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Extreme Conditioning Programs: High-Risk or Vulnerable Risk Takers?
Justin D. Baca & Len Kravitz, Ph.D.

Article reviewed:
Bergeron, M.F., et. al. 2011. Consortium for Health and Military Performance and American College of Sports Medicine Consensus Paper on Extreme Conditioning Programs in Military Personnel. Current Sports Medicine Reports, 10(6), 383-389.

Introduction: What is Extreme Conditioning?
Extreme conditioning programs (ECPs) are well marketed exercise programs targeted to a wide audience of participants. They boast claims of vastly improved fitness in relatively short periods of time. Some of the ECPs provide the convenience of working out in settings other than a gym, an enticing attraction for individuals interested in training opportunities that do not involve joining a fitness facility. However, the extreme conditioning fitness craze is not without controversy. In 2010 a group of sports medicine professionals from the American College of Sports Medicine, the Consortium for Health and Military Performance, and the Department of Defense convened to develop a consensus platform of some evidence-based guidelines for these programs (Bergeron et al., 2011). This consortium of professionals proceeded to define extreme conditioning programs (ECPs) as “high-volume aggressive training workouts that use a variety of high-intensity exercises and often timed maximal number of repetitions with short rest periods between sets.” These programs are multi-faceted, incorporating aspects of circuit training, resistance training, high intensity interval training and various body weight exercises. Yet, many exercise professionals use these same training protocols (albeit very safely and effectively) with clients on a daily basis. The concern with the popular ECPs is the intensity and high metabolic and physical demand these programs are being taught. Bergeron and colleagues highlight that primary physicians and rehabilitation providers have identified an emerging problem of disproportionate musculoskeletal injury risk, particularly with novice participants in ECPs. The military professionals involved in this consortium are quite concerned that Warfighters (anyone serving in a military capacity under the American flag) believe these ECPs have the essential training needs to make them more effective on the battlefield. Yet for some active military, ECPs are leading to lost duty time and lowered military readiness due to musculoskeletal injury (Armed Forces Health Surveillance Center, 2013). Proper identification of the risks and benefits of such programs is of vital importance for the fitness professional to educate clients and exercise enthusiasts.

What are the Positive Characteristics of Extreme Conditioning Programs?
Many ECPs are developed from the concept of integrating high-intensity metabolic conditioning, which Bergeron et al. (2011) explain are exercises that 'impose a moderate to high demand on the cardiovascular system and energy metabolism of the active muscle fibers to meet with the muscles' repeated high-energy requirements.” Observed benefits from participation in these programs include reduced body fat, increased local muscular endurance, and increased cardiovascular capacity (Bergeron). Another focus of extreme conditioning is “functional fitness”, which in ECPs refers to the body's ability to repeatedly perform whole-body (or multi-joint) movements under highly fatiguing conditions (Bergeron). Bergeron and colleagues explain that the multifaceted nature of these programs entices participants, as they believe they are getting benefits beyond typical physical fitness programs. Many Warfighters consider these programs as training methods that enhance combat readiness, camaraderie and teamwork. Thus, in addition to the fitness gains that one seeks from an ECP, having the opportunity to complete individual workouts and/or group exercise ECP sessions is also very appealing.

What are the Risks of Extreme Conditioning?
According to Bergeron (2011) certain characteristics of extreme conditioning programs appear to disregard the current standards for developing muscular fitness. For instance, repetitive performance of maximal timed repetitions, with insufficient rests periods between sets, may readily lead to premature fatigue, elevated oxidative stress (inability of body to remove biological products that lead to cell damage), increase risk to musculoskeletal strain and injury, and impaired exercise technique (Bergeron). Bergeron and colleagues continue that this extreme challenging training regime may lead to overuse injuries, overtraining, and overreaching (going beyond normal progressive overload training parameters).

The risk for injury also increases when the exercise sessions become competitive. For example, military personnel and exercise enthusiasts in a class often seek peer approval by attempting to keep up with others who may be more fit and stronger (Bergeron). This mindset can also be seen in recreational sports conditioning, where training as a team is very important. Individuals are often encouraged to push themselves unknowingly to excess, which leads to a greater potential for injury (Bergeron). In a team setting it becomes difficult to scale back. Although individual pacing and progression are essential for proper fitness development, these aspects are often perceived as showing signs of weakness (Bergeron). This overreaching phenomenon may be more common in entry-level participants in ECPs.

Are There Other Special Concerns with Extreme Conditioning Programs?
Certain medical status and health-related factors warrant reduced physical activity and should preclude ECP participation including the following: persons who have had a traumatic brain injury (including concussion), suffered a recent musculoskeletal injury, or with a predisposing medical condition such as sickle cell trait (Bergeron, 2011).

Persons with the sickle cell trait are much more vulnerable to exertional rhabdomyolysis, an excessive, repetitive exercise outcome in which the muscle cell membranes breakdown and release myoglobin and other intracellular proteins into the blood, causing kidney damage and potential kidney failure. Other notable clinical conditions, which suggest caution with ECPs, include hypertension, a recent bout of heat-related illness (e.g. heat cramps, heat exhaustion, heat stroke, and hyponatremia--a very low level of sodium in the blood associated with dehydration), or previous episodes of exertional rhabdomyolysis (including those persons without the sickle cell trait) (Bergeron).

Also, some common prescribed medications (or often combination of medications) may impair balance, and thus may worsen exercise performance in an ECP. These medications include antidepressants, anti-anxiety drugs, antihistamines prescribed to relieve allergy symptoms, blood pressure and other heart medications, pain relievers (both prescription and nonprescription) and sleep aids (over-the-counter and prescription forms) (Harvard Health Publications, 2013). According to Bergeron, sleep deprivation, recent illness and recurring headaches would also be an alert to suspend or reduce participation in ECPs.

Recommendations to Improve ECP Safety
Practical solutions to effectively improve extreme conditioning program implementation and reduce injury risk are of paramount importance. Safety is of particular concern and begins with conducting careful inspections of designated exercise equipment and areas (Bergeron, 2011). Secondly, ECPs should be introduced gradually with a planned, stepwise progression to exercise intensity and duration, particularly for beginning students with low fitness levels (Bergeron). Individualization of supplemental conditioning programs should be based on fitness, training goals, and job specific functional needs and demands (Bergeron). Training should include regularly planned days of reduced or no supplemental conditioning, especially in more active populations such as the military and among recreational athletes (Bergeron). Exercise professionals should be aware of pre-workout client usage of caffeine and products containing substantial levels of caffeine, such as the popular energy drinks on the market. This should be discouraged as caffeine can easily mask fatigue, leading to overreaching and over exertion. Other recommendations for ECP implementation are:
1.Encourage clients to attain adequate sleep (7-8 hrs nightly) and appropriate pre-workout and post-workout optimal nutrition.
2. Suitable rest periods between sets of exercises is imperative.
3. Gradually introduce advanced skill exercises. Assure proper technique prior to increases in exercise intensity and duration.
4. Monitor signs of overtraining such as lingering muscle soreness, drop in exercise motivation, decrease in fitness results, increase in emotional stress and irritability, and ongoing tiredness.
5. Balance high-intensity training with stress reducing modes, such as yoga, pranayama breathing, and meditation.
6. Minimize training protocols that lead to exhaustive fatigue.
7. Persons with clinical conditions should be cleared for participation in ECPs.
Final Thoughts
With the growing interest in extreme conditioning programs it is essential that exercise professionals know the potential contraindications of participation in these programs and educate their clients and students appropriately. Extreme conditioning programs can be effective in enhancing certain aspects of physical fitness, however they need to target the fitness level, conditioning and training needs for the individual participants (Bergeron, 2011). Bergeron and colleagues suggest that ECPs may actually be recommended as a supplement to an incremental, well-rounded exercise regimen. Individuals seeking to engage in ECPs should pay particular attention to their personal limitations, before and during participation. As with other forms of training, risk factors should be considered before participation in ECPs and the principle of progression should be employed to ensure a safe workout. Lastly, and perhaps most impressively, Bergeron and consortium colleagues state that “qualified fitness trainers also are better equipped to more appropriately design, individualize, implement, and oversee an effective progressive and periodic program.”

Justin D. Baca is an undergraduate in the Exercise Science program at the University of New Mexico, Albuquerque. He plans to pursue a doctoral degree in Physical Therapy.

@bio:Len Kravitz, PhD, is the program coordinator of exercise science and a researcher at the University of New Mexico, Albuquerque, where he won the Outstanding Teacher of the Year award. He has received the prestigious Can-Fit-Pro Lifetime Achievement Award and American Council on Exercise Fitness Educator of the Year.

Additional References:

Armed Forces Health Surveillance Center (2013). Update: Exertional rhabdomyolysis, active component, U.S. Armed Forces 2008-2012, Medical Surveillance Monthly Report, 20(3), 21-24.

Harvard Health Publications (2013). How medications can affect your balance. Harvard Medical School. Accessed June 16, 2013