A clinical exercise physiologist (CEP) is an allied health professional trained to work with persons diagnosed with a chronic disease for which exercise training has been shown to be therapeutically beneficial. Such conditions include cardiovascular, pulmonary, metabolic, neuromuscular, immunological and orthopedic disorders, among others. Primarily, CEPs work in medically supervised environments providing programs or services directed by a licensed physician. The ACSM Certified Clinical Exercise Physiologist^® (ACSM-CEP) credential is the gold standard certification and has the most rigorous educational requirements in the fitness industry. According to the U.S. Bureau of Labor and Statistics, the 2020-30 employment outlook for exercise physiologists is growing at a faster-than-average growth rate of 13%.

There has been much forward movement with both recognition of the profession and employment opportunities. The Clinical Exercise Physiology Association (CEPA), an affiliate society of ACSM, published the 2020 Clinical Exercise Physiology Practice Survey, reporting certified professionals earned higher median hourly wage than those who were not certified. Over the past few years, ACSM-CEPs earned 17% higher salaries than wages reported in the 2015 salary survey. Additionally, individuals with a master’s degree and ACSM certification reported $7,500 higher earnings than those without certification.

ACSM-CEPs are dedicated to improving clients’ quality of life through individualized prescribed exercise and behavior-change interventions to address and attenuate declines in fitness and health. Working with a wide variety of populations, the ACSM-CEP provides primary and secondary strategies promoting physical activity for children to older adults. Employers range from collaborative care and multidisciplinary teams in hospitals or physician-based programs to self-employed, direct-pay employment settings.

Common areas for ACSM-CEP employment

• Cardiac rehabilitation
• Cardiovascular stress testing
• Exercise oncology
• Diabetes and exercise
• Bariatric and weight management
• Neurological rehabilitation
• Pulmonary rehabilitation
• Pediatrics congenital cardiovascular testing
• Primary prevention programs
• Commercial/community fitness center
• Medical fitness center
• Nonuniversity/clinical research
• Corporate wellness

Current need for certified exercise professionals

The COVID-19 pandemic has amplified levels of habitual inactivity, increasing levels of overweight and obesity and decreasing cardiorespiratory fitness. Many individuals present with physical limitations and chronic diseases (e.g., diabetes mellitus) warranting safe and effective physical activity programming. The pandemic created a shift in the mode of delivery, with many exercise centers and clinics pivoting to virtual, home-based settings and digital fitness. Albeit a common transition during the pandemic, delivering primary and secondary exercise programing continues to grow with innovative infrastructure. Many current job vacancies describe academically prepared exercise professionals with adaptable and flexible skill sets to meet the varying modes of delivery for hybrid workspace to mitigate barriers to exercise adherence.

There is also the potential to see an uptick in ACSM-CEPs employed in clinical settings commonly staffed by registered nurses (e.g., cardiac rehab, cardiovascular stress testing) due to the ongoing nursing shortage. A recent publication supports the idea that ACSM-CEPs are specifically prepared to evaluate the acute and chronic responses to exercise and likely better suited for those roles than other allied health professionals. ACSM-CEPs are among the only allied health care providers specifically trained to develop exercise prescriptions and provide risk-factor modification counseling in the management of chronic disease.

Action items for professionalism

Professional membership can be very valuable during the job search process. Both ACSM and CEPA are key organizations that continually post job vacancies. Some other tips to keep in mind when seeking employment:

1. Craft a well written resume — highlight specific skills and experience
2. Network — contact past employers, professors, internship mentors
3. Social media — use LinkedIn, ACSM Careers, and other job-search platforms
4. Recognize CEP synonyms — some organizations may use terms other than “clinical exercise physiologist” in job titles, including “exercise physiologist,” “exercise specialist,” “exercise trainer,” “health educator,” or “wellness coordinator.” Be sure to read job descriptions carefully prior to applying.

As the profession continues to grow, ACSM-CEPs must advocate for advancement by encouraging other skilled exercise professionals to become certified. Additionally, ACSM-CEPs are eligible for an individual a National Provider Identifier (NPI). Registering for one will help expand recognition of the profession as critical members of health care teams.

Increasing life expectancy continues to fuel the growth of allied health professions, which are projected to grow at more than double the rate of other occupations. ACSM-CEPs’ proficiency at administering chronic disease management commonly found in both primary and secondary settings widens their potential employment opportunities. There’s a lot of momentum behind implementing physical activity and therapeutic exercise! 

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Laura A. Richardson, Ph.D., ACSM-CEP, RCEP, FACSM, president of the Clinical Exercise Physiology Association (CEPA) and Clinical Associate Professor of Applied Exercise Science and Movement Science in the University of Michigan School of Kinesiology. Dr. Richardson is a Registered Clinical Exercise Physiologist^® (RCEP^®) with over two decades in health care working with patients diagnosed with immunological, metabolic, pulmonary, neuromuscular, cardiovascular and orthopedic disorders using exercise as a mode of therapeutic intervention. Her expertise is working with metabolic patients utilizing behavior-modification strategies for lifelong weight management with bariatric surgery, along with advocating for the advancement of the CEP profession.

An appropriate and individualized dose of regular aerobic exercise is recommended to promote and preserve cardiorespiratory health throughout life. The exercise dose is defined by four ingredients: frequency, intensity, time and type of exercise. Among these, intensity is the most elusive term of the exercise “prescription.” It is typically determined from an external load (such as speed, watt or pace) that elicits a desired metabolic intensity (e.g., a fraction of maximal or reserve oxygen consumption).

Whenever this approach is not feasible, heart rate (HR) is commonly used as a convenient intensity measure in both clinical practice and sport. Exercise prescriptions that use HR targets rely on the existence, and constancy over time, of a linear relationship with metabolic intensity. However, during constant-load exercise lasting more than 10 minutes, a mismatch between HR and oxygen consumption emerges over time as a result of a slow rise in HR independent of metabolism. This phenomenon has been known for years under the name of “cardiovascular drift” and, more recently, “HR slow component.” In 2018, Zuccarelli et al. suggested a practical implication of this phenomenon. They showed the use of HR targets for exercise-intensity implementation can lead to an unanticipated and undesired reduction in work rate and metabolic activation during a prolonged session rather than the desired constant training intensity. This phenomenon has been consistently observed in males, both healthy and those with obesity. However, its physiological quantification and relationship with oxygen consumption across exercise intensities and in different populations are missing, along with its physiological underpinnings.

In our study, published in the April 2022 issue of Medicine & Science in Sports & Exercise_®, we tested the hypothesis that an HR increase over time also occurs in postmenopausal women, possibly with an intensity-dependent amplitude. Eighteen postmenopausal women performed several constant-work exercises at relative intensities from 40 to 80% maximal oxygen consumption on a cycle ergometer. During each test, we measured cardiorespiratory responses (HR and oxygen consumption) and body temperature over 30 minutes. This investigation demonstrated that increments in HR over time are present at all relative exercise intensities, their amplitude being larger with increasing intensity. The observed HR slow component was significantly correlated with relative intensity (r² = 0.66) and increase in body temperature (r² =0.52). However, its amplitude was about twice as large as that of oxygen consumption, implying a mismatch between HR and metabolic intensity that becomes larger both with intensity and over time. To deal with this mismatch, we proposed an equation that adjusts HR targets over time based on relative exercise intensity to account for the HR drift.

The take-home message is that whenever the implementation of the metabolic intensity of prolonged exercise is done using HR targets, one needs to be mindful of the mismatch between HR and metabolic intensity that emerges over time. Intensity- and time-adjusted HR targets are needed to assure that the desired stimulus is maintained throughout the exercise session in a given individual. 

Massimo Teso, M.Sc., is a Ph.D., student in exercise physiology at the University of Verona in Italy. His research is focused on the slow component of oxygen consumption and heart rate kinetics and their implications for the exercise intensity prescription.

Silvia Pogliaghi, M.D., Ph.D., FACSM, is an associate professor of human physiology at the University of Verona and an adjunct associate professor at the University of Western Ontario and the University of Calgary, the latter both in Canada. Specializing in sports medicine, she studies the physiological mechanisms that regulate and limit the acute and adaptive responses to aerobic exercise in physiological and pathological conditions.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

As Women’s History Month draws to a close, it’s a fitting time to reflect on the accomplishments of women in our field and the gains we’ve made, as well as thank the mentors and leaders who blazed a path forward. The American College of Sports Medicine (ACSM) continues to lead in this regard, with accomplished women at the helm of the organization, including President-Elect Dr. Stacy Fischer, Immediate Past President Dr. NiCole Keith and CEO Kristin Belleson.

As a result of initiatives like Title IX, female participation in active pursuits has grown steadily over the decades — 49% of 2022 summer Olympians were female — and with this growth has come an increased focus on identifying and acknowledging the unique needs and challenges female athletes may face. There have been substantial gains in the number of women engaged in scientific research careers and an increase in policies to enhance the engagement, recruitment and retention of women in clinical research. Likewise, more women are being included in in clinical trials, and there’s a growing appreciation for the differences between male and female athletes.

However, there is still an appreciable difference in the amount of sports medicine-related research focused solely on female athletes and health-related research across the lifespan. Costello and colleagues reported that there is a significant difference in the number of males and females included as participants in sports medicine research: 61% and 39%, respectively. We also know that from childhood to older adulthood, the number of females who meet recommended physical activity guidelines is lower than that of their male counterparts, and that girls are less likely to play sports than boys. As the physiological and psychological benefits of physical activity are irrefutable, it is vital that we address this disparity by promoting physical activity and exercise to female participants from childhood to older adulthood. Having a deeper understanding of how to best motivate, train, and treat women for musculoskeletal injuries, pain management, mental health, nutrition, sleep, and pelvic-floor dysfunction while also accounting for the effect of the menstrual cycle can only enhance the impact of research and application to health and wellness for women across the lifespan.

In closing: ACSM recently conducted a Job Task Analysis for each of our core health fitness certification programs, and over 60% of the participants identify as female, demonstrating the commitment and engagement of our stakeholders and the impressive impact ACSM certified professionals are having in their communities. We are making great progress, but there is still much work to be done.


Christie L. Ward-Ritacco, Ph.D., FACSM, ACSM-EP, is the chair of ACSM's Committee on Certification and Registry Boards and is an associate professor in the Department of Kinesiology at the University of Rhode Island. 



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Several international guidelines and position statements have recommended that exercise should be embedded as standard practice in cancer care. The main argument for this has been symptom control, in particular for fatigue. Exercise during or after cancer treatment also improves quality of life, physical and role functioning, and reduces anxiety and depression. Following the 2018 ACSM Roundtable on Exercise and Cancer Prevention and Control, updated exercise guidelines for people living with or beyond cancer were issued. Simultaneously, practical recommendations were made regarding the implementation of exercise in clinical cancer care. Despite these and ongoing efforts, exercise is still not always addressed, and patients are not always referred.

An often-heard reason for non-referral is the notion that a patient is too physically unfit to join an exercise program during chemotherapy. However, poor physical functioning also leads to the postponement, alteration or premature cessation of chemotherapy treatment. Such deviations from the chemotherapy regimen may have detrimental consequences for treatment efficacy. In breast cancer in particular, there are survival implications if the relative dose intensity (RDI) drops below 85%.

In our study, published in the April 2022 issue of Medicine & Science in Sports & Exercise_®, we examined the relationship between physical fitness at the start of chemotherapy and chemotherapy completion rates in women with breast cancer. We reanalyzed the combined raw data of two previously conducted randomized controlled trials on exercise during chemotherapy for breast cancer. The PACES study compared two exercise interventions: The first was a low-moderate intensity, self-directed, home-based program with nurse support. The second was a moderate-high intensity, combined aerobic and resistance exercise program supervised by a physical therapist. The latter study, the PACT study, had one exercise arm, similar to the moderate-high arm in PACES. Both studies used a non-exercise control group.

We found that overall, patients with lower physical fitness at baseline had much lower odds of attaining 85% RDI, compared to fitter patients. We did not observe this association in the subgroup of patients who followed a moderate-high intensity exercise program during their chemotherapy, while the association was two times as strong in those who did not exercise during their chemotherapy.

It is understandable that patients who are not fit are reluctant to join an exercise program, or even discuss exercise during their medical appointments. It is also, to a certain extent, understandable that health care professionals may have doubts about referring physically unfit patients to exercise during toxic treatments. This is why it is important to recognize our finding that, in fact, these patients have the most to gain from being referred to exercise programs under the supervision of qualified professionals. In clinical practice, we have seen numerous examples of low-fit patients suffering from fatigue and nausea due to the chemotherapy who surprised themselves and their caretakers with their ability to exercise. We have observed again and again how exercising helps these patients remain resilient during cancer treatment. Scientific studies, including this one, have repeatedly confirmed such clinical observations.

Summarizing, our study underscores that while there is little to lose, there is much to gain by exercising during breast cancer treatment — also, or maybe especially, when one is not physically fit. Future studies will have to shed more light on which mechanisms drive these benefits. This will allow us to further optimize exercise prescription for people with cancer.

Martijn M. Stuiver, P.T., Ph.D., is a clinical epidemiologist at the Netherlands Cancer Institute, Center for Quality of Life and Division of Psychosocial Oncology and Epidemiology. He holds a chair as lector at the Amsterdam University of Applied Sciences Faculty of Health and is vice principal of the master’s program Evidence Based Practice in Health Care at the Faculty of Medicine, University of Amsterdam. He has a background in physical therapy and over 20 years of clinical experience in cancer care. His research focuses on functional recovery from cancer and its treatment, and in particular the role of exercise.

Anne M. May, Ph.D., is a professor in clinical epidemiology of cancer survivorship and the head of the Department of Epidemiology at the Julius Center, University Medical Center Utrecht, the Netherlands. She has been involved in exercise-oncology research for almost 20 years and has performed several multicenter randomized controlled trials showing positive effects of exercise on treatment-related side effects in patients with, amongst others, breast, colon or esophageal cancer. Currently, she is leading the international PREFERABLE consortium investigating effects of exercise in patients with metastatic breast cancer in Europe and Australia.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent positions or policies of ACSM. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

During their undergraduate academic careers, students majoring in exercise science-related fields contemplate various career paths and often seek guidance regarding the necessary steps to begin their career upon graduation. It is common to encounter soon-to-be graduates who want to work in the fitness industry but are confused about the wide breadth of certifications currently available. 

Who

The ACSM Certified Exercise Physiologist® (ACSM-EP) certification is ideal for those who want to work with generally healthy populations, and potentially clinical populations in the future. Most importantly, the ACSM-EP certification recognizes the certified professional’s educational background. All certified EPs must possess a bachelor’s degree in kinesiology or an exercise science-related field, which indicates that they have had in-class and experiential learning opportunities directly related to their work as an EP. This sets ACSM-EPs apart from certified professionals whose certifications lack such requirements. 

Why

Additionally, the ACSM-EP certification provides a stepping stone for those who have ambitions to become an ACSM Clinical Exercise Physiologist® (ACSM-CEP), which requires clinical experience in addition to a bachelor’s and/or master’s degree. Thus, being an ACSM-EP provides the certificant the opportunity to work with generally healthy individuals in nonclinical settings while gaining the required clinical experience in a supervised setting to become an ACSM-CEP.

How to apply

A qualified ACSM-EP candidate must possess these basic credentials, and master knowledge, skills and abilities within four domains:

Credentials —

1. Bachelor’s degree in an exercise science-related field (or be enrolled in the last semester of the degree program). View course requirements here.

   1. Starting August 15, 2027, candidates will be required to have a bachelor’s degree from an institution that is accredited through the Commission on Accreditation of Allied Health Education Programs (CAAHEP), which will further strengthen the credibility of the certification. Learn more. 

2. Currently CPR/AED certified 

Knowledge, Skills and Abilities —

1. Health and Fitness Assessment 

2. Exercise Prescription and Implementation 

3. Exercise Counseling and Behavior Modification 

4. Risk Management and Professional Responsibilities  

Access detailed exam content outline

Value to employers

Employers can expect ACSM-EPs to be highly knowledgeable in the aforementioned areas, such that they can immediately work with generally healthy individuals, as well as those with medically controlled diseases. An ACSM-EP should be able to successfully conduct proper client assessments, develop and apply evidence-based exercise programs, implement proper behavior-change techniques and minimize the risk of injury for clients and staff. 

Thus, employers should be eager to provide the ACSM-EP with the opportunity to enhance the lives of individuals that they serve and be confident in their ability to lead others through appropriate exercise programs and related tasks.