New Aerobics Guidelines Announced by Women’s Health Care Specialists

Concerned that millions of American women and their aerobics instructors may be sustaining unnecessary injuries in exercise routines, the nation’s largest group of specialists in women’s health care has introduced safety guidelines to try to stem the toll.

The new guidelines were announced in New Orleans on Monday by the American College of Obstetricians and Gynecologists at its annual convention.

The guidelines are a response to growing criticism that some aerobics instructors may be perpetuating a sort of aerobics-macho mind-set that drives women to attempt useless and dangerous routines.

Focus on Women

Some of the safety concerns extend equally to men participating in aerobics, the physician group said, but the focus of the new safety drive is on women because they account for at least 90% of the estimated 24 million to 25 million people who participate in aerobics programs of all types today. Industry groups estimate there are between 100,000 and 250,000 instructors in the aerobics business, working at between 50,000 and 100,000 studios.

An unknown number of women exercise in their homes to aerobics videocassettes, sales of which have been consistently strong. In listings published by Billboard magazine, four of the nation’s 40 top-selling videocassettes last week were aerobics tapes, including two of the top 10.

California--by a significant margin--is believed to have more participants, instructors and exercise outlets than any other state. California became the first state where government licensing of instructors was proposed when a bill was introduced last year in the state Senate after concern was voiced over injury rates. The legislation died in committee, but a weaker version, providing for state regulation of instructor training, has been reintroduced.

One concern about aerobic instruction is that women in some classes are advised to continue an uncomfortable maneuver so they can “go for the burn”--a burning sensation in the muscle tissue--in the mistaken belief the pain is a sign they are eliminating excess fat from their bodies. Actually, this practice may cause muscle tissue to break down, experts interviewed by The Times agreed.

“The burn,” in fact, is a sensation caused by a buildup of lactic acid--a symptom, in turn, of the breakdown of the normal chemical balance in the muscle fibers.

Other women who keep up any of a variety of exercises in which they jump repeatedly from the floor may be risking stress fractures of any of the bones of their legs and even their pelvises, as well as permanent damage to ligaments, cartilages and tendons in the knees and ankles, said several experts who participated in drawing up the new guidelines.

Common Maneuver

Also seen as particularly hazardous is a common maneuver in which aerobics participants bend at the waist and then twist their upper bodies from side to side. This can set the stage for breakdown of discs between the vertebrae, several experts noted.

“I would say we (the college) came to this (issuing of guidelines) from the perspective of reading some of the articles (in the medical literature) on the high rate of injury of instructors and participants,” said Dr. Harry Visscher, the college’s Washington-based vice president. “We also heard there are significant--if not large--numbers of women going to orthopedic offices for care because of injuries related to exercising.” The actual extent to which injuries are occurring remains uncertain, however, because research in the field is limited. Most of reseach has been supported by sponsors like shoe companies and aerobics studio chains with a commercial interest in the results.

One study cited by a California aerobic exercise advocacy group contends that injury rates among instructors have plunged as a result of improved private sector regulation.

Other reported results range from at least two California studies finding that injury rates to participants and instructors are as high as 75% to another study, also done here, in which the principal researcher said he began his project certain he would find an alarmingly high incidence of injuries but concluded “aerobics isn’t the blood bath it has been portrayed to be.”

The introduction of the safety guidelines by the American College of Obstetricians and Gynecologists has a commercial tie of its own. The college later this month will begin selling a videocassette illustrating safe exercise routines. The cassette was produced by Dr. Art Ulene, a Los Angeles television commentator who is also a board-certified obstetrician-gynecologist.

The tape, “Balanced Fitness Workout,” will be sold through doctors’ offices and video stores. Ulene and the college collaborated last year on two videocassettes on safe exercise for pregnant women and those who have just had babies.

A Mistaken Belief

The college found that women and instructors who overindulge in aerobics often do so in the mistaken belief that the more vigorous and taxing a workout, the better. This sets the stage for a serious incidence of what are called “overuse” injuries in which joints and muscles that can tolerate--and profit from--a few repetitions of certain maneuvers break down when too many are done.

Peter and Lorna Francis, a married couple from San Diego State, were consultants to the American College of Obstetricians and Gynecologists in the aerobics study. She is a physical education and telecommuncations expert and he is a biomechanics researcher. Instructors often find, the Francises agreed, that female clients at aerobics studios expect workouts to be exhausting and painful in the belief, Lorna Francis said, “that if a little (pain) is good, a lot is better.

“That’s not true. There is a law of diminishing return as you get to the higher end. There is a macho image that encourages people to push push push and unless they feel awful when they leave, physically drained and falling out the door, they think they haven’t had a workout. Under those circumstances, it’s hard even once the instructor is properly educated to pass on to the participant that, if you don’t feel that your body is falling apart, that’s OK. Pain is the body’s way of saying your are doing something you are not supposed to.”

Because of mistaken consumer expectations, the Francises said, instructors, who are generally paid meager wages ($5 to $20 per session), depending on the number of classes and students they teach, are caught in an economic cycle where if they do not overtax their clients, they find their already modest incomes significantly reduced because clients favor instructors who demand a more macho performance.

New Guidelines

To try to eliminate the many misimpressions that have led to what amounts to aerobics folklore--or even folk medicine--the new guidelines suggest that:

- In aerobics classes utilizing “impact” exercises--any maneuver in which participants jump from the floor--maximum intensity levels should not raise the heartbeat above 75% of its calculated maximum rate. The heart rate should be measured at peak output periods during an exercise routine. The maximum rate can be determined by use of standardized tables.

- Exercises involving jumping in the air should be limited to not more than four consecutive landings on either foot. The figure is significantly below the number commonly done in many aerobics classes or demonstrated on videocassettes.

- Duration of impact workouts should never exceed 30 minutes and such routines should not be done on consecutive days. The day of rest between vigorous impact workouts is necessary to avoid the risk of muscle, joint and bone damage from overuse.

- Contrary to what aerobics participants may believe, as the intensity of exercise increases, the proportion of body fat used up as an energy source actually goes down--meaning that if aerobics is intended to trim fat from the body, increasing intensity has the opposite effect from what is intended.

- Special care should be taken in selection of a floor surface on which to exercise. Unpadded concrete surfaces common in California are the worst since they offer no shock-absorption capabilities at all. If a resilient floor is not available, exercise routines should be modified to minimize impact maneuvers.

- Close attention should be paid to wearing well-designed shoes. Acceptable shoes must have a sole that slides readily on the floor. For that reason, shoes designed for running, basketball and court sports generally are not safe for aerobic dance. Running shoes are worst of all. Exercising in bare feet is exceptionally dangerous since it robs the participant of the impact-absorbing capabilities of well-designed shoes.

- Care should be taken in exercising muscles on all sides of joints, avoiding a situation in which the hamstrings (in the buttocks and rear of the thighs), for instance, are developed but the quadriceps (the muscle group in the front of the thigh) is not. Such muscle imbalance can result in serious muscle pulls as one set of muscles literally tears the other apart. - Extreme flexing of the joints, like deep-knee bends and sudden hyperextension of the knee, should be avoided since such exaggerated flexion and extension can result in injury to ligaments (elastic tissues that limit the range of joint motion), cartilage (the tissue that lubricates the surfaces of bones that meet in joints) or tendon (tissues that attach muscle to bone and permit coordinated joint motion).

“I think there are a number of things (about the guidelines) that may be seen as surprises,” Ulene said. The surprises include, he said, “the advice that women should not do impact aerobics every day and the notion that one should do no more than four repetitions of an impact-type activity. The problem is the rates of injury begin to rise when you start to do foot impact activities (jumps and landings) more than four times each.”

Ulene and the Francises agreed that a major problem in the aerobics and fitness industry is that many classes and virtually all videocassettes take either no or too little note of physiological differences among individuals. “The interesting thing is that the exercise gurus have treated all exercises as if they are alike,” Ulene said. “They’ll tell you no matter what you are doing, as long as you don’t go beyond breathlessness, it’s OK. Well, the truth is that that ignores the differences between exercises and the differences between individuals.”

Dr. Robert Kerlan, the prominent Los Angeles orthopedic surgeon, agreed that there are significant disparities in the quality and resilience of connective tissues--ligaments, tendons and cartilages--among people. These innate, genetically predetermined, differences cannot be changed by exercise, he said.

“Aerobics is a fitness activity,” Lorna Francis said. “It’s not like being an athlete participating in a soccer match where the end is to get as high a score as possible. There shouldn’t be that type of competitive sense.”

The Francises agreed that, while there has been some progress in the quality of instructors in the last two or three years, far too many exercise studios still employ instructors, as Lorna Francis put it, “because they are young and enthusiastic and look good in a leotard.”

Despite the progress toward better quality instruction in many studios, however, said Peter Francis, “the intensity problem is still one that many people have to resolve . . . They (instructors) will say, ‘That’s great, Mary. You’re really going hard!’

“But what they should be saying is, ‘Mary, remember, you have a knee problem. Keep your leg down.’ ”

Aerobics Injury Rates

The Francises did some of the first research on aerobics injury rates and last year published a study in the journal Physician and Sports Medicine reporting that, in a survey of 135 instructors, 76.3% had sustained or aggravated one or more injuries during aerobic dancing. More than a quarter of the instructors could not give an estimate of injury rates among their students.

Another study by Seal Beach podiatrist Douglas Richie found an injury rate of 75.9% among instructors and 43.3% among students, with significantly more than half involving problems below the knee. A third study by a team of Baltimore orthopedists found 61 patients treated during an 18-month period who apparently sustained aerobics injuries--more than half of them clearly caused by errors in training technique.

Two commercial groups representing instructors--the San Diego-based International Dance Exercise Assn. and the Los Angeles-based Aerobics and Fitness Assn. of America--contend that injury rates have slowed since the exercise industry began trying to implement voluntary instructor training standards. The first written certification examination for instructors will be given later this month.

The Aerobics and Fitness Assn. of America recently published a report of a study it helped sponsor that found that, of 141 instructors surveyed last year at a certification training seminar, only 36.9% had experienced injuries--though, of that group, the average injury was severe enough to cause the instructor to miss work for 14 days.

The association said the study, by Dr. Herman Falsetti, formerly of the University of Iowa but now the operator of a fitness clinic in Laguna Niguel, indicates that industry training and certification programs already have begun to reduce injuries. (Falsetti became prominent during the 1984 Olympics as the physician who administered “blood doping” of U.S. Olympic cyclists. The controversial practice involved transfusing an athlete’s own blood, which had been stored, prior to an event in an effort to enhance competitive performance.)

Dr. James Garrick, of the sports medicine center at St. Francis Memorial Hospital in San Francisco, said he undertook a study--partially financed by the Jane Fonda fitness organization--because, as an orthopedist, he “kept seeing these people who were having injuries.

“And I must confess I thought it was a horrible thing and continued to think it was a horrible thing until we called all the aerobic dance facilities in San Francisco and found out that, at the time (two years ago), there were 68,000 people regularly taking aerobic dance. It didn’t sound so bad after that.”

To test his observation, Garrick selected 411 aerobics participants--60 of whom were instructors--and followed their injury problems for several months, assigning injuries to four classes, depending on severity. Three quarters of all injuries were minor and resulted in nothing more than a passing complaint of pain, Garrick said in a telephone interview.

Garrick concluded that injury statistics expressed as percentages were useless since they do not adequately take into account differences in activity levels among individuals. Instead, he broke down the rates as injuries sustained per 100 hours of aerobics, finding that instructors had .93 injury complaints per 100 hours of dancing (three-quarters of the complaints of very minor natures) and students had 1.16 complaints per 100 hours.

The data, Garrick said, led him to conclude in a presentation to an exercise convention that “aerobic dance is not the blood bath it has been portrayed to be.” He also said his figures found little differences in injury rates between types of floor surfaces and shoes being worn.

Steven Blair, director of research for Dr. Kenneth Cooper’s Aerobics Center in Dallas, said the disparities between injury studies underscore a major problem for aerobic medicine today--there has not yet been enough reliable research.