL-C) concentrations in comparison
to athletes with SCI, as well as sedentary and
active nondisabled individuals (46-48) . Furthermore,
reduced basal metabolic rate due to skeletal muscle
wasting and lower daily energy expenditure (49) due to
physical inactivity may lead to weight gain . Excessive
body weight, which can also contribute to cardiovascu8
RRDS Physical Fitness : A Guide for Individuals with Spinal Cord Injury
lar risks, as well as making activities of daily living
more stressful (50), may be counteracted by increased
physical activity . Thus, there is evidence to support that
habitual arm exercise training by individuals with SCI
may improve their health status and reduce cardiovascular
risks in a similar manner as leg exercise training
benefits nondisabled individuals (23,48).

Participation in exercise and wheelchair sports
programs can have a profound impact on rehabilitation
outcome. Such practices can challenge individuals with
SCI to overcome physical obstacles and expand functional
independence . Indeed, sports competition provides
many opportunities for the pursuit of excellence
from the novice to the Olympic levels depending upon
the particular needs and abilities of the person . Figures Figure 3.
3 and 4 illustrate well-trained wheelchair athletes wheelchair road racers in action.
participating in road racing and basketball, respectively.
Regardless of one's motivation to begin exercise
training and participation in wheelchair sports, clinicians
should consider prescribing such programs early
in the post-traumatic rehabilitation process to optimize
outcome.

Regardless of age, gender, and medical history,
most wheelchair users can derive benefits from appropriately
designed exercise programs. Well-established
principles of "specificity" and "overload" should be
followed to obtain the desired results in an efficient
manner (1,2) . Thus, specific exercise regimens (i .e .,
modes and protocols) are used for muscle strength
versus endurance training, as well as for cardiopulmonary
(i.e., aerobic) training . It has been clearly
documented that exercise training has resulted in
significant improvements in fitness, which can lead to
greater physical capability and functional independence,
and reduced relative stresses for perfointing given
activities of daily living (1,2,4,50–54) . There is also
evidence that appropriate exercise training can potentially
lower the risk for occurrence of secondary
medical complications associated with wheelchair confinement
and sedentary lifestyles . These include muscle
atrophy, osteoporosis, decubitus ulcers, and a host of
cardiopulmonary disorders.

If exercise and sports participation can enhance
health and fitness, as well as societal interactions for
wheelchair users, it seems reasonable to assume that
there would be psychological benefits in terms of
self-esteem and body image . Indeed, several studies
have indicated that wheelchair users who engaged in
sports and recreation programs experienced significant
increases in skill performance, self-concept and self- Wheelchair basketball players.
Figure 4 .
9
Chapter One: The Physiology of Exercise
acceptance. However, these results are most likely
influenced by inherent differences of exercise habits,
attitudes, beliefs, and personality prior to SCI . It is also
apparent that psychosocial outcome of individuals with
disabilities is highly influenced by societal attitudes . In
this regard, wheelchair sports can have a positive effect
upon reducing stigmatization, stereotyping and discrimination,
and acceptance of those with disabilities as fully
functioning members of society.
PHYSIOLOGIC RESPONSES TO ARM VERSUS
LEG EXERCISE

Wheelchairs users are required to employ their
relatively small and weak upper body musculature for
locomotion and most other activities of daily living.
This places them at a marked disadvantage due to the
limited maximal power output (PO) capability and peak
oxygen uptake for arm exercise, which has been
reported to be approximately two-thirds of leg exercise
values for nondisabled individuals who are not arm
exercise trained (55-58) . Arm exercise capability may
be further reduced due to factors related to the SCI (as
indicated above), as well as diminished muscular and
cardiopulmonary fitness resulting from sedentary
lifestyle and aging . Furthermore, studies have shown
that arm exercise is rather inefficient (energy wasteful),
and stressful to the muscles involved, as well as to the
cardiovascular and pulmonary systems in comparison to
the same intensities of leg exercise (56,59,60) . Indeed,
compared to walking at the same velocities and le g
cycling at the same POs, handrim wheelchair propulsion
generally elicited greater magnitudes of physiologic
responses (61-63) . These differences tended to be more
pronounced at the greater exercise intensities that
occurred at higher locomotive velocities and when
negotiating architectural barriers, such as carpeting and
upward grades.

When comparing arm crank and wheelchair
ergometry to leg cycle ergometry at matched
submaximal PO levels in nondisabled subjects, the arm
exercise modes elicited greater metabolic stress, as
indicated by the higher oxygen uptake and blood lactate
(LA) values; heavier cardiac load, as indicated by
higher heart rate (HR), peripheral vascular resistance,
intra-arterial blood pressure, and stroke work; and
greater demand on the pulmonary system, as indicated
by higher pulmonary ventilation . Arm exercise also
tends to elicit lower cardiac output (Q) and ventricular
stroke volume (SV) (56,59,64 67) . Lower cardiac
output and stroke volume may be due to a greater
afterload on the heart because of the higher peripheral
vascular resistance, and a lower end diastolic volume
due to attenuated venous return of blood to the heart.
During arm exercise by individuals with SCI, it is
feasible that venous return is restricted by inactivity of
the skeletal muscle pump in the paralyzed legs (1,2,23).
Furthermore, elevated intrathoracic pressure during
handrim stroking might decrease thoracic pump effectiveness.
These combined factors may reduce the
effective blood volume during wheelchair activity and
limit maximal PO and peak oxygen uptake . Therefore,
wheelchair locomotion, even at low PO levels, can
represent relatively high exercise loads that can lead to
the rapid onset of fatigue. Excessive cardiovascular and
pulmonary stresses that may be elicited can hinder
rehabilitative efforts and impose risks upon certain
patients, such as those with cardiovascular or pulmonary
impairments and the elderly (1,2) . As indicated above,
individuals with higher level and more extensive spinal
cord lesions will be placed at greater disadvantage when
performing given activities . This can be especially
obvious during sporting events where competitors have
a wide range of physical capabilities . Therefore, classification
systems based upon anatomical, physiological,
and functional considerations have been devised for
wheelchair sports competitors in an attempt to better
group them according to physical capability, and to
improve the fairness of competition.
ASSESSMENT OF PHYSIOLOGIC RESPONSES

TO ARM EXERCISE STRESS
Limiting Factors for Leg Versus Arm Exercise
Exercise stress testing is important since it enables
exercise capacity and metabolic and cardiopulmonary
responses to be ascertained . By repeating this testing
periodically, fitness changes over a period of time can
be objectively tracked . To assess physiologic responses
to exercise in nondisabled individuals, leg exercise
modes such as treadmill walking/running, bench stepping,
and leg cycle ergometry are typically used . Here, a
large muscle mass is rhythmically contracted, which can
stimulate maximal metabolic, cardiovascular, and pulmonary
responses for valid functional evaluation of
these systems. Many exercise physiologists suggest that
the primary factor limiting maximal PO and oxygen
uptake during these tests is central circulatory in nature,
ess : A Guide for Individuals with Spinal Cord Injury
Figure 3.

Figure 4.
11 as making activities of daily living
50), may be counteracted by increased
Thus, there is evidence to support that
ercise training by individuals with SCI
sir health status and reduce cardiovascumanner
as leg exercise training
bled individuals (23,48).

In in exercise and wheelchair sports
ave a profound impact on rehabilitation
practices can challenge individuals with
le physical obstacles and expand func-
Lence . Indeed, sports competition pro-
)ortunities for the pursuit of excellence
to the Olympic levels depending upon
zeds and abilities of the person . Figures
,trate well-trained wheelchair athletes Wheelchair road racers in action.
road racing and basketball, respectively.
one's motivation to begin exercise
rrticipation in wheelchair sports, clini-
)nsider prescribing such programs early
matic rehabilitation process to optimize
of age, gender, and medical history,
it users can derive benefits from approed
exercise programs . Well-established
'specificity" and "overload" should be
)tain the desired results in an efficient
Thus, specific exercise regimens (i .e.,
otocols) are used for muscle strength
nce training, as well as for cardio-
., aerobic) training . It has been clearly
lat exercise training has resulted in
1rovements in fitness, which can lead to
1 capability and functional independence,
relative stresses for performing given
ally living (1,2,4,50—54). There is also
appropriate exercise training can poten-
;he risk for occurrence of secondary
ications associated with wheelchair conedentary
lifestyles. These include muscle
porosis, decubitus ulcers, and a host of
ry disorders.

e and sports participation can enhance
less, as well as societal interactions for
°rs, it seems reasonable to assume that
be psychological benefits in terms of
id body image . Indeed, several studies
l that wheelchair users who engaged in
reation programs experienced significant
kill performance, self-concept and self- Wheelchair basketball players .
ng of exercise
it would be
tat provides a
ocity.
- ation WERGnaximal
effort
similar peak
as arm crank
ower maximal
concentration.
bolic rates, it
and arm crank
Its for exercise
However, the
:hat wheelchair
1riate than arm
is who propel
since it more
motion (77). It
bolic rate (i .e .,
ary responses
try exercise, as
d, suggest that
m stroking for
lith, et al . (78)
(—32 percent),
md heart rate
in arm-crankoperating
a
lair under the
een confirmed
eelchair mounted
being collected .
11

Chapter One: The Physiology of Exercise
Figure 6.
Wheelchair aerobic fitness trainer (WAFT).
Wheelchair Aerobic Fitness Trainer (WAFT)
A new wheelchair ergometer called the Wheelchair
Aerobic Fitness Trainer (WAFT) is another wheelchair
exercise mode that can be used for rehabilitation and
stress training (Figure 6) . The device was developed
under the sponsorship of the Department of Veterans
Affairs, Rehabilitation Research and Development Service,
Baltimore, Maryland, John W . Goldschmidt, M .D.,
Director. It was clinically tested at the Rehabilitation
Research and Development Center, Edward Hines, Jr.
VA Hospital, Hines, Illinois, and is currently being
tested in six VA Medical Center cardiopulmonary
exercise testing and rehabilitation programs . Mandates
for its design include evaluation, rehabilitation, and
development of cardiorespiratory fitness in persons
whose primary mode of mobility is the manually
operated wheelchair . For this particular mode, the
WAFT is a wheelchair exercise device designed to
accommodate the user's own wheelchair, provide a
form of exercise that requires the use of motor patterns
specific to wheelchair propulsion, and provide a valid
and reliable device for medically supervised graded
exercise testing and medically prescribed rehabilitation
and/or aerobic exercise.
A variety of equipment is available for the
assessment and improvement of aerobic capacity and
cardiovascular health of the nondisabled . However,
there is a shortage of appropriate equipment for
promoting the cardiorespiratory fitness of persons limited
to upper body exercise because of disabilities
resulting from lower limb amputation and
musculoskeletal and neurological impairments . Moreover,
lower limb disabled individuals are frequently
sedentary ; this lack of physical activity often leads to
significant decrements in physical fitness and further
increases the risk of cardiovascular disease.
The WAFT is a stationary device . Its design uses
electronic particle braking incorporated in the ergometer
to provide a reliable method of creating variable power
output for graded exercise testing and aerobic conditioning.
The wheelchair sits on two independently
computer-controlled rollers (Figure 7) . Changes in
12

RRDS Physical Fitness : A Guide for Individuals with Spinal Cord Injury
work load are accomplished by increasing the roller
resistance created by the ergometer's electronic brake
and/or by increasing the speed at which the individual
pushes the wheelchair wheel (Figure 8) ; thus simulating
the physical stress normally experienced during daily
wheelchair propulsion . Moreover, this unique design
makes the WAFT appropriate for graded exercise
testing and conditioning of persons with widely varying
levels of cardiorespiratory fitness.

The WAI=T is interfaced to an IBM-compatible
computer, which controls the ergometer's roller resistance.
A computer monitor displays graphical feedback
to the user, indicating right and left wheel speeds, target
wheel speed, resistance setting, accumulated distance,
exercise time, and expended kilocalories (Figure 9).
Information provided by the WAFT from graded
wheelchair exercise tests is useful for developing
exercise prescriptions, evaluating the effectiveness of
conditioning or rehabilitation programs, charting the
effects of disability on functional capacity, formulating
procedures for predicting peak exercise capacity from
submaximal graded wheelchair exercise testing, and
conducting exercise physiology research.
Exercise stress testing is a well-established technique
for the detection of ischemic heart disease . When
exercise electrocardiography (ECG) testing is combined
with echocardiographic analysis of myocardial contractility,
the accuracy of the stress test is improved (81,82).
Clinicians and researchers often address treadmill or
bicycle ergometry for exercise testing as those suitable
for individuals who are not lower limb disabled (i .e .,
spinal cord injury or amputation) . The detection and
assessment of coronary artery disease in individuals
with lower limb disability is a commonly encountered
Figure 7.
WAFT with wheelchair alone .
13

Chapter One: The Physiology of Exercise
problem . These individuals are unable to satisfactorily
complete traditional forms of exercise testing . Many
people in this population depend daily on the manual
wheelchair for mobility . Therefore, the concept of
specificity of exercise suggests that wheelchair exercise
would be the desired mode of testing for individuals
with lower limb disabilities'.
Another wheelchair exercise mode that can be
useful for stress testing and training is operating a
wheelchair on a motor-driven treadmill (83-86). Figure
10 illustrates a subject with paraplegia performing an
exercise stress test with his own wheelchair on a
specially designed and constructed motor-driven treadmill
. Exercise intensity can be regulated by adjustment
of velocity, grade (i.e., elevation angle), or by applying
additional resistive force via a cable-pulley system (86).
Using this exercise mode, Janssen, et al . (52) had
groups of individuals with lesions between C4-C8,
T1-T5, T6-T10, and T1l-L5 perform a maximal effort
Figure 8.
WAFT in use.

For further information on the WAFT, contact W . Edwin Langbein, PhD,
Research Physiologist, at Edward Hines Jr., VA Hospital, Hines . IL 60141 .
stress test . Generally, the higher the lesion level, the
lower were the values for these variables, as indicated
previously . This type of exercise system enables better
simulation of actual wheelchair locomotion than wheelchair
ergometers, but is not practical for most wheelchair
sports participants. For testing outside the laboratory
environment, a rather simple and inexpensive
technique that can be used by most wheelchair users is
to propel their own wheelchair at paced or self-selected
velocities over an established test course in a standardized,
repeatable manner (62,63,87). Knowing the length
of the course and the time to complete the given task
can provide information concerning locomotive performance
capability. Heart rate monitoring may be used to
give an indication of relative stress for the exercise bout
if cardiovascular reflexes are sufficiently intact.

Stress Testing Protocols
The fundamental principles followed for lower
body stress testing of nondisabled individuals may be
employed for upper body stress testing of wheelchair
users . These tests are usually progressive with respect to
exercise intensity, and have well-defined submaximal or
maximal effort end-point criteria . Protocol design may
utilize either continuous (nonstop exercise) or discontinuous
(alternating exercise and recovery periods)
exercise. Discontinuous, submaximal protocols may be
preferable for stress testing of wheelchair users, since
they are relatively safe and comfortable, and easy to
administer. A suitable protocol would be to have
exercise bouts that are d 6 minutes in duration,
separated by 5—10 minutes of rest.

For wheelchair
ergometer and arm crank ergometry exercise, the
propulsion velocity is typically held constant (e .g.,
wheel velocity of 3 km•h-' and crank rate of 50
revolutions per minute, respectively) while the braking
force (resistance) is incrementally increased to elevate
PO level. With wheelchair ergometry, 5 W appears to
be an appropriate initial PO, as this level is frequently
encountered during daily wheelchair locomotion (89).
PO progression increments of 5—10 W may be usable
for many individuals, and PO can be limited to 25—35
W for submaximal tests (73,89,90) . For more fit
individuals, the PO increment and maximal PO permitted
can be greater. With arm crank ergometry, the
protocol can be the same, but the PO levels used could
be up to two times that for wheelchair ergometry.
Steady rate physiologic responses can be determined
during the last minute of each exercise bout . Criteria for
exercise stress test termination include : 1) voluntary
14

RRDS Physical Fitness : A Guide for Individuals with Spinal Cord Injury
cessation, 2) symptoms of cardiovascular or pulmonary
abnormalities (e.g ., chest discomfort, inappropriate EKG
changes, marked hypertension, dyspnea), 3) achievement
of the maximal PO level required for the test, and
4) attainment of a predetermined heart rate for example,
75 percent of age-adjusted heart rate reserve
(1,75). However, for individuals with high-level SCI,
the heart rate criterion may be less useful due to the
interruption of sympathetic pathways to the heart and
limited ability for cardioacceleration.

To actually determine maximal PO and peak
oxygen uptake, the discontinuous, submaximal test can
be extended to a maximal effort test by increasing the
rate.number of exercise bouts . But drawbacks to this
protocol are: 1) much time would be required to
STAGE BRAKE Name
WHEEl ING, T.J.
® LEFT I RIGHT ~
2 :00 Min . LOW ] LOW Number
123 - 12 - 1234
MPH
Department of
Veterans Affairs CALORIES
10
=
5 PUSH
RIGHT?
_50 .0
-
-
_
25 .11
3 .0 3 .5 20 .4
LEFT RIGHT
DISTANCE ELAPSED TIME WORK
Stage I 0 .05 Miles 1 :00 Min . 4 .92 Cal.
Total 0 .13 Miles 5 :00 Min . 20 .37 Cal .
Figure 9.
View of monitor reflecting activity of subject in wheelchair while
using WAFT.
Figure 10.
Maximal effort wheelchair stress test being performed by an
individual with paraplegia on a motor-driven treadmill . A cablepulley
system with load weights is used to establish the work rate .
complete the test, and 2) the multiple bouts of exercise
could have fatiguing effects, which may result in
reduced maximal PO and peak oxygen uptake values
being obtained. Therefore, if maximal effort physiologic
responses are desired, and data at several submaximal
PO levels are not needed, a continuous, maximal
exercise protocol can be utilized . This shorter protocol
would usually begin at a low-to-moderate PO to serve
as a warm-up . PO is then increased by a certain
increment every 1—2 minutes until maximal effort is
reached. By estimating fitness with previous
submaximal stress testing, the initial PO level (e .g ., 50
percent max PO) and the magnitude of the PO
increments can be set so that the individual will
complete the test in several minutes (71,91–94).
Stress testing fitness criteria are usually based upon
the magnitudes of metabolic and cardiopulmonary
responses obtained at given PO levels, as well as the
maximal PO level achieved (73) . At given submaximal
PO levels, well-trained individuals typically exhibit
lower heart rate and pulmonary ventilation responses
indicating higher cardiopulmonary fitness, lower relative
stress, and more functional reserve . In individuals
with high-level SCI, however, care must be taken not to
interpret low exercise heart rate responses as superior
cardiovascular fitness. As previously indicated,
cardioacceleration in these individuals is limited by
insufficient sympathetic stimulation, and most observed
increases in heart rate are probably due to vagal
withdrawal . Nevertheless, heart rate can still be used as
an indicator of fitness in this population when expressed
as a percentage of heart rate reserve, such as the
functional range between resting and maximal heart rate
(52) .

For activities that do not require much skill (e .g .,
arm crank ergometry), the submaximal oxygen uptake
would be similar for both trained and untrained
individuals . However, for activities requiring a greater
degree of skill, a lower submaximal oxygen uptake
response may be obtained from the trained individual
indicating lower aerobic energy expenditure and higher
mechanical efficiency . At maximal effort exercise, PO,
as well as peak values for oxygen uptake, pulmonary
ventilation, cardiac output, and stroke volume would be
expected to be higher for fit individuals . But, maximal
heart rate may not be markedly different between more
and less fit individuals, whereas it is reduced with age.
Therefore, more fit individuals would possess greater
metabolic and cardiopulmonary reserve, and given
submaximal tasks would be less stressful, since they are
15

Chapter One : The Physiology of Exercise
performed at a lower percentage of maximal PO, peak
oxygen uptake and pulmonary ventilation, and heart rate
reserve.

EXERCISE TRAINING TECHNIQUES FOR
IMPROVING PHYSICAL FITNESS
It had been stated that normal daily wheelchair
activity may not provide sufficient exercise to train the
muscular and cardiopulmonary systems, and it was
indicated that supplemental exercise training is necessary
to stimulate fitness improvement (32,85,95,96).
Enhancing exercise capability and cardiopulmonary
fitness with specific exercise training programs could
increase organ system reserve and make activities of
daily living less stressful since they would be performed
at lower percentages of maximal PO, as well as of peak
oxygen uptake, pulmonary ventilation and heart rate
reserve (4,50,52) . This could possibly contribute to
improved functional independence and rehabilitation
outcome. Indeed, with wheelchair locomotion at 7 watts
(W), well-trained wheelchair athletes (mean age=25 yr)
are estimated to utilize less than 7 percent of their
maximal PO and 18 percent of peak oxygen uptake.
This is in contrast to 9 percent of maximal PO and 29
percent of peak oxygen uptake for their sedentary
colleagues . Older, sedentary wheelchair users have a
more difficult plight in that 50—60-yr olds may utilize
44 percent of maximal PO and 51 percent of peak
oxygen uptake, whereas 80–90-yr olds may be required
to use 100 percent of their maximal PO and peak
oxygen uptake for this routine locomotive task (63,90).
In a 3-year study, Janssen, et al . (50) demonstrated that
a decline of only 5—10 W in PO capability of sedentary
wheelchair users with quadriplegia could result in a loss
of independence . In contrast, however, their peers who
regularly participated in sports activities and increased
physical fitness generally maintained their independence
and performed activities of daily living with less stress.
Thus, it is feasible that regular exercise may reduce the
stresses of wheelchair locomotion and other activities of
daily living, retard the decline in physical capability that
typically accompanies aging, and lower some of the
risks associated with secondary cardiovascular disabilities.

Arm Exercise Training Protocols
To enhance muscular and cardiopulmonary fitness,
as well as performance, arm exercise training for
wheelchair users should, like leg exercise training,
incorporate the fundamental principle of overload
(1,2,97). Thus, exercise should be performed at intensities
and/or durations that are beyond those normally
encountered during daily activities . Furthermore, exercise
intensity and/or duration should be progressively
increased as performance improves until fitness goals
are reached . Regular exercise at the final intensity/
duration levels is required to maintain the achieved
fitness status. If exercise is discontinued, detraining will
occur and fitness level will diminish in a matter of
several weeks (98) . For optimal outcome, exercise
should also follow the principle of exercise specificity
where the mode used should be closely matched to the
activity in which performance improvement is desired.
Thus, the biomechanics involved and the physiologic
responses elicited would be more representative to
produce the desired gains in performance.
Arm exercise protocols may be either continuous
or discontinuous (intermittent) in design. If enhancing
cardiopulmonary fitness is the primary goal, PO should
be adjusted to moderate levels that enable exercise
bouts of relatively long durations (e .g., 15–60 minutes
for continuous bouts, and 3–5 minutes for each of the
several discontinuous bouts) without eliciting excessive
fatigue or respiratory distress (i .e., marked accumulation
of lactate in the blood) . Exercise sessions should occur
2–5 times per week (97) . Traditionally, arm crank
ergometry exercise has been used for endurance training
of wheelchair users . This exercise mode is readily
available and it has been shown to improve
cardiopulmonary fitness (53,54) . Although wheelchair
ergometer exercise elicits similar peak metabolic and
cardiopulmonary responses (77,79,92), it has the advantage
of more closely resembling actual wheelchair
activity so it may better enhance locomotive performance.
In contrast to aerobic training, if enhancing
muscular power is the primary goal, higher levels of PO
would be used and exercise bouts would be of relatively
short duration (e .g ., from a few seconds to a few
minutes) . The large anaerobic energy component would
result in a marked accumulation of lactate in the blood.
This form of exercise would be useful for wheelchair
athletes who want to improve sprinting performance, as
well as for most other wheelchair users, since many
activities of daily living (e .g., transfers, overcoming
architectural barriers) require intense, short duration
efforts.
When developing an aerobic training program for
leg exercise by nondisabled individuals, a suitable
16

RRDS Physical Fitness: A Guide for Individuals with Spinal Cord Injury
intensity can be established by maintaining heart rate
between 60–90 percent of their heart rate reserve, which
usually corresponds to 50–85 percent of peak oxygen
uptake . The objective is to exercise at high enough
intensity for a sufficient duration to permit cardiopulmonary
adaptations to occur. But, exercise intensity
should be kept below the point where marked
anaerobiosis occurs and a high concentration of lactate
accumulates in the blood, which can severely shorten
endurance and create discomfort . Actual measurement
of heart rate during maximal effort exercise for each
individual would be preferred over prediction techniques
to facilitate appropriate setting of training
intensity. But for arm exercise by individuals with
SCI, an effective training intensity may be more
difficult to set, since heart rate response can be quite
diverse. Thus, actual measurement of maximal heart
rate can be important . Janssen, et al . (52) showed
that percentage of peak oxygen uptake and heart rate
reserve were highly correlated during wheelchair exercise
on a treadmill by individuals with paraplegia and
quadriplegia . However, the absolute values for heart
rate were lower in the individuals with the higher level
lesions . Their regression equations predicted that exercise
at 50–85 percent of peak oxygen uptake corresponded
to heart rate reserve values of 40–85 percent
for individuals with low-level paraplegia and
30–80 percent for those with high-level paraplegia
and quadriplegia . Thus, heart rate response expressed
either as a percentage of heart rate reserve or maximal
heart rate can be a usable indicator of exercise
stress in these populations, but the actual value used
would be dependent upon the exercise response characteristics
of the individual (52,99) . Therefore, to set
arm exercise intensity for various individuals with
SCI, direct determination of peak values for PO, oxygen
uptake, pulmonary ventilation, heart rate, and
blood lactate concentration (during stress testing) would
be desirable if the instrumentation is available . In
individuals who do not exhibit a clear relationship
among these variables (which is more common in
those with quadriplegia), training at a percentage of
maximal PO may be preferable (100) . Where laboratory
testing is not available, intensity criteria may be
established according to the subjective feeling of
stress and the actual exercise endurance capability.
In most cases, it is likely that several trials will be
needed for each individual to effectively set exercise
intensity .

Physiologic Adaptations to Arm Exercise Training
Studies on individuals with lower limb disabilities
indicated that several weeks of endurance-type arm
exercise training can significantly increase PO capability,
peak oxygen uptake, and cardiopulmonary performance
(32,91,101) . Arm crank ergometry training of
active wheelchair users increased their peak oxygen
uptake by 12–19 percent in 7–20 weeks (91) . Even
greater gains in cardiopulmonary fitness were obtained
in only 5 weeks of training for individuals with
quadriplegia who had relatively low initial fitness levels
(101) . Using wheelchair ergometer exercise, Miles, et
al . (102) reported that 6 weeks (3 times per week) of
interval training by 8 wheelchair athletes resulted in
increases of 31 percent for maximal PO capability, 26
percent for peak oxygen uptake, and a 32 percent for
peak pulmonary ventilation . These gains were even
more remarkable considering that the athletic subjects
used had relatively high levels of fitness prior to
participating in the program.

Although arm exercise limits the absolute level of
aerobic fitness that can be achieved with training some
cardiopulmonary benefits can be expected for most
participants . However, the magnitudes by which aerobic
fitness and exercise performance can be increased with
training appear to depend on the initial fitness level and
the size of the muscle mass available for exercise . For
instance, several studies on wheelchair athletes perfonniing
maximal effort arm crank ergometry and wheelchair
ergometer exercise indicated that their peak oxygen
uptake is in the 2–3 L/minute range (1,102–105) . This is
approximately one-half of the maximal oxygen uptake
that would be expected for healthy nondisabled athletes
performing maximal effort leg exercise (e .g ., cycling,
running) . Greater gains in fitness may be expected from
individuals with SCI who initiate training programs at
relatively low fitness levels depending upon pathological
limitations (1,2) . It is plausible that many of the
observed gains in arm exercise performance are due to
peripheral adaptations such as hypertrophy, enhanced
arterial vasodilation, and improved capillary density
and/or metabolic capability within muscles (which
would increase arteriovenous 02 difference), rather than
central circulatory adaptations (106) . Yet habitual arm
exercise training appears to increase maximal PO
capability and peak oxygen uptake, and may also
decrease levels of physiologic responses for given
submaximal exercise tasks and ADLs, including wheelchair
locomotion (107,108) .
17

Chapter One : The Physiology of Exercise
Exercise Training and Coronary Heart Disease
Studies suggest that habitual arm exercise training
and sports participation can also reduce the risk for
acquiring coronary heart disease (CHD) . Cross-sectional
studies on sedentary wheelchair users and those who are
physically active showed that the more active individuals
had a superior blood lipid profile as indicated by a
lower total cholesterol (TC), lower low-density
lipoprotein-cholesterol (LDL-C) level, and greater highdensity
lipoprotein-cholesterol level (6,47,109) . In a
longitudinal study, Hooker and Wells (110) reported a
decrease in total cholesterol (—8 percent), a significant
increase in high-density lipoprotein-cholesterol level
(+20 percent), and a decrease in low-density lipoprotein-
cholesterol level (—15 percent) in men with SCI
following 8 weeks of moderate intensity wheelchair
ergometry training (60—70 percent peak oxygen uptake;
20 minutes per day, 3 times per week) . These apparently
beneficial alterations in the blood lipid profile
extrapolated to a mean decrease of 20 percent in the
group ' s future risk for coronary heart disease . Thus, if
high-density lipoprotein-cholesterol does have a protective
effect against coronary heart disease, and total
cholesterol and low-density lipoprotein-cholesterol increase
its risk, these high-density lipoprotein-cholesterol,
total cholesterol and low-density lipoproteincholesterol
changes that appear to occur with increased
physical activity suggest that the risk of coronary heart
disease in individuals with SCI may be decreased with
arm exercise intervention in a similar fashion as leg
exercise training benefits nondisabled individuals . More
research is necessary to develop appropriate exercise
modes to document their efficacy for reducing the risk
of cardiovascular disease in this population.
Enhancing Arm Exercise Performance by Increasing

Venous Return
In some individuals with lower limb paralysis, the
etiology of upper body muscle fatigue may be due to a
central factor that is secondary to a peripheral factor . It
is conceivable that inactivity of the skeletal muscle
pump combined with impaired vasoregulation in the
paralyzed lower limbs and abdominal region can limit
venous return of blood from the legs to the heart
(peripheral factor), and thereby restrict cardiac output
capability during arm exercise (central factor) .

Thus,
pooling of blood in the legs and abdominal veins can
potentially lead to a hypokinetic circulation that can
reduce the availability of blood to the active upper body
musculature and consequently decrease its exercise
capability (1,2). Since individuals with SCI typically
perform arm exercise in an upright, sitting position, this
can elevate hydrostatic pressure and blood pooling in
leg veins . It is plausible that arm exercise performance
may be enhanced by placing the individual in a supine
(lying face up) position . This can minimize the gravitational
effects on blood, facilitate venous return, elevate
cardiac output, and increase arm muscle blood flow to
boost resistance to fatigue.

In a preliminary study2 , subjects with quadriplegia
performed maximal effort arm chair ergometry in a
sitting and in a supine position on separate occasions . It
was found that this exercise in the supine position
elicited significantly higher maximal power output, as
well as peak oxygen uptake, pulmonary ventilation,
heart rate, stroke volume, and cardiac output . Similar
results have been found in subjects with high-level
paraplegia, but not to the same degree. The greater
magnitudes of these responses suggest that cardiopulmonary
training capability in individuals with SCI
may be enhanced by using the supine position . Indeed,
McLean and Skinner (111), who used arm crank
ergometry exercise to train subjects with quadriplegia in
the sitting and supine positions, showed greater improvement
in peak oxygen uptake (during testing in
both the sitting and supine positions) when trained in
the supine position. Although these studies suggest that
the supine position can improve exercise outcome, more
research is needed to determine advantageous protocols
and long-term training effects.

Other techniques have been studied in an attempt
to reduce the effects of gravity on venous return during
arm exercise . Kerk, et al. (112) used an abdominal
binder with wheelchair athletes with high-level paraplegia
during submaximal and maximal effort wheelchair
ergometry exercise, but found no differences in metabolic
and cardiopulmonary responses, as well as
biomechanical characteristics compared to not using the
abdominal binder. Hopman, et al . (113), showed that
use of a fighter pilot anti-G suit, which applied constant
external pressure (52 mmHg) to the calves, thighs, and
abdomen of men with paraplegia (below T5), during
submaximal arm crank exercise can facilitate venous
return and increase stroke volume . However, they did
not show any improvement in maximal exercise capacity
(114). Pitetti, et al . (115) also used a fighter pilot
'A report on the preliminary results of this pilot study entitled "Exercise
Hemodynamics of Quadriplegics," by S .F. Figoni . Gupta S .C ., Glaser R .M..
et al ., can be found on page 108 of the 1988 Rehabilitation R&D Progress
Reports .
18

RRDS Physical Fitness: A Guide for Individuals with Spinal Cord Injury
anti-G suit, but fluctuated pressure every 2 minutes to
simulate skeletal muscle pump activity, and found a
significant increase in peak oxygen uptake during arm
crank ergometry and wheelchair ergometry exercise by
individuals with predominantly high-level SCI . Although
use of external compression to the lower limbs
and abdomen may have some effect on facilitating
venous return during arm exercise, use of rhythmic
contractions of lower limb muscles that are induced by
a multichannel electrical stimulator may better activate
the skeletal muscle pump for more effective results.

FES-INDUCED EXERCISE OF THE
PARALYZED LOWER LIMB MUSCLES
Functional electrical stimulation (FES) research has
been conducted for almost 20 years with the goal of
inducing exercise in paralyzed lower limb muscles
(116) . Several devices are now commercially available,
so FES-induced exercise can be used by those who are
interested in expanding their training capability . This
technique typically uses electrical impulses (from a
stimulator), which are applied to muscle motor points
via skin surface electrodes, to directly induce tetanic
contractions of controlled intensity . Therefore, FESinduced
exercise of the paralyzed legs has the potential
of utilizing a large muscle mass that otherwise would be
dormant. Furthermore, this exercise can augment the
circulation of blood by activation of the skeletal muscle
pump. It is thus apparent that FES exercise modes can
improve the health, cardiopulmonary fitness, and rehabilitation
potential of individuals with SCI to levels
higher than can be attained with only arm exercise.
Individuals with quadriplegia would most likely find
this induced exercise mode to be particularly advantageous
due to the small muscle mass that is under their
voluntary control.

Considerations and Precautions for FES Exercise
The primary requirement for FES use is that the
muscles to be exercised are paralyzed due to upper
motor neuron damage, and that the motor units (lower
motor neurons and the skeletal muscle fibers they
innervate) are intact and functional . The presence of
stretch reflex activity and spasticity may indicate that
the individual can perform FES exercise . But, if the
individual retains some degree of feeling in the skin,
FES may cause discomfort or pain at the high
stimulation current levels required to induce forceful
contractions.

Before participating in an FES exercise program,
the individual should undergo a medical examination,
which includes radiographs of the paralyzed limbs,
range of motion testing, neurological examination, and
an EKG. He/she should be informed of the potential
benefits and risks of FES exercise, and clearly understand
that FES will not regenerate damaged neurons and
cure paralysis . It should also be understood that, similar
to voluntary exercise training, any health and fitness
benefits derived from FES exercise training will be lost
several weeks after this activity is discontinued.
FES-induced contractions should be kept as
smooth as possible and the contraction force generated
should be limited to a safe level to prevent injury, since
the muscles, bones, and joints of paralyzed lower limbs
tend to be deteriorated . Although FES exercise training
can improve the strength and endurance of the paralyzed
muscles, there is currently no evidence that this
activity can reverse osteoporosis . Therefore, with continued
training, the muscles could ultimately produce
more force than the bones can endure . Furthermore,
FES may trigger severe muscle spasms, so it is
important that the quality of the contractions be
observed by a physician to insure that they are not
hazardous (117) . In individuals with high-level SCI,
FES exercise may provoke autonomic dysreflexia
(36,116) . Blood pressure should, therefore, be monitored
periodically, especially during initial FES use . Of
course, exercise should be discontinued immediately, as
indicated above, if any response is observed that places
the individual at risk.
FES-Induced Leg Muscle Contractions to Promote

Venous Return
As indicated above, arm exercise performance, and
the ability to develop high levels of cardiopulmonary
fitness, may be restricted by hypokinetic circulation due
to impaired skeletal muscle pump activity . Although
techniques to promote venous return, such as exercising
in a supine position and use of external compression
devices, may help alleviate this problem, another viable
approach to promote venous return and enhance cardiac
output and blood flow to the exercising upper body
muscles is FES-induced rhythmic contractions of the
paralyzed leg muscles . It is feasible that FES may have
several clinical applications including deep venous
thrombus prophylaxis, reducing excessive edema, and
alleviating orthostatic hypotension .
19

Chapter One: The Physiology of Exercise
FES-Induced Resistance Exercise
It has been shown that the same resistance training
principles known to be effective for muscle strengthening
by nondisabled individuals can be adapted for
FES-induced training of paralyzed muscles . These
include dynamic contractions through a specific range
of motion, progressive overload, and multiple sets of
exercise consisting of a relatively low number of
repetitions at relatively high load resistance (117,1 18).
Research studies clearly indicate that several weeks of
FES-induced weight training exercise of the quadriceps
muscles can markedly increase their strength and
endurance for this induced activity (117-119).
FES-Induced Leg Cycle Ergometer Exercise
A leg cycle ergometer (LCE) is propelled by
FES-induced contractions of the paralyzed lower limb
muscle groups . Computer-controlled FES is used to
induce contractions of the quadriceps, hamstring, and
gluteal muscle groups during particular angle ranges of
the pedals . Thus, pedaling at the 50 revolutions per
minute target rate induces a total of 300 muscle
contractions per minute. A microprocessor, which
receives pedal position and velocity feedback information
from sensors, controls the cyclic stimulation pattern
and cun-ent intensity . As muscle fatigue progresses
during exercise, FES current increases automatically to
a maximum of about 140 mA to recruit additional
muscle fibers in an attempt to maintain revolutions per
minute . When the pedal rate falls below 35 revolutions
per minute, exercise is automatically terminated.

CONCLUSION
This chapter presents an overview of what is
known about exercise physiology as applied to those
with SCI . Research has clearly shown that there can be
marked differences in physiologic response patterns
between individuals with SCI performing arm exercise
and nondisabled individuals performing either arm or
leg exercise . There can also be marked differences in
physiologic response patterns among individuals with
SCI as influenced by the level and extent of the lesion.
Thus, when establishing guidelines for exercise testing
and training techniques, programs would have to be
adapted with respect to the performance characteristics
of particular individuals to provide optimal efficacy and
to minimize risk . Furthermore, FES-induced exercise of
the paralyzed lower limb muscles can possibly elicit
superior physiologic responses than for use in only arm
exercise, especially for those with quadriplegia . Clearly,
individuals with SCI can derive health and fitness
benefits, and reduce the relative stresses for performing
activities of daily living when habitually participating in
appropriately designed exercise programs and sports
activities . Conversely, it is also clear that maintaining a
sedentary lifestyle can cause losses in health, fitness,
and rehabilitation potential . Therefore, knowledge of
exercise physiology is important to provide motivation
for those with SCI and to help insure successful
outcome for participation in exercise and sports programs,
which may have a positive impact on the quality
of life.

ABBREVIATIONS
ADL=activities of daily living
CNS=central nervous system
EKG=electrocardiogram
FES=functional electrical stimulation
L=lumbar
L/min=liters per minute
mA=milliamperes
SCI=spinal cord injury
WAFT=wheelchair aerobic fitness trainer
ACKNOWLEDGMENTS
The authors wish to thank the Dayton Veterans
Affairs Medical Center and the Rehabilitation Institute
of Ohio at Miami Valley Hospital for allowing the
authors to conduct their exercise research projects on
wheelchair users. We would also like to thank all
participants in this study.

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ROGER M. GLASER, PhD, in addition to being Director of
the Institute for Rehabilitation Research and Medicine,
Wright State University School of Medicine, is also Professor
of Physiology and Biophysics at WSU School of Medicine.
AGARAM G. SURYAPRASAD, MD, in addition to being
Chief of Cardiology at the Dayton VA Medical Center, is also
Professor of Medicine at WSU School of Medicine.
THOMAS MATHEWS, MD, in addition to being Chief of
Neurology at the Dayton VA Medical Center, is Professor and
Chair of Neurology at WSU School of Medicine .

Healthy Mind,
Healthy Body:
Benefits of Exercise
Thursday, March 13, 2014 6:00 – 7:30 p.m.
The Joseph B. Martin Conference Center
Harvard Medical School
77 Avenue Louis Pasteur
Boston, MA 02115
Healthy Mind, Healthy Body: Benefits of Exercise
Moderator
Myechia Minter-Jordan, MD, MBA
President and CEO of The Dimock Center
Clinical Instructor in Medicine, Harvard Medical School Faculty Director for the Abundance Agents of Change Program, Center for Primary Care, Harvard Medical School
Speakers

Irene S. Davis, PhD, PT, FAPTA, FACSM, FASB
Director, Spaulding National Running Center
Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School
Zolt Arany MD, PhD
Associate Professor Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center Harvard Medical School
About the Speakers
Myechia Minter-Jordan, MD, MBA
Myechia Minter-Jordan is president & CEO of The Dimock Center, a community institution serving Boston's Roxbury, Dorchester and Jamaica Plain neighborhoods. As the second largest health center in Boston, Dimock is considered a national model of comprehensive health and human services with an emphasis on the integration of clinical and behavioral health practices.
Dr. Jordan earned both her undergraduate and medical degrees from Brown University. After graduation, she joined Johns Hopkins first as an attending physician and instructor of medicine at Johns Hopkins Medical Center and subsequently as director of medical consultation services at Johns Hopkins Bayview Medical Center.

Coming from a family that stressed the value of giving back, in 2007 Dr. Jordan was inspired to leave a successful career in academic medicine to lead the Dimock Community Health Center. As chief medical officer, Dr. Jordan was a fierce advocate for increasing access to care for some of the city’s most vulnerable residents. Her collaborative approach led to significant partnerships linking Dimock to world-class institutions such as Harvard Medical School, Beth Israel Deaconess Medical Center and Partners HealthCare. An innovative physician administrator, Dr. Jordan was responsible for the successful transition to the Electronic Medical Record, established Dimock’s first Institutional Review Board to pave the way for research using human subjects and in 2012 led the effort to secure a $4.9 million federal grant to expand the capacity of Dimock’s health center facility.

Widely respected for her expertise and insight, Dr. Jordan has published articles in medical publications including The New England Journal of Medicine, was recently appointed to the Commonwealth of Massachusetts Health Planning Council Advisory Committee and served as one of seven governor-appointed physician members of the Commonwealth of Massachusetts Board of Registration. Dr. Jordan serves on the Advisory Board for the Kraft Center for Community Health at Partners HealthCare and in 2013 was named to the board of directors of The Boston Foundation.
An avid runner and biking enthusiast, Dr. Jordan is also engaged in community programs and active in the PTO. She and her husband Larry, an educator, live in West Roxbury with their two young daughters.
Irene S. Davis, PhD, PhD, PT, FAPTA, FACSM, FASB
Dr. Davis is a professor in the Department of Physical Medicine and Rehabilitation, Harvard Medical School and founding director of the Spaulding National Running Center. Dr. Davis received her bachelor’s degree in Exercise Science from the University of Massachusetts, and in Physical Therapy from the University of Florida. She earned her master’s degree in Biomechanics from the University of Virginia, and her PhD in Biomechanics from Pennsylvania State University. She is a Professor Emeritus in Physical Therapy at the University of Delaware where she served on the faculty for over 20 years.
Her research has focused on the relationship between lower extremity structure, mechanics and injury. Her interest in injury mechanics extends to the development of interventions to alter these mechanics through gait retraining. She is interested in the mechanics of barefoot running and its effect on injury rates, and is a barefoot runner herself. Along with gait analysis, her research encompasses dynamic imaging and modeling.

She has received funding from the Department of Defense, Army Research Office and National Institutes of Health to support her research related to stress fractures.
Dr. Davis has given nearly 300 lectures both nationally and internationally and authored over 100 publications on the topic of lower extremity mechanics during running.
She has been active professionally in the American Physical Therapy Association, the American Society of Biomechanics, and International Society of Biomechanics.
She is a Fellow of the American College of Sports Medicine, the American Society of Biomechanics, and a Catherine Worthingham Fellow of the American Physical Therapy Association. She is a past President of the American Society of Biomechanics. She has organized and coordinated international research retreats on topics of the foot and ankle, anterior cruciate ligament injuries and patellofemoral pain syndrome. She has been featured on ABC World News Tonight, Good Morning America, Discovery, The New York Times, The Wall Street Journal, Parade and Time Magazine.

Zolt Arany, MD, PhD
Dr. Zolt Arany is an associate professor of medicine in the Cardiovascular Institute at the Beth Israel Deaconess Medical Center and Harvard Medical School. He graduated from Harvard College, and received his MD-PhD from Harvard Medical School, during which time he worked with Dr. David Livington on novel molecular mechanisms driving the response of cancers to low oxygen.
After completion of Internal Medicine residency at Massachusetts General Hospital and Cardiology Fellowship at Brigham and Women’s Hospital, Dr. Arany trained as post-doctoral fellow with Dr. Bruce Spiegelman at the Dana Farber Cancer Institute, investigating novel regulatory mechanisms of metabolism in heart and skeletal muscle. Dr. Arany’s active laboratory currently focuses on how metabolism is regulated in heart and
muscle, with a focus on blood vessels. His lab has a particularly strong interest in how the heart and muscle respond to normal challenges of life, like exercise and pregnancy.
Dr. Arany has received a number of awards, including the American Heart Association Established Investigator Award, and he was recently elected to the American Society of Clinical Investigators. Dr. Arany also actively teaches courses to Harvard medical and graduate students.

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Benefits of exercise
Longwood Seminars, March 13, 2014
The inside scoop: Exercise and your body
What goes on inside your body when you pedal a bike or take a stroll? These activities set off complicated physical processes that affect nearly every organ system. When you exercise several times a week or more, your body adapts so you’re able to do so more efficiently. Knowing about this process will help you understand why physical activity has so many benefits.

Energy to burn
Like all machinery, your muscles must have fuel. This fuel comes from the food you eat and your body’s reserves of fat and glucose. The catch is that nutrients from food cannot be turned directly into usable energy for the trillions of cells in your body. Each cell has one primary source of energy: a molecule called adenosine triphosphate (ATP).

Your body’s ability to create ATP is critical because it determines your capacity for physical exertion. And the reverse is also true: your physical conditioning influences how well you can generate ATP.
The food you eat contains energy stored in a variety of forms — proteins, fats, and carbohydrates. Your body needs to extract that energy and capture it in the form of ATP. To do this, your stomach and small intestine break the food into millions of tiny molecules, which enter the bloodstream and find their way to every cell in the body (see the figure). There, in small cell structures called mitochondria, the food molecules undergo a series of chemical reactions that ultimately lead to the creation of ATP.
Your body stores only a small amount of ATP, but makes it as quickly as it’s needed. When demand increases — such as when you are exercising — your body must churn out more. To do this, it taps into glucose stored in the muscle and liver and fats from various places in the body. These substances make their way through the bloodstream to the muscles.

Stored glucose (also known as glycogen) and fat can be broken down for ATP production in two ways: aerobic (requiring oxygen) and anaerobic (requiring no oxygen). Aerobic processes produce more ATP, but grind to a halt without oxygen. When your body is working so hard that it is unable to deliver enough oxygen to support aerobic metabolism of food for fuel, it switches to anaerobic production of ATP, which creates a byproduct known as lactic acid. The lactic acid enters the bloodstream, creating an acid imbalance. To compensate, your breathing speeds up to take in more oxygen and your heart beats faster to move that oxygen to your muscles.
But you can’t sustain anaerobic activity. Your lungs and heart reach their maximum work efforts, and your body can only neutralize the resulting acid imbalance for a short time. The lactic acid generated from the anaerobic process also leaves muscles feeling fatigued. Eventually, you need to slow down. By doing so, you are able to take in enough oxygen that once again you can rely primarily on aerobic
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production of ATP. Lactic acid production stops, the muscles start to recover, and your body restores normal acid balance.

Your level of fitness determines how swiftly this happens. Regular exercise conditions the lungs, heart, and blood vessels, enabling them to deliver oxygen to muscle cells more quickly and efficiently. Walking up a hill with a fitter friend illustrates this nicely. While you’re still huffing and puffing, your friend isn’t struggling to catch her breath.

 

When you engage in physical activity, your body doesn’t rely solely on one process or the other; both are used to generate ATP, but one more so than the other. Because of this distinction, exercise is classified into two broad categories — aerobic and anaerobic — depending on which process is predominantly used for ATP production. If the intensity of exercise is such that your lungs and heart are able to supply oxygen for energy production, then the activity is almost exclusively aerobic. But if intensity rises so that demand for oxygen outstrips supply, then the activity becomes anaerobic. Walking, jogging, cycling, or swimming at an even pace are aerobic activities. Activities in which your body tends to go anaerobic more quickly include wind sprints and weight lifting.
Food, oxygen, and energy
Once the food you eat is digested in your stomach, its components are absorbed into your bloodstream and delivered to cells throughout the body. Oxygen from your lungs also travels to your cells, where tiny structures called mitochondria use it to convert the food nutrients into a chemical called adenosine triphosphate (ATP), which provides energy for everything from walking to thinking.
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Heart and blood vessels
Your cardiovascular system transports oxygen to cells and removes carbon dioxide, carries away metabolic waste products, and shuttles hormones to the intended organs. In addition, it helps maintain body temperature and preserve your body’s acid balance. Most people can engage in light activity, about the equivalent of walking 2 mph, without placing excess demand on their circulatory and respiratory systems. When you exercise more intensely, however, your muscles’ need for oxygen increases. Your heart must pump harder and faster. The amount of blood your heart pumps and the oxygen your body consumes rise in direct proportion to the amount of work your muscles are performing. And once again, your level of physical conditioning dictates how well this system works.
Arteries in your working muscles dilate to accommodate their increased need for blood. At the same time, the heart’s increased output causes your blood pressure to rise. Arterioles (tiny arteries) in your skin expand, allowing for more blood flow there. As you continue to exercise, especially in hot, humid weather, more blood is diverted to your skin to maintain a safe body temperature.
While your arteries dilate, veins serving distant parts of your body contract. When you are resting, the venous system stores roughly 65% of the body’s blood supply. But when veins contract, they make more blood available to your heart and exercising muscles. Your body further optimizes the distribution of blood by limiting the amount sent to the kidneys, liver, digestive system, and other organs not immediately involved in the exercise process.

When you exercise regularly, your circulatory system adapts by boosting your cardiorespiratory endurance. Your body creates more plasma, the saltwater fluid that carries glucose and other nutrients to cells and ferries away waste. Because plasma is a component of blood (along with blood cells), a greater volume of blood is available to pump. That blood is slightly thinner than usual, which lowers the resistance it encounters while circulating. The main pumping chambers of your heart, called the ventricles, stretch to hold more blood and contract with greater force. Over the long term, the heart muscle increases in size, which strengthens the heart.

Likewise, the capillaries that serve the working muscles — including the heart — increase in number. These additional blood vessels serve two valuable functions. First, they feed the muscles more oxygen-rich blood. Second, the presence of more vessels means that the heart’s powerful pumping chamber, the left ventricle, has a more plentiful energy supply and is able to pump the blood with greater ease. The more efficient pumping action allows you to do more work with less effort.
The greater need for oxygen-rich blood that occurs during aerobic exercise can also lead to an increase in the size and number of branches of the coronary arteries feeding the heart. This provides other channels for oxygenated blood to reach heart muscle. So if an artery serving the heart becomes blocked, heart muscle damage is less likely because alternative channels keep the blood supply flowing. The boost in oxygen and other benefits of exercise offer some protection against dangerous heart rhythm disturbances as well.
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Benefits of exercise
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Muscles
When you decide to move a part of your body, your brain transmits the message to your muscle fibers via your nerves. The fibers respond by contracting, which creates motion. To reverse the movement, your brain signals fibers in the opposing muscle group to tighten. For example, when you contract your biceps, the triceps on the back of your arm relaxes.
Exercises that involve continuous motion, such as rowing, walking, or swimming, result in the rhythmic tightening and releasing of muscle fibers. In addition to moving your body, this process produces a “milking” action that helps move blood through your veins and back to your heart. With aerobic exercise, an increase in fibers containing iron-rich myoglobin also occurs, permitting more oxygen to enter and be stored in the muscle.
Combined with the greater number of capillaries and increased blood flow to the muscles, these changes improve muscular endurance. Fit muscles adapt in other ways, too. Well-trained muscles not only are able to stockpile more glycogen, but they also can burn fat for energy more directly, which preserves glycogen stores.

Exercise by the numbers
While you exercise:
• Unless you are taking medications, your heart rate can reach 130 to 150 beats per minute (sometimes higher, particularly in young, fit individuals). That nearly doubles the resting norm of 70 to 80 beats per minute for most people.
• Your heart may pump up to 20 liters of blood per minute (40 liters for well-trained endurance athletes), which is quadruple the 5 liters per minute that’s typical while resting.
• Your skin and muscles receive 80% of your total blood flow. This quadruples the usual 20% of blood flow these areas get during rest.
• Systolic blood pressure (the top number) increases by 20 millimeters of mercury (mm Hg) or more during the first few minutes of exercise before leveling off. The diastolic reading (bottom number) remains largely unchanged. After you cease strenuous activity, however, blood pressure drops to lower than pre-exercise levels for two to three hours. Over time, regular exercise can help you maintain lower blood pressure.

• Millions of capillaries open up to feed muscle fibers.
• Your lungs pass up to 200 pints of air in and out each minute. When not exercising, the average for most people is 12 pints a minute.

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Benefits of exercise
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Bones
Throughout your life, your body is constantly building and dismantling bone tissue. This maintains your skeleton by replacing old bone with new bone and frees calcium, the main building block of bone, for other tasks. Calcium is vital to many physical processes, including maintaining heart rate and blood pressure, and a small amount of it circulates in your blood. When the amount of calcium in your blood gets low, your body draws on the reservoir of calcium stored in the bones.
Early in your life, your body builds bone faster than it loses it. But with age, bone is lost more rapidly than it’s formed. Eventually, this leaves bones more fragile and susceptible to breaks. Exercise plays a key role in slowing bone loss. Muscle is tethered to bone by cords of tissue called tendons. Tendons tug on bones during physical activity. This stress increases bone strength and density. Exercises that work against gravity (such as walking, jogging, tennis, basketball, and strength training) provide the greatest benefit.

Hormones
Exercise affects nearly all of the dozens of hormones your body produces. Two of these substances, epinephrine and norepinephrine, are key players in promoting physical changes while you are exercising. When your brain detects more muscle movement, it responds by releasing this pair of chemicals, which speed your heartbeat, contract arteries serving non-exercising parts of your body, and stimulate the release of sugars and fats from body stores for energy.
Endorphins, natural opiates that help block pain perception and may improve mood, rise after 30 minutes or more of exercise. These hormones are probably responsible for the sense of euphoria endurance athletes are said to experience, sometimes called a “runner’s high.” Norepinephrine also regulates mood.

Insulin, a hormone made in the pancreas, fluctuates in response to exercise. Insulin’s main function is to help usher glucose from the bloodstream into cells. While exercise boosts the concentrations of most hormones, levels of insulin drop during and for a short while after vigorous activity. This seems counterintuitive, because exercise accelerates the muscles’ demand for fuel in the form of glucose. However, insulin transports glucose more effectively during exercise, so less of it is needed. Also, exercise seems to enhance your body’s ability to draw energy directly from fat stores.
Research has found that exercise can also affect levels of estrogen. After menopause, when a woman’s ovaries stop producing estrogen, fat tissue becomes her body’s major source of estrogen. Some evidence suggests regular vigorous activity — and possibly moderate activity as well — may reduce circulating estrogens on an ongoing basis, partly because women who exercise tend to be leaner. This would expose breast cells to less of this hormone, which fuels many cancers.
Immune system
Experts believe that moderate exercise reduces levels of stress hormones and other chemicals that suppress immune system functioning and increase inflammatory activity. Other changes occur, too. A

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2005 study measured immune components in 15 healthy women during exercise and at rest. Researchers noted modest, short-term upswings in natural killer cells and white blood cells after 30 minutes of walking compared with sitting.
Although the immune system returns to a pre-exercise state shortly after the exercise session is done, moderate activity on a daily or almost-daily basis seems to have a cumulative benefit for your immune system, improving its ability to fight off infection.
To learn more… This information was prepared by the editors of the Harvard Health Publications division of Harvard Medical School. It was excerpted from the Special Health Report Exercise: A program you can live with. You can learn more about this publication at hvrd.me/tZRRT.

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Benefits of exercise
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What can exercise do for you?
Many people spend more than half their waking hours sitting down. And activities that don’t enhance health account for quite a lot of the remainder. This growing trend may cause more trouble than most people realize. Observational studies suggest habitual inactivity raises risks for obesity, diabetes, cardiovascular disease, deep-vein thrombosis, and metabolic syndrome.
In fact, one study that followed more than 50,000 middle-aged women for six years found that even among women who were avid exercisers, the more television they watched, the more likely they were to gain weight or develop diabetes — regardless of how much physical activity they did. For every two hours the women spent watching television each day, they had a 23% greater risk of becoming obese and a 14% greater risk of developing diabetes. Sitting at work for many hours also heightened their risks for obesity and diabetes. When planning your day, it may be beneficial not only to increase the time you spend exercising but also to try to reduce your “sitting time.”
The case for exercise is strong. Decades of solid science confirm that adding as little as half an hour of moderately intense exercise to your day improves health and extends life.
Here’s a quick snapshot of the benefits exercise provides — not just while you are engaging in the exercise, but also over the long term:

• Lessens the likelihood of getting heart disease, the No. 1 killer of both women and men in America. Exercising regularly helps prevent plaque buildup by striking a healthier balance of blood lipids (HDL, LDL, and triglycerides), helps arteries retain resilience despite the effects of aging, and bumps up the number of blood vessels feeding the heart. It also reduces inflammation and discourages the formation of blood clots that can block coronary arteries. Even if you already have heart disease, exercise lowers your chances of dying from it.
• Lowers blood pressure, a boon for many body systems. Long-term hypertension (high blood pressure) doubles or triples the odds of developing heart failure and helps pave the way to other kinds of heart disease, stroke, aortic aneurysms, and kidney disease or failure.
• Helps prevent diabetes by paring off excess weight, modestly lowering blood sugar levels, and boosting sensitivity to insulin so that less is needed to transport glucose into cells. If you have diabetes, exercise helps control blood sugar.
• Reduces risk for developing colon and breast cancers, and possibly cancers of the endometrium (uterine lining) and lung. By helping you attain a healthy weight, exercise lessens your risk for cancers in which obesity is a factor, too.
• Helps shore up bones. When combined with calcium, vitamin D, and bone-saving medications if necessary, weight-bearing exercise like walking, running, and strength training helps ward off age-related bone loss. And balance-enhancing activities, including tai chi and yoga, help prevent falls that may end in fractures.

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• Helps protect joints by easing swelling, pain, and fatigue and by keeping cartilage healthy. Strong muscles support joints and lighten the load upon them. Activities that boost flexibility, such as stretching, yoga, and tai chi, extend range of motion.
• May limit and even reverse knee problems by helping to control weight — quite a bang for the buck, since every pound of weight lost reduces the load on the knee by 4 pounds.
• Lifts spirits by releasing mood-lifting hormones and relieving stress. In some studies, exercising regularly has helped ease mild to moderate depression as effectively as medications; combining exercise with medications, therapy, and social engagement is even better.
• May boost your ability to fend off infection.
• Adds years to your life. In the long-running Framingham Heart Study, moderate activity tacked on 1.3 years of life for men and 1.5 years of life for women versus low activity. Raising the bar to high activity added 3.7 years for men and 3.5 years for women.
To learn more… This information was prepared by the editors of the Harvard Health Publications division of Harvard Medical School. It was excerpted from the Special Health Report Exercise: A program you can live with. You can learn more about this publication at hvrd.me/tZRRT.

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Benefits of exercise
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The fundamentals: What you need to know to get started
How much exercise do I need?
You can track either your time or calories, or both, to make sure you’re getting enough exercise. If you have been sedentary for a long time or have certain health problems, be sure to work up to these goals gradually.

Time. The 2008 Physical Activity Guidelines for Americans recommend at least two hours and 30 minutes (150 minutes) of moderate aerobic activity per week. If you enjoy vigorous aerobic activities, you can pare this down to at least one hour and 15 minutes (75 minutes) per week. An equivalent combination of the two also fills the bill. As a guide, one minute of vigorous-intensity activity equals about two minutes of moderate-intensity activity.

Twice a week, also set aside time to do strength exercises for all the major muscle groups (legs, hips, back, chest, abdomen, shoulders, and arms). Older adults at risk for falls benefit from including balance exercises, too. Even if you are not able to reach the minimum exercise guidelines right away, it is important to do as much exercise as you are able and try to increase it gradually.

The physical activity guidelines reflect the minimum amount of exercise recommended for adults. For even greater health benefits, adults who are able should strive for five hours per week (300 minutes) of moderate-intensity aerobic activity or two-and-a-half hours (150 minutes) of vigorous-intensity aerobic exercise. Again, you can also mix the two. Adults with health problems that limit their ability to exercise should strive to do as much as they can.

Calories. Health benefits kick in when you expend between 500 and 1,000 calories per week through physical activity, although many studies find additional and extended health benefits flow from expending closer to 2,000 calories a week. For example, one New England Journal of Medicine study analyzed research conducted on 17,000 Harvard alumni. The greatest gains in longevity and lowered risk for disease occurred among those expending approximately 2,000 calories per week through dynamic physical activity, such as walking, gardening, or sports. The most active group recorded an average two-year gain in life span.

How often should I exercise?
The 2008 Physical Activity Guidelines don’t spell out how many days a week you should exercise; instead, they focus on overall time per week. Generally, though, experts recommend spreading activity throughout the week and being active at least three days a week.
Starved for time? It’s tempting to wonder if you can compress activities into one or two days a week. While scientists haven’t delved into this extensively, some research tantalizingly suggests that “weekend warriors” who regularly burn through more than 1,000 calories in one or two sessions a week do have a

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lower risk of dying than entirely sedentary adults — that is, if they have no major risk factors. However, safety issues, common sense, and the bulk of research stressing benefits that flow from regular activity on most days of the week argue against adopting this pattern.
How long must my exercise sessions be?

Sessions as brief as 10 minutes of aerobic exercise deliver health benefits, so do what works best for you. For example, one person may prefer doing three 10-minute exercise sessions a day for five days in order to meet the guidelines, while another may prefer walking 30 minutes twice a week and cycling along a bike path for 90 minutes on a sunny weekend day.
How vigorously should I exercise?

Whether you are healthy or have medical issues, moderate activity is safe for most people and does plenty to improve your health. If you’re in good shape, adding vigorous activities to your workouts cuts time spent exercising and is a boon to health. If you’re not fit, work up to vigorous activities slowly. Higher-intensity activities raise your chances for muscle or joint injury and very slightly increase the odds of developing a serious heart problem. This applies particularly to people who are unaccustomed to physical activity, who suddenly start exercising vigorously (although the overall risk of dying from heart disease is lower than if you did no exercise).
How can you judge the pace of your workout? The easiest way to measure exertion characterizes the intensity of an activity through broad categories, such as light, moderate, or vigorous (see the table). Called perceived exertion, it’s especially helpful for staying in a safe range of activity. As you improve your fitness, you’ll find your perception of the intensity of a particular activity — walking up a nearby hill, for example — changes.

The table describes physical changes at each level of exertion. If you’re just getting started with an exercise program, aim for a moderate pace. (If health problems or disabilities make moderate activity impossible, simply do as much as you can.) As you build up, try a mix of moderate and vigorous activities to help build endurance. As you work out more often, you’ll notice gains as exercises become easier. Whenever an activity becomes easy, boost the length of your workout or your intensity again.
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How hard are you working?
Intensity
It feels
You are…
Light
Easy
• Breathing easily
• Warming up, but not yet sweating
• Able to talk — or even sing an aria, if you have the talent
Light to moderate
You’re working, but not too hard
• Breathing easily
• Sweating lightly
• Still finding it easy to talk or sing
Moderate
You’re working
• Breathing faster
• Starting to sweat more
• Able to talk, not able to sing
Moderate to vigorous
You’re really working
• Huffing and puffing
• Sweating
• Able to talk in short sentences, but concentrating more on exercise than conversation
Vigorous
You’re working very hard, almost out of gas
• Breathing hard
• Sweating
• Finding talking difficult

To learn more… This information was prepared by the editors of the Harvard Health Publications division of Harvard Medical School. It was excerpted from the Special Health Report Exercise: A program you can live with. You can learn more about this publication at hvrd.me/tZRRT.
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Be SMART
Fitting exercise into your life will pay off in everyday activities, sports successes, stronger muscles, independent living, and all-around fitness. Sounds great, right? Even so, marshaling the time and will to exercise may not be easy. Experts say you’re more likely to meet success if you set goals that are SMART—that is, specific, measurable, achievable, realistic, and time-based. So as you’re setting a goal and penciling it in on the worksheet we’ve provided, make sure it passes the SMART test, described below.

SMART: Set a very specific goal—for example, I will do strength training on Mondays and Wednesdays. Or, I will do a set of front and side planks on Tuesday, Thursday, and Sunday.
SMART: Find a way to measure progress—for instance, I will log my efforts daily on my calendar, checking off days when I met my goal.
SMART: Make sure it’s achievable. Be sure you’re physically capable of safely accomplishing your goal. If not, aim for a smaller goal initially.
SMART: Make sure it’s realistic. Choose the change you’re most confident you’ll be able to make, not the change you most need to make. Focus on sure bets: on a scale of 1 to 10, where 1 equals no confidence and 10 equals 100% certainty, your goal should land in the 7–10 zone. If it doesn’t, cut it down to a manageable size. For example, I’ll do cardio three times a week.
SMART: Set time commitments. Pick a date and time to start—for example, Starting this week, I’ll get up half an hour earlier on Wednesday and Friday to go to a yoga class. Also choose weekly check-in times to keep track of whether you’re meeting goals or hitting snags: I’ll check my calendar every Friday evening and decide if I should make any changes in my routines to succeed. Outside deadlines can be really helpful here, too: Signing up for a tennis tournament or knowing you’ll need to wiggle into beach clothes in six weeks prods you to get your exercise program under way.

 

Motivate yourself
Usually, we do our best work when motivated. That extends to exercise, too. It’s not uncommon to launch a new exercise program raring to go, only to wind up back on the couch with your feet propped up just a few weeks later. If your will wavers, the tips here may help.
Refresh your memory. Remind yourself how the exercises will help you by reading your goals again. Emphasize the positive aspects. Rather than sternly saying, “I should do my workout,” try saying aloud “My back feels better when I do my exercises,” or “My backhand and serve are much stronger when I exercise consistently.”
Find the time. Skimming time from your busy schedule is an art. Here are some ideas that can help. Over the course of a week, skip two half-hour TV shows, or exercise while you watch; you can also fit exercises into commercial breaks or downtime in your workday. Get up half an hour earlier each day to
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Longwood Seminars, March 13, 2014
finish a full workout. Throughout the day, be on the lookout for pockets of time. Be efficient: a short, challenging workout tunes up muscles just as well, if not better, than racking up set after set of easier exercises. As you advance to more challenging exercises, leave the simpler ones behind to make the best use of your time.

Slip exercises into your day. While on the phone, do 10 side leg lifts or pliés, or try a few stretches. Before shifting from calls to other projects or back again, do a few front or side planks. Spend the first five minutes of your lunch break doing reverse lunges or squats with knee lifts.
Plan simple rewards. Give yourself a pat on the back for every small or big step toward success. Blast your favorite tune at the end of a workout. Download the “Attaboy” app for your smart phone or tablet to enjoy a stream of compliments whenever you need to hear it. A bigger reward for staying on track toward your goal for two to four weeks might be new workout gear or sports equipment you’ll enjoy.
Get a workout buddy. Workouts with a friend or family member are more fun, plus you’re less likely to cancel on the spur of the moment. Or, if you belong to a gym, ask if there is a buddy program. Some gyms offer interactive workout equipment like Expresso bikes or Concept2 rowers, which let you race against a real or virtual buddy or compete in team or individual challenges.

At home, you could try using your computer and working out with a friend via Skype. If finding a real-time or virtual workout buddy isn’t possible, go low-tech: ask a friend to check in with you regularly—on workout days or maybe just once a week—to give you a pat on the back or a pep talk.
Reach for your smartphone. Or iPad, computer mouse, or game system remote. Smartphone fitness apps, health-driven websites, and a slew of fitness games on systems like Wii and Xbox make it easy to set baselines and log calories and activities. Options like these can help you learn new exercises, track progress, and get friendly nudges that encourage you to stick to your goals. Check smartphone fitness options at Apple’s App Store, Google’s Android Market, or Blackberry’s App World.
On the Web, try the American Council on Exercise fitness library (www.acefitness.org/exerciselibrary) or other virtual trainer and interactive tools. You can also find fitness games at local gaming shops, large retailers, and online stores.

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Not getting anywhere?
Brainstorming solutions for foreseeable bumps in the road can start you off on the right foot and help keep workouts on track. Once you get going, jot down any hurdles you run into and then think your way around them. Here’s some help with common hurdles.
• Need the okay to start exercising? Call your doctor today. It may help to fax or send a copy of the workouts you hope to do, then follow up with a phone call to discuss whether any modifications will be needed.
• Don’t belong to a gym (or can’t seem to get to one)? Try doing bodyweight workouts, which require no equipment. Or buy the equipment necessary for doing certain workouts at home. Start with the less expensive items, such as medicine balls or a stability ball, and work up.
• Just don’t feel motivated? Ask a friend to check up on you, or consider working out with a personal trainer.
• Not yet buff enough to make it through a workout? Try one or more of these options:
1. Focus on the easy variations of exercises you find too hard.
2. Start with fewer reps (or holding a position like a plank for fewer seconds). When that becomes easy, do additional reps or hold longer.
3. Do just half of the exercises in a workout twice a week. Each week, try to add another exercise until you’re doing the full workout.
• Bored by your routine? If you’ve mastered the basic moves, try the harder variations. Or change over to another workout entirely.
• Still stuck? Sometimes breaking a bigger goal down—I want to do work out twice a week—is the best way to succeed. For example, the options above offer a way to break down a big workout into more manageable steps.
To learn more… This information was prepared by the editors of the Harvard Health Publications division of Harvard Medical School. It was excerpted from the Special Health Report Core Exercises. You can learn more about this publication at hvrd.me/u1iOB.
Healthy Mind, Healthy Body
Benefits of exercise
Longwood Seminars, March 13, 2014
Planning worksheet
My goals are to
• enhance my health
• tone my muscles
• extend my endurance
• lose ____ pounds (a pound a week is reasonable, so break down bigger goals into smaller, manageable chunks) in the next ____ weeks
• strengthen my upper body
• strengthen my lower body
• strengthen my core and back muscles
• step up my game in a sport ________
• be able to enjoy ________
(Here, consider what tasks and fun you are missing out on. Does your back hurt? Are you finding it hard to make it up stairs, smash an overhead in tennis, or dig deep while gardening?)
Right now, I exercise
• rarely or never
• once a week for ____ minutes
• twice a week for ____ minutes
• three to five times a week for ____ minutes
I’d like to
• exercise ____ times a week for ____ minutes
• add cardio exercise to my weekly routine
• add strength training to my weekly routine
• change up my weekly routine
Healthy Mind, Healthy Body
Benefits of exercise
Longwood Seminars, March 13, 2014
My new plan:
Fill in some goals for a week, writing in cardio sessions like 30 minutes of brisk walking (remember, this can be in two or three chunks) or the workouts you plan to try. If you’re wondering what mix of exercise to choose, read “Special section: Exercise 101” and see Table 1.
I can do
• __________ on Monday at __________
• __________ on Tuesday at __________
• __________ on Wednesday at __________
• __________ on Thursday at __________
• __________ on Friday at __________
• __________ on Saturday at __________
• __________ on Sunday at __________
I will gain support for my new plan by
• hiring a personal trainer on these days (circle those that apply): Monday Tuesday Wednesday Thursday Friday Saturday Sunday
• lining up an exercise partner for walks or workouts on these days (circle those that apply): Monday Tuesday Wednesday Thursday Friday Saturday Sunday
• telling a friend about my plan and asking her to check in with me once a week on ________ to cheer me on and encourage me to stay the course
• rewarding myself by doing ________ at the end of the week
• measuring my gains on ____________________
To learn more… This information was prepared by the editors of the Harvard Health Publications division of Harvard Medical School. It was excerpted from the Special Health Report Workout Workbook. You can learn more about this publication at hvrd.me/u240f.
Exercising the Mind
Scientists identify protein produced during muscular exertion that boosts brain health
By RICHARD SALTUS
October 10, 2013

A protein increased by endurance exercise has been isolated and given to non-exercising mice, turning on genes that promote brain health and encourage the growth of new nerves involved in learning and memory, scientists from Harvard Medical School and Dana-Farber Cancer Institute have reported.
The findings, published in the journal Cell Metabolism, help explain the well-known capacity of endurance exercise to improve cognitive function, particularly in older people. If the protein can be made in a stable form and developed into a drug, it might lead to improved therapies for cognitive decline in older people and slow the toll of neurodegenerative diseases such Alzheimer’s and Parkinson’s, according to the investigators.
“What is exciting is that a natural substance can be given in the bloodstream that can mimic some of the effects of endurance exercise on the brain,” said Bruce Spiegelman, the HMS Stanley J. Korsmeyer Professor of Cell Biology and Medicine at Dana-Farber. He is co-senior author of the publication with Michael Greenberg, the Nathan Marsh Pusey Professor of Neurobiology and head of the Department of Neurobiology at HMS.

The Spiegelman group previously reported that the protein, called FNDC5, is produced by muscular exertion and is released into the bloodstream as a variant called irisin. In the new research, endurance exercise—mice voluntarily running on a wheel for 30 days—increased the activity of a metabolic regulatory molecule, PGC-1α, in muscles, which spurred a rise in FNDC5 protein. The increase of FNDC5 in turn boosted the expression of a brain-health protein, BDNF (brain-derived neurotrophic protein) in the dentate gyrus of the hippocampus, a part of the brain involved in learning and memory.
It has been found that exercise stimulates BDNF in the hippocampus, one of only two areas of the adult brain that can generate new nerve cells. BDNF promotes the development of new nerves and synapses—connections between nerves that allow learning and memory to be stored—and helps preserve existing brain cells.

How exercise raises BDNF levels in the brain wasn’t known; the new findings linking exercise, PGC-1α, FNDC5 and BDNF provide a molecular pathway for the effect, although Spiegelman
and his colleagues suggest there are probably others.
Having shown that FNDC5 is a molecular link between exercise and increased BDNF in the brain, the scientists asked whether artificially increasing FNDC5 in the absence of exercise would have the same effect. They used a harmless virus to deliver the protein to mice through the bloodstream, in hopes the FNDC5 could reach the brain and raise BDNF production. Seven days later, they examined the mouse brains and observed a significant increase in BDNF in the hippocampus.
“Perhaps the most exciting result overall is that peripheral delivery of FNDC5 with adenoviral vectors is sufficient to induce central expression of Bdnf and other genes with potential neuroprotective functions or those involved in learning and memory,” the authors said. Spiegelman cautioned that further research is needed to determine whether giving FNDC5 actually improves cognitive function in the animals. The scientists also aren’t sure whether the protein that got into the brain is FNDC5 itself, or irisin, or perhaps another variant of the protein.

Spiegelman said that development of irisin as a drug would require creating a more stable form of the protein.
The research was supported by the JPB Foundation and National Institutes of Health grants DK31405 and DK90861.
Adapted from a Dana-Farber news release.
Life-Saving Exercise
In many common diseases, physical activity is as effective as taking drugs at reducing the risk of death
By JAKE MILLER
Harvard Medical School
October 2, 2013
Physical activity is potentially as effective as many drug interventions for patients with existing cardiovascular diseases and other chronic conditions.
In the few conditions where the life-saving benefits of exercise have been studied, physical activity was often found to be as effective as drugs at reducing the risk of death, according to the first study to aggregate and assess the comparative benefits of drugs and exercise for reducing mortality in a wide range of illnesses.

The study was published online in BMJ on October 1.
“We were surprised to find that exercise seems to have such powerful life-saving effects for people with serious chronic conditions,” said Huseyin Naci, an HMS visiting fellow in population medicine at the Harvard Pilgrim Health Care Institute, and a graduate student at the London School of Economics. “It was also surprising to find that so little is known about the potential benefits of physical activity for health in so many other illnesses.”
The study, conducted in collaboration with John Ioannidis, C.F. Rehnborg Professor in Disease Prevention and Director, Stanford Prevention Research Center, Stanford School of Medicine, found only four conditions where the effects of exercise on reducing mortality had been studied: prevention of severe illness in patients with coronary heart disease, rehabilitation from stroke, treatment of heart failure and prevention of diabetes.
In addition to providing guidance for patients and clinicians about the importance of discussing the potential benefits of exercise, the researchers highlighted the importance of continuing to research the value of exercise for health.

The researchers argue that more trials comparing the effectiveness of exercise and drugs are urgently needed to help doctors and patients make the best treatment decisions. In the meantime, they say exercise “should be considered as a viable alternative to, or alongside, drug therapy.”
“We’re not saying people who have had a stroke should go off their medication and head to the gym,” Naci said, “but having a conversation with their physician about incorporating exercise into their treatment might be beneficial in many cases.”
In the United States, 80 percent of people 18 and older failed to meet the recommended levels of aerobic and muscle-strengthening physical activity in 2011, according to the CDC. What’s more, the average number of retail prescriptions per capita for calendar year 2011 was 12.1, according to the Kaiser Family Foundation.
For the current study, the researchers analyzed the results of 305 randomized controlled trials involving 339,274 individuals and found no statistically detectable differences between exercise and drug interventions for secondary prevention of heart disease and prevention of diabetes.
Among stroke patients, exercise was more effective than drug treatment, while in congestive heart failure diuretic drugs were more effective than all other types of treatment, including exercise.
The authors point out that the amount of trial evidence on the mortality benefits of exercise is considerably smaller than that on the benefits of drugs, and this may have had an impact on their results. Of the nearly 340,000 cases analyzed, only 15,000 patients had had exercise-based interventions.
The researchers argue in the paper that this “blind spot” in available scientific evidence “prevents prescribers and their patients from understanding the clinical circumstances where drugs might provide only modest improvement but exercise could yield more profound or sustainable gains in health.”
Despite this uncertainty, the authors claim that based on the available data physical activity is potentially as effective as many drug interventions and more trials to address the disparity between exercise and drug-based treatment evidence are needed.
“What we don’t know about the benefits of exercise may be hurting us,” Naci said.

For More Information
*If clicking on a link below does not take you to the website, please copy and paste the URL into your browser*
Spaulding National Running Center
http://www.runsnrc.org/RUNSNRC/Home.html
From the Heart: A Physician-Scientist Tells Us What Makes Him Tick (Q&A with Zolt Arany)
http://www.bidmc.org/Centers-and-Departments/Departments/Cardiovascular-Institute/CVI-Newsletter/Archives/Fall13/PhysicianScientist.aspx
Want Better, Cheaper, More Seamless Health Care? Ask Me How
WBUR (Guest post by Myechia Minter-Jordan)
http://commonhealth.wbur.org/2014/01/community-health-center-as-model
Aping the Early Human Workout
The Wall Street Journal (features Irene Davis)
http://online.wsj.com/news/articles/SB10001424052702303745304576357341289831146
Walking By the Numbers
Beth Israel Deaconess Medical Center
http://www.bidmc.org/Centers-and-Departments/Departments/Cardiovascular-Institute/CVI-Newsletter/WalkingSteps.aspx
The Benefits of Physical Activity
Harvard School of Public Health
http://www.hsph.harvard.edu/nutritionsource/staying-active-full-story/
Exercise as Preventive Medicine
The New York Times
http://well.blogs.nytimes.com/2013/10/09/exercise-as-preventive-medicine/?_r=1
How Exercise Could Lead to a Better Brain
The New York Times
http://www.nytimes.com/2012/04/22/magazine/how-exercise-could-lead-to-a-better-brain.html?pagewanted=all&_r=0
13 Mental Health Benefits of Exercise
The Huffington Post
http://www.huffingtonpost.com/2013/03/27/mental-health-benefits-exercise_n_2956099.html
9 Health Problems You Can Treat with Exercise
ABC News/Prevention Magazine
http://abcnews.go.com/Health/health-problems-treat-exercise/story?id=21659158
The Harvard Medical School Office of Communications and External Relations would like to thank:
Dr. Zolt Arany
Dr. Irene S. Davis
Dr. Myechia Minter-Jordan
Harvard Health Publications
Beth Israel Deaconess Medical Center
Spaulding Rehabilitation Hospital
The Dimock Center
The Center for Primary Care at HMS
&
The Joseph B. Martin Conference Center at Harvard Medical School
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