Effects of a five-week intensive and multidisciplinary spine-specific functional restoration program in chronic low back pain patients with or without surgery.

OBJECTIVE: Evaluating the efficacy of an intensive, dynamic and multidisciplinary spine-specific functional restoration program in patients with chronic low back pain with or without surgery. METHODS: One hundred and forty-four subjects with chronic low back pain included in the retrospective study and divided into two groups: patients who had spine surgery (GI, n=81) and patients who did not have surgery (GC, n=37). The two groups followed the same functional restoration program (175 hours). All the subjects were evaluated before (T0) and after (T5wks) rehabilitation care based on physical, functional, psychological and professional parameters. RESULTS: All outcome measures were significantly improved for all subjects at the end of the study, regardless of the group. Eighty-one percent of patients returned to work. The surgery group obtained better results at the end of the program for pain and back muscle isometric endurance measures. CONCLUSIONS: The effects of the intensive program were validated; nevertheless, spine surgery seems to have a positive impact on some physical parameters of this spine-specific functional restoration program.

Characterising the slope of the distance-time relationship in swimming.

The aim of the present study was to assess whether the critical speed calculated by the slope of the distance-time relationship (S(d-t)) represents the boundary between the heavy and severe intensity domains in swimming and would be sustainable during intermittent exercise. Nine competitive male swimmers (mean+/-SD: aged 21.2+/-2.6 yrs; peak (.)VO2 of 3866+/-529 mL min(-1)) performed, (a) four fixed-distance (100-200-400-800 m) all-out efforts to determine S(d-t) and peak (.)VO2; (b) three constant-speed efforts to exhaustion (TTE) at and 5% above and below S(d-t) (S(d-t)(+5%) and S(d-t)(-5%), respectively); (c) a set of 10 x 400 m at S(d-t) with 40-s recovery in between. Capillary blood lactate concentration ([La](B)), oxygen uptake ((.)VO2), and RPE remained stable at S(d-t)(-5%) (TTE=48.9+/-14.1 min) with end values of 3.8+/-1.9 mmol L(-1), 87+/-14% peak (.)VO2, and 4.7+/-1.3. TTE decreased at S(d-t)(+5%) (8.6+/-3.1 min), with end [La](B) of 10.2+/-1.9 mmol L(-1). Peak (.)VO2 was reached at exhaustion. Similarly, S(d-t) could only be maintained for 24.3+/-7.7 min with an increase in RPE and [La](B), (.)VO2 reaching its peak (95+/-5% peak VO2). RPE increased but [La](B) remained stable throughout the ten 400 m blocks performed at S(d-t) (overall time of 53.9+/-2.7 min). The physiological responses when swimming 5% below and 5% above S(d-t) are those characterising the heavy and severe intensity domain, respectively. While S(d-t) lies within the severe intensity domain, intermittent swims at this intensity induce [La](B) steady state alongside high rates of perceived exertion.

Why does exercise terminate at the maximal lactate steady state intensity?

OBJECTIVE: The purpose of this study was to measure physiological responses during exercise performed until exhaustion at the exercise intensity corresponding to the maximal lactate steady state (MLSS) in order to determine why subjects stopped. METHODS: Eleven male trained subjects performed a test at MLSS on a cycle ergometer until exhaustion. RESULTS: Time to exhaustion was 55.0 (SD 8.5) min. No variation was observed between the 10th and the last minute for arterial pyruvate, bicarbonate, and haemoglobin concentrations, redox state, arterial oxygen pressure, arterial oxygen saturation, osmolality, haematocrit, oxygen uptake, carbon dioxide output, and gas exchange ratio (p>0.05). Arterial lactate concentration and arterial carbon dioxide pressure decreased significantly whereas pH, base excess and the Ratings of Perceived Exertion (RPE) increased significantly (p<0.05). Although respiratory rate, minute ventilation and heart rate increased significantly until exhaustion (p<0.05), values at termination of the MLSS test were significantly lower than values measured during a maximal exercise test (p<0.05). Blood ammonia concentrations rose progressively during the MLSS test. However, there is no known mechanism by which this change could cause peripheral fatigue. CONCLUSIONS: Exercise termination was not associated with evidence of failure in any physiological system during prolonged exercise performed at MLSS. Thus the biological mechanisms of exercise termination at MLSS were compatible with an integrative homoeostatic control of peripheral physiological systems during exercise.

Stroke frequency and arm coordination in front crawl swimming.

This study aims to determine whether the arm coordination observed at different stroke rates (SR, number of arm stroke cycles per minute) differs according to the level of expertise. Thirteen non-expert (G(NE)) and 14 expert (G(E)) swimmers swam crawl five 25-m lengths at five stroke rate values: 35, 40, 45, 50, and 55 cycles.min(-1). Results show that the pattern of 45 % of G(NE) switched from the catch-up (a lag time is performed between the propulsive phases of the two arms) to the superposition coordination mode (both arms pushing simultaneously during a short period of the cycle) between 45 and 50 cycles.min(-1). Patterns of 62.4 % of G(E) switched in the same way between 50 and 55 cycles.min(-1). Significant differences in coordination patterns were found between G(NE) and G(E) only when SR was set at 45 cycles.min(-1). As non-expert swimmers seldom produce the superposition mode, but adopt this pattern when required to swim at high stroke rate values, it is suggested that this coordination mode is an emergent property of the movement.

Self selected speed and maximal lactate steady state speed in swimming.

AIM: The purposes of this study were to ascertain whether physiological and stroking parameters remain stable during a 2-hour exercise performed at self-selected swimming speed (S4) and whether this speed corresponds to those associated with the maximal lactate steady state (SMLSS). METHODS: Ten well-trained competitive swimmers performed a maximal 400-m front crawl test, 4 30-min swimming tests in order to determine S(MLSS) and a 2-hour test swum at their preferred paces to determine self-selected swimming speed (S4), stroke rate (SR4), and stroke length (SL4) defined as the mean values observed between the 5th and the 15th min of this test. The stroking, metabolic and respiratory parameters, and ratings of perceived exertion (CR10) were reported throughout the 2-hour test. RESULTS: S4 and SMLSS were not significantly different and were highly correlated (r=0.891). S4 and SL4 decreased significantly after a steady state of 68 min and 100 min, respectively, whereas SR4 remained constant. Mean VO2, dioxide output, and heart rate values did not evolve significantly between the 10th and 120th minute of the test whereas capillary blood lactate concentration (La) decreased significantly (p<0.05). Moreover, respiratory CR10 did not evolve significantly between the 10th and the 120th minute of the test whereas general CR10 and muscular CR10 increased significantly. CONCLUSIONS: Considering the (La), SL4 and CR10 values variations, muscular parameters and a probably glycogenic depletion seem to be the main limiting factors that prevent maintaining the self selected swimming speed.

Critical swimming speed does not represent the speed at maximal lactate steady state.

Critical power and critical swimming speed (CSS) are mathematically defined as intensities that could theoretically be maintained indefinitely without exhaustion. Several investigations have been conducted to attribute a physiological meaning to these variables, but results in swimming remain equivocal. Thus, the purpose of this study was to compare CSS with direct determination of the speed at maximal lactate steady state (S (MLSS)). Eight well-trained swimmers (aged 18.6 +/- 1.9 years) performed four tests to exhaustion (95, 100, 105, and 110 % of maximal aerobic speed [MAS]) in order to determine CSS from the distance-time relationship. S (MLSS) was determined from four sub-maximal 30-min constant intensity tests (ranging from 75 % to 90 % MAS). CSS (92.7 +/- 2.6 % MAS) was significantly higher than S (MLSS) (88.3 +/- 2.9 % of MAS) and the bias +/- 95 % limits of agreement for comparisons between CSS and S (MLSS) (0.07 +/- 0.13 m x s(-1)) indicated that the extent of disagreement was too great to use these two variables interchangeably. However, CSS and S (MLSS) were strongly correlated (r = 0.87; SEE = 0.033 m x s(-1); p < 0.01). Results from the present study demonstrate that in swimming, CSS does not represent the maximal speed that can be maintained without a continuous rise of blood lactate concentration and direct determination of S (MLSS) is necessary if precision is required in experimental studies.

Intracyclic velocity variations and arm coordination during exhaustive exercise in front crawl stroke.

The purpose of this study was to analyse the effects of an exhaustive exercise on arm coordination and intracyclic velocity variations (IVV) to better understand the ways in which they are modified under fatigue conditions. Seventeen competitive swimmers performed a 200-m all-out test and a set of two 25-m (before and after the 200-m) at maximal intensity to measure stroking parameters, IVV, and the relative duration of the different parts of the stroke cycle and identify the model of arm coordination by using the index of coordination (IdC). Results showed an increase in the relative duration of the propulsive time, which induced a change in arm coordination as fatigue developed in relation to a decrease in stroke length (SL) and stroke rate (SR) (p<0.05). The evolution of IdC corresponds to a reduction of the non-propulsive lag time between the two arms' propulsive actions. Despite these modifications, IVV were not significantly modified (p<0.05). The present results highlighted that IdC and relative durations of each part of the cycle (particularly the pull phase) could be assessed to complete the "SL x SR" model and to partly understand the technique modifications under fatigue condition.

Preferred pedal rate: an index of cycling performance.

The purpose of this study was to determine whether preferred pedal rate (PPR) could be used as an index of cycling performance. Thirteen competitive cyclists cycled at PPR during a graded test and a supra-threshold constant power test (CPT). The results showed that PPR values reported in CPT were correlated to both peak power determined from the graded test and exhaustion time assessed in CPT. Furthermore, multiple regression revealed that PPR values and P (peak) were two predictors of exhaustion time in CPT. Hence, this study suggests that coaches and sports scientists have to take into account PPR values complementary to P (peak) in order to evaluate the capacity of cycling performance.

Stroking parameters in front crawl swimming and maximal lactate steady state speed.

In order to increase or maintain speed at sub-maximal intensities, well-trained swimmers have an increase in their stroke rate, thus a decrease in their stroke. The purposes of this study were i) to ascertain whether the maximal speed from which the stroke length decreases significantly (SSLdrop) corresponds to the maximal lactate steady state swimming speed (SMLSS), and ii) to examine the effect of the exercise duration on the stroking parameters above, below, and at SMLSS. Eleven male well-trained swimmers performed an all-out 400-m front crawl test to estimate maximal aerobic speed (MAS) and four sub-maximal 30-min tests (75, 80, 85, and 90 % MAS) to determine SMLSS and SSLdrop and to analyse the evolution of the stroking parameters throughout these tests. SMLSS (88.9 +/- 3.3 % MAS) and SSLdrop (87.3 +/- 4.5 % MAS) were not significantly different from each other (p=0.41) and were highly correlated (r=0.88; p <0.001). Moreover, a slight stroke rate increase, and a stroke length decrease, were observed above S (MLSS) but were only significant for the 5 swimmers unable to maintain this speed for 30 min (p >0.05). During the 30-min tests swum below and at SMLSS, a steady state of stroking parameters was statistically reported. Thus, SMLSS seems to represent not only a physiological transition threshold between heavy and severe sub-maximal intensities but also a biomechanical boundary beyond which the stroke length becomes compromised.

Effects of spontaneously chosen crank rate variations on electromyographic responses in sub-maximal arm exercise in inexperienced subjects.

The aim of the present study was to compare electromyographic responses during arm exercises with a crank rate chosen spontaneously ( T(S)) or set at 20% below or above ( T(-20), T(+20)) the spontaneously chosen crank rate (SCCR). Ten male physical education students performed arm exercises with intensities ranging from 20% to 80% of maximal power. Muscular activity levels were analysed for the biceps brachii and the triceps brachii muscles using integrated rectified surface electromyography (iEMG). All values were presented as the mean and standard deviation. During T(S), the sum of iEMG for the two muscles studied was significantly ( P<0.05) lower than during T(+20) for each power output. No significant differences were observed in iEMG values between T(S) and T(-20). The hypothesis that SCCR relates to a minimisation of muscle activation during an upper body exercise was not confirmed. Variations superior or inferior to a 20% increase of the iEMG responses do not influence it. Moreover, the selection of crank rates depends on the power output and the SCCR increased significantly ( P<0.05) with increasing power output.

Maximal lactate steady state does not correspond to a complete physiological steady state.

The purpose of this study was to verify whether the maximal lactate steady state (MLSS) corresponds to a physiological steady state. Eight male trained subjects performed a 30-min test on a cycle ergometer at a constant power corresponding to their own MLSS which had been previously determined. No significant variation was observed between the 10th and the 30th min for arterial lactate concentration, redox state, arterial oxygen pressure, arterial oxygen saturation, bicarbonates concentration, base excess, hematocrit, hemoglobin concentration, plasma volume, oxygen uptake, carbon dioxide output, gas exchange ratio, minute ventilation, ventilatory equivalents for oxygen and carbon dioxide, and arterial systolic blood pressure values. However, arterial carbon dioxide pressure and pH values were significantly different between the 10th and the 30th min (p < 0.01). Respiratory rate values and heart rate significantly increased (p < 0.01). These results indicate that MLSS does not correspond to a complete physiological steady state.

Maximal lactate steady state, respiratory compensation threshold and critical power.

Critical power (CP) and the second ventilatory threshold (VT(2)) are presumed to indicate the power corresponding to maximal lactate steady state (MLSS). The aim of this study was to investigate the use of CP and VT(2) as indicators of MLSS. Eleven male trained subjects [mean (SD) age 23 (2.9) years] performed an incremental test (25 W.min(-1)) to determine maximal oxygen uptake (.VO(2max)), maximal aerobic power (MAP) and the first and second ventilatory thresholds (VT(1) and VT(2)) associated with break points in minute ventilation (.V(E)), carbon dioxide production (.VCO(2)), .V(E)/.VCO(2) and .V(E)/.VO(2) relationships. Exhaustion tests at 90%, 95%, 100% and 110% of .VO(2max), and several 30-min constant work rates were performed in order to determine CP and MLSS, respectively. MAP and .VO(2max) values were 344 (29) W and 53.4 (3.7) ml.min(-1).kg(-1), respectively. CP [278 (22) W; 85.4 (4.8)% .VO(2max)] and VT(2) power output [286 (28) W; 85.3 (5.6)% .VO(2max)] were not significantly different (p=0.96) but were higher (p<0.05) than the MLSS work rate [239 (21) W; 74.3 (4.0)% .VO(2max)] and VT(1) power output [159 (23) W; 52.9 (6.9)% .VO(2max)]. MLSS work rate was significantly correlated (p<0.05) with those noted at VT(1) and VT(2) (r=0.74 and r=0.93, respectively). VT(2) overestimated MLSS by 10.9 (6.3)% .VO(2max), which was significantly higher than VT(1) [+21.4 (5.6)% .VO(2max); p<0.01]. CP calculated from a given range of exhaustion times does not correspond to MLSS.

Plasma lactate and plasma volume recovery in adults and children following high-intensity exercises.

AIM: To compare plasma lactate concentration recovery kinetics when measured and corrected for variations in plasma volume between children and adults. METHODS: Nine boys (11.3 +/- 1.1 y) and 8 men (21.9 +/- 1.9 y) performed a maximal and a supramaximal exercise until exhaustion. Plasma lactate concentrations, haemoglobin and haematocrit were measured at rest, immediately on completion of exercise and after the 2nd, 5th, 12th and 30th minute of recovery. The plasma lactate concentrations and the rate of recovery were corrected for variations in plasma volume. RESULTS: The maximal decreases in plasma volume were significantly higher in adults than in children for maximal exercise (-18.7 +/- 2.6% vs -14.5 +/- 3.2%; p < 0.05), but similar for the supramaximal exercise (-16.9 +/- 3.4% vs -15.2 +/- 3.4%). During recovery, measured and corrected plasma lactate concentrations were significantly higher in adults. The rate of plasma lactate recovery was higher in adults for maximal exercise only. The same results were obtained when the rates of plasma lactate decrease were calculated from corrected plasma lactate concentrations. CONCLUSION: The correction of the plasma lactate concentrations for variations in plasma volume did not influence the comparison of the concentrations obtained in adults and children, or their rate of recovery.

Plasma lactate recovery from maximal exercise with correction for variations in plasma volume.

BACKGROUND: To compare plasma lactate concentrations and plasma lactate kinetics during recovery, for measured and corrected values for changes in plasma volume, after a maximal aerobic exercise. METHODS: Sixteen male subjects performed an incremental and maximal exercise in order to reach maximal aerobic power. Prior to the exercise, at the end and during recovery (2, 5, 12 and 30 min), blood samples were collected through an antecubital catheter. Samples were analysed for lactate, hematocrit and hemoglobin in order to calculate changes in plasma volume. Plasma lactate concentrations ([La]p) were corrected for changes in plasma volume. Plasma lactate kinetics was estimated through the ratio between [La]p after 5 min recovery minus [La]p after 30 min to time (25 min) and expressed in percentage per minute. RESULTS: Maximal changes in plasma volume (-19.7 +/- 3.8%) were correlated to maximal measured [La]p (r=0.66, p<0.01). Maximal measured [La]p values (14.9 +/- 2.6 mmol x l-1) were 17.3% higher (p<0.001) than corrected values (12.7 +/-2.0 mmol x l-1). The kinetics of [La]p decrease was significantly higher (p<0.001) for measured values (2.38 +/- 0.29 % x min-1) than for corrected values (2.22 +/- 0.33 % x min-1). CONCLUSIONS: These results suggested that changes in plasma volume must be taken into account when peak postexercise plasma lactate concentration or lactate recovery curves are analysed.

Validity and reliability of critical speed, critical stroke rate, and anaerobic capacity in relation to front crawl swimming performances.

The purpose of this investigation was to determine whether the concepts of critical swimming speed, critical stroke rate and anaerobic swimming capacity could be used by coaches as a reliable index in order to monitor endurance performances in competitive swimmers. The results of this study conducted with well-trained swimmers showed that the 30-min test velocity (V30) is not different from the critical swimming speed determined from 200- and 400-m tests but is overestimated by 3.2 %. Furthermore, a regression analysis of the number of stroke cycles on time calculated for each swimmer showed a linear relationship (r(2) greater than 0.99 and p less than 0.01). The 30-min stroke rate test (SR30) was not different from the critical stroke rate determined from 200- and 400-m tests after a correction of minus 3.9 %. These data suggest that the slope of this regression line represents the critical stroke rate defined as the maximal stroke rate value, which can theoretically be maintained continuously without exhaustion. Coaches could easily use critical swimming speed combined with critical stroke rate in order not only to set aerobic training loads but also to control the swimming technique during training. Besides, anaerobic swimming capacity (ASC) values defined as the y-intercept of the regression line between distance and time were not correlated (p > 0.05) with the determined distance over which a significant drop in the maximal speed could be noticed on a 25-m test. Thus, ASC does not provide a reliable estimation of the anaerobic capacity.

Spontaneously chosen crank rate variations in submaximal arm exercise with inexperienced subjects. Effects on cardiorespiratory and efficiency parameters.

The aim of the present study was to compare the physiological responses during arm exercises when the crank rate was chosen spontaneously (TS) or set at +/- 20 % (T-20, T+ 20) of the spontaneously chosen crank rate (SCCR). Eight physical education male students, aged 22 +/- 3.2 years, performed an upper body exercise in which intensities ranged from unload to 80 % of maximal power. No significant difference was observed in oxygen uptake, ventilation, gross and net efficiency values between TS and T+ 20 or T-20. Nevertheless, oxygen uptake and ventilation were significantly (p < 0.05) lower and gross and net efficiencies higher (p < 0.05) during T-20 than T+ 20. No significant difference was noticed for heart rate, delta and work efficiency between TS, T-20 and T+ 20. The hypothesis that SCCR is the most economical one according to the efficiency parameters was not quite verified. However, crank rates lower than SCCR could be interesting because they increase gross efficiency compared to higher crank rates. Moreover, the selection of crank rates depends on power output. Indeed, SCCR increased significantly (p < 0.05) with power output. In the physical reconditioning of injured or handicapped subjects, the latter are very sensitive to the power output, and the crank rate could be another constraint.

RPE responses during arm and leg exercises: effect of variations in spontaneously chosen crank rate.

The aim of this study was two-fold. First, the rating of perceived exertion (RPE) was compared between two different upper and lower body exercises. Subjects (n = 12) performed with spontaneously chosen crank or pedal rates: (i) incremental maximum power tests (Test 1), with an initial work rate of 50% of maximal power followed by increases of 10% at each 120-sec. work stage and (ii) tests (Test 2) with exercise bouts set at 20, 40, 60, and 80% of maximal power separated by passive recovery periods. Second, the effects of variations in spontaneously chosen crank rate on RPE was analysed using the second test performed only with upper body. Subjects performed Test 2 three times with crank rates spontaneously chosen by the subjects, set at plus or minus 20% of spontaneously chosen crank rate. During both Tests 1 and 2 for upper or lower body, RPE increased linearly (p<.01) with power output. No significant difference was noticed between upper and lower body tests; however, RPE was significantly different (p<.05) between Test 1 results for upper and lower body at 70, 80, 90, and 100% of maximal power. The greater RPE at high power output could be linked to the important effect of fatigue during upper body exercise. Among the three crank-rate conditions, no significant difference in RPE was noticed. The choice of crank rate does not seem to influence the perception of exertion in upper body cycling exercise.

Stroking parameters in top level swimmers with a disability.

PURPOSE: The purposes of this study were to analyze velocity (V), stroke length (SL), and stroke rate (SR) values during the 100-m freestyle competitive events in top level male and female swimmers with a disability (DS) according to the international Functional Classification System (FCS) and to compare the results obtained with those of able-bodied swimmers (ABS). METHODS: DS (N = 119) and ABS (N = 32) were tested in real competitive conditions during European and French swimming championships in the A finals of the 100-m freestyle. RESULTS: V and SL increased significantly (P < 0.01) according to the level of ability from class S3 up to S10. SL values were significantly different (P < 0.01) between males and females in each class group. On the contrary, SR was not significantly different between genders, between each class group of FCS, and also with ABS. The major result of this study was that stroke length was related to velocity whereas stroke rate was not. The differences in weekly training time between each class of DS were not significantly different and showed that performances seemed to be more related to the various locomotor disabilities than to the training status. CONCLUSIONS: These findings, which are discussed, showed that stroke index (SI = V.SL) could be used as a sensitive criterion to assess the swimmer with a disability in relationship to his classification level.

Physiological effects of variations in spontaneously chosen crank rate during sub-maximal and supra-maximal upper body exercises.

The aim of the present study was to compare the physiological responses when the crank rate was chosen spontaneously (Ts) or set at +/- 10% (T-10%, T+10%) of the freely chosen rate, during two upper body exercises: i) a sub-maximal test (T(SUB)) in which intensities ranged from 50 to 80% (118.4 +/- 10.2 to 189.5 +/- 16.3 watts) of maximal power (MP) and ii) a supramaximal test (T(SUPRA)) in which power output was set at 110 and 120% (260.5 +/- 22.4 and 284.2 +/- 24.4 watts) of MP. Eight nationally and internationally ranked kayakers, aged 20 +/- 2 years, performed these tests in which power outputs were normalised in relation to the maximal power output determined during T(MP). In T(SUB+10%), oxygen uptake and ventilation were significantly (P< 0.05) higher than during T(SUBxS). In T(SUB+10%) and T(SUB-10%), energy expenditure was significantly (P<0.05) higher and gross and net efficiencies lower than during T(SUBxS). During T(SUPRA-10%) when the power output was set at 110% of MP, time to exhaustion was significantly higher (P<0.05) than during T(SUPRAxS). The findings of the present study suggest that upper body exercise performed on an ergocycle should be conducted using the freely and spontaneously chosen crank rate.

Relationship in humans between spontaneously chosen crank rate and power output during upper body exercise at different levels of intensity.

The aim of this study was to assess the relationship between spontaneously chosen crank rate (SCCR) and power output during two upper body exercise tests: firstly, an incremental maximal aerobic power test (T1), with an initial intensity of 50 W followed by 15-W increases at each subsequent 90-s stage and secondly, a test (T2) with consecutive exercise periods set at 50%, 60%, 70%, 80%, 110% and 120% of maximal power (Pmax) separated by passive recovery periods. Eight nationally and internationally ranked kayakers, aged 20 (SD 2) years, performed the tests. During both T1 and T2, mean SCCR values were correlated (r = 1) and increased significantly (P < 0.05) in association with the increases in power output. The finding that the subjects consistently increased their crank rate as the power output increased in different tests, i.e. at submaximal, maximal and supramaximal intensities, strongly suggests that SCCR depended on power output and not on the type of exercise (incremental or rectangular exercise). Moreover, the equation relating crank rate and power output determined from T1 suggests that it may be used to predict the crank rate which will be chosen in upper body exercise, whatever the intensity. Finally, the results of testing at 110% and 120% of Pmax would suggest that a high crank rate (>90 rpm) should be used during the test procedure using supramaximal exercises where accumulated oxygen deficit is calculated, and more particularly when exercise is performed using the upper body.