OWNERS MANUAL

F OR M AXIMUM E FFECTIVENESS
S AFETY, P LEASE R EAD T HIS
O WNER S M ANUAL B EFORE U SING Y OUR N EW B ALANCE 9.5e E LLIPTICAL T RAINER

TABLE OF CONTENTS

Important Safety Instructions...2 Unit Warning Labels...3 Specifications & Parts...3 Introduction....4 Assembly Instructions...5-8 Getting Started...9 Using Your New Balance 9.5e Elliptical Trainer..9-10 Operating the Computer..11-13 Exercise Guidelines...14 Knowing the Basics...14 A Complete Exercise Program..14-15 Aerobic Exercise: How Much? How Often?..15 When to Exercise...15 Measuring Your Heart Rate..15 -16 Clothing...16 Tips to Keep You Going...16 Heart Rate Target Zone Chart..17 Warm Up & Cool Down Stretches..18-19 Care & Storage of Your New Balance 9.5e..20 Workout Progress Charts...21-22 Exercise Data Charts...23-24
New Balance Fitness Equipment
2004 Fitness Quest Inc. All rights reserved. Made in Taiwan. Fitness Quest, Inc., d/b/a New Balance Fitness Equipment. U.S. Patent #6,390,954 B1 New Balance and NB logo are trademarks of New Balance Athletic Shoe Inc. Fitness Quest Inc. is the exclusive licensee of New Balance Athletic Shoe Inc.

5/24/04

IMPORTANT SAFETY INSTRUCTIONS
Read all instructions before using this machine

CAUTION:

Exercise of a strenuous nature, as is customarily done on this equipment, should not be undertaken without first consulting a physician. No specific health claims are made or implied as they relate to the equipment.
1) Before starting this or any other exercise program, consult your physician, who can assist you in determining the target heart rate zone appropriate for your age and physical condition. Certain exercise programs or types of equipment may not be appropriate for all people. This is especially important for people over the age of 35, pregnant women, or those with pre-existing health problems or balance impairments. 2) Monitor your heart rate while you exercise and keep your estimated pulse rate within your target heart rate zone. Follow the instructions on pages 15 and 16 in this manual regarding heart rate monitoring and how to determine your appropriate target heart rate zone. When used properly, the heart rate pulse sensors and display monitor provide a reasonably accurate estimate of your actual heart rate. This estimate is not exact and persons with medical conditions and/or a specific need for accurate heart rate monitoring should not rely on the estimations provided. 3) Warm up before any exercise program by doing 8 minutes of aerobic activity, followed by stretching. 4) Wear comfortable clothes that allow freedom of movement and that are not tight or restricting. 5) Wear comfortable shoes made of good support with non-slip soles. 6) Breathe naturally, never holding your breath during an exercise. 7) Avoid over training. You should be able to carry on a conversation while exercising. 8) After an exercise session, cool down with slow walking and stretching.
9) This machine should not be used by or near children. 10) Handicapped or disabled people must have medical approval before using this machine and should be under close supervision when using any exercise equipment. 11) If you are taking medication which may affect your heart rate, a physician's advise is absolutely essential. 12) Use this machine only for its intended use as described in this manual. Do not use attachments not recommended by the manufacturer. 13) Only one person at a time should use this machine. 14) Do not put hands, feet, or any foreign objects on or near this machine when in use by others. 15) Always use this machine on a level surface. 16) Never operate the machine if the machine is not functioning properly. 17) Start exercise slowly and gradually increase the amount of resistance. 18) If the user experiences dizziness, nausea, chest pain, or any other abnormal symptoms, stop exercise at once and consult a physician immediately. 19) Use caution not to pinch fingers or hands in moving parts when using the unit. 20) Risk of electrical shock. This unit is to be used only indoors and in a dry location.

KEEP THESE INSTRUCTIONS

UNIT WARNING LABELS
Important: See below for placement of the following warning labels on your unit.
WARNING LABEL 1 WARNING LABEL 2

WARNING

FAILURE TO READ AND FOLLOW THE SAFETY INSTRUCTIONS STATED IN THE OWNERS MANUAL MAY RESULT IN POSSIBLE SERIOUS INJURY OR DEATH. KEEP CHILDREN AWAY. MAXIMUM USER WEIGHT 300 LBS. REPLACE THIS LABEL IF DAMAGED, ILLEGIBLE OR REMOVED.
DO NOT PLUG THE AC ADAPTER INTO WALL UNTIL ELECTRONICS MONITOR IS COMPLETELY ASSEMBLED.
WARNING LABEL 3 (six locations)

WARNING LABEL 4

WARNING LABEL 5
CRUSH HAZARD. KEEP HANDS CLEAR OF MOVING PARTS.
PINCH POINT. KEEP HANDS CLEAR OF MOVING PARTS.
RISK OF ELECTRICAL SHOCK. THIS UNIT IS TO BE USED ONLY INDOORS AND IN A DRY LOCATION.

Pulse Sensors

Computer

Book Holder

Stationary Handlebar
SPECIFICATIONS & PARTS
New Balance 9.5e Specifications:
Approximate: Length: 85 Width: 22 Height: 65-1/2 Product Weight: Approx. 176 lbs. Maximum User Weight: 300 lbs.

Vertical Column

WARNING LABEL 1

Snap Caps

Water Bottle and Holder

Left Swing Arm

Right Swing Arm

Main Frame Assembly

placed on both sides of swing arm cover - both sides of unit
Vertical Column Cover Foot Tube Cover

WARNING LABEL 3

Swing Arm Cover

Foot Platforms

Rollers

Wheel Covers

WARNING LABEL 5 WARNING LABEL 2

AC Adapter Receptacle

Right Roller Tube

AC Adapter

WARNING LABEL 3 placed on both tubes

Left Roller Tube

Stabilizer Bar
INTRODUCTION CONGRATULATIONS ON PURCHASING YOUR NEW BALANCE 9.5e ELLIPTICAL TRAINER
With this product in your home, you have everything you need to start your own workout program to tone and firm the major muscle groups of your lower body. This is vital for all of us, regardless of age, sex, or fitness level, and regardless of whether your primary goal is toning, health maintenance, or more energy for daily activities. Proper exercise, including a low fat diet, strength training and aerobic exercise, tones and conditions the muscles we use every day to stand, walk, lift and turn. It can actually transform our body composition by reducing body fat and increasing the proportion of lean muscle in our bodies. Using the Elliptical Trainer will help in reducing body fat and increasing cardiovascular endurance. Be sure to read through this Owners Manual carefully. It is the authoritative source of information about your New Balance 9.5e Elliptical Trainer. Retain this manual for future reference.

COMMENTS OR QUESTIONS

Dear Customer, Congratulations on your purchase of the New Balance 9.5e Elliptical Trainer. Were sure that you will be completely satisfied with the product and we invite your comments so that we can hear about your success. Please write or call our Customer Service Specialists at the address or phone number listed below, or contact us by email or on our web site, with any comments or questions you may have. New Balance 9.5e Customer Service Department 1400 Raff Road SW, Canton OH 44750-0001 1-800-292-5009, Monday through Friday 9:00am to 5:00pm, Eastern Standard Time email: customersupport@newbalancefitness.com www.newbalancefitness.com
All details depicted in this Owners Manual, and of the product itself, are subject to change without notice.
ORDERING MISSING OR DEFECTIVE PARTS
When ordering parts, always provide the following information: 1) Name, Mailing Address and Telephone Number 2) Date of Purchase 3) Where Product was Purchased (Name of Retail Store, City) 4) Model Number (NBP01095-2) 5) Part Order Number and Description

ASSEMBLY INSTRUCTIONS

Occasionally our products contain components that are pre-lubricated at the factory. We recommend that you protect flooring, or anything else the parts may contact, with newspaper or cloth.

vertical column cover

main frame assembly
right roller tube left roller tube

stabilizer bar

foot platform computer
rear foot tube foot platform

book holder

left arm

right arm

bushing caps

left swing arm

AC adapter stationary handlebar left and right swing arm covers snap caps
right swing arm water bottle with holder

vertical column

M8 x 60mm allen bolts M8 washers and M8 nylon nuts
Tools Required: (included)
Multi Hex Tool with Phillips Screwdriver Allen Wrench

13mm 15mm

Fastener Pack
multi hex tool with phillips screwdriver

heart rate chest strap

heart rate receiver

allen wrench

STEP 1 Main Frame Assembly
a) Remove the Allen Bolts, Washers, Nuts and Nut Caps from the Foot Base on the Main Frame Assembly. Slip the Roller Tubes onto the Main Frame making sure the Roller Tracks are facing up and the Bolt Holes on the rear of the Roller Tubes are facing each other. To secure the Roller Tubes to the Base Frame replace the Bolts and Washers you just removed. b) Remove the Allen Bolts and Washers from the rear of the Roller Tubes. Place the Stabilizer Bar (with the Warning Label up) between the Roller Tubes. Replace the Bolts and Washers you just removed. c) Tighten all bolts with Wrench provided.

STEP 5 Stationary Handlebar Assembly
Remove the Allen Bolts, Washers and Nuts with Caps from the Stationary Handlebar and the Bolt and Washer from the Vertical Column. Position the Stationary Handlebar in place on the Vertical Column with the bolt hole at the bottom. Replace the Bolts, Washers, Nuts and Caps you just removed and tighten with the Wrench provided.

bolt hole

stationary handlebar

looking from left side

STEP 6 Computer Assembly

computer

a) Remove the four Phillips Screws from the back of the Computer. b) Snap together Connectors for Computer, tucking the Wires inside the Vertical Column. Be careful not to pinch wires. heart rate The Book Holder can be attached receiver to the Computer at any time. c) Attach the Computer using the connectors four Screws removed in (a). Tighten with the Screwdriver 6b provided. d) Remove Battery Door on the back of the Computer. Insert four C Batteries (included) in numbered order and replace Battery Door.
four "C" batteries

battery door

Front View

back of computer

Back View
STEP 7 Water Bottle Holder Assembly

pulse wires

vertical column pulse wires

STEP 8 AC Adapter

remove and re-insert phillips screw
a) Remove Phillips Screws from Vertical Column. Line up Water Bottle Holder and attach to the Vertical Column by re-inserting Phillips Screws and tightening them with the Screwdriver provided. b) At this time connect the Pulse Wires on looking from the ng looking from both sides of the eft left the left side side of the unit he of the unit Vertical Column.
Insert AC Adapter into front of unit, then plug into wall.
water bottle holder remove and re-insert phillips screw
Assembly is now complete.
IMPORTANT: Please read pages 9-10 before beginning your workout for important instructions on how to use your New Balance 9.5e Elliptical Trainer.

GETTING STARTED

Once your New Balance 9.5e Elliptical Trainer is assembled, make sure that your workout space has a solid, level surface with plenty of space around it. We recommend placing a mat under your unit to protect your flooring. Before you begin your first workout on the New Balance 9.5 Elliptical Trainer, practice getting on and off your trainer a few times until you are comfortable with this movement.

Getting On

Move the left foot platform to its lowest position. 1) Face forward and put your hands on the stationary handlebars. 2) Place your left foot on the left foot platform and balance yourself. 3) Carefully lift your right foot over the machine and place your right foot on the right foot platform. Make sure that you feel completely balanced before beginning your workout.

Getting Off

When stepping off, you must gradually slow down the rate at which you are pedaling until the unit comes to a complete stop. 1) Grasp the stationary handlebars with both hands (see Fig 3 above). 2) Step off the higher foot platform onto the floor (see Fig 2 above). 3) Then carefully take your other foot off the machine and down to the floor (see Fig 1 above). Let go of the stationary handlebars.

Correct Workout Position

When exercising, it is important to keep your back straight and knees soft or slightly bent. Do not lock out your knees. Keep your head up as this will minimize neck and upper back strain. Always try to use the New Balance 9.5e with a smooth and rhythmical motion.
USING YOUR NEW BALANCE 9.5e ELLIPTICAL TRAINER
RISK OF ELECTRICAL SHOCK. THIS UNIT IS TO BE USED ONLY INDOORS AND IN A DRY LOCATION. The New Balance 9.5e provides a completely smooth and natural feeling elliptical path that minimizes the impact on your hips, knees and ankles while providing a superior aerobic and muscle toning workout. The durable steel frame and transport wheels make the unit mobile and easy to use. IMPORTANT: This unit is not recommended for children. Always wear rubber soled workout shoes. Always make sure that you feel balanced and secure. Always use your machine on a clean, solid and level surface.

CHANGING FOOT POSITIONS

The generously sized foot platforms are 9wide x 18 inches long which provides workout stability and allows you to vary your foot position for maximum comfort. Position your feet on the platforms so that you do not have to lean forward while performing the exercise.

USING THE HANDLEBARS

Your New Balance 9.5e comes with both swing arms and stationary handlebars.

Using the Swing Arms

Grasp the swing arms. Use a firm grip but try to avoid white knuckles. Bend your elbows slightly so that your arms are not hyperextended or locked out. As your legs move in the elliptical motion, pump your arms back and forth as if you were walking. Using the swing arms will work your upper body in addition to your lower body. By using the swing arms, you are recruiting more muscles which will both elevate your heart rate and burn more calories than simply doing a lower body workout.
Using the Pulse Sensors on the Swing Arms
The pulse window on your computer works in conjunction with the pulse sensors found on the swing arms. When you are ready to read your pulse: 1) Place both hands firmly on the pulse sensors. For the most accurate reading, it is important to use both hands and to temporarily stop moving. 2) Look at your pulse window. The small heart will begin to blink. 3) Your estimated heart rate will appear in the window approximately 6 seconds after you grasp the pulse sensors. 4) Refer to the Target Heart Rate Zone Chart found on page 17 of this manual. For additional information about the importance of working within certain heart rate ranges, see page 15 and 16 Measuring Your Heart Rate. 5) This estimate is not exact and persons with medical conditions and/or a specific need for accurate heart rate monitoring should not rely on the estimations provided.

Stationary Handlebars

Place your hands in the middle of the the stationary handlebars. Adjust your hands left and right until you find the position most comfortable for you. Bend your elbows slightly so that your arms are not hyperextended or locked out. Using the stationary handlebars during your workout will decrease the amount of work in your upper body and increase the amount of work in your lower body.
OPERATING THE COMPUTER WARNING
The batteries must be installed as instructed on page 8. Do not carry batteries loosely, such as in a purse or pocket. The batteries may explode or leak and cause injury if installed improperly, misused, disposed of in a fire or recharged.
Do not plug AC Adapter into wall until computer is completely assembled.

Introduction

Your unit is equipped with a programmable computer to help you track your progress and motivate you to reach your fitness goals. This computer provides different programs designed to tailor to your fitness goals. Simply choose the program you like, set the time limit and begin exercising. Your computer will then show your approximate pulse, approximate calories burned, elapsed time, speed and distance traveled. reaches 999, it will reset to 0 and begin counting from 0.1 again. AGE: Your computer is age-programmable from 10 to 99 years when you choose all programs except Program 8. When using Program 8 you will set Target Heart Rate instead of Age. Note: This unit is not recommended for children. If you do not set an age, this function will always default to age 30. PULSE (approximate): Your computer displays your pulse rate in beats per minute during your workout. Pulse sensors, located on the Swing Arms enable the user to read his/her pulse rate. By grasping the sensors and holding firmly, the display will read your pulse rate in the display window. Your pulse will continue to read as long as your hands stay on both of the pulse sensors. See Heart Rate Chest Strap and Receiver section on page 13.
When used properly, the heart rate pulse sensors and display monitor provide a reasonably accurate estimate of your actual heart rate. This estimate is not exact and persons with medical conditions and/or a specific need for accurate heart rate monitoring should not rely on the estimations provided.

Functions and Features

QUICK START BUTTON: Allows you to start the computer without selecting a program. TIME automatically begins to count up from zero. Use the UP and DOWN buttons to adjust the resistance. TIME: Shows your elapsed workout time in minutes and seconds. Your computer will automatically count up from 0:00 to 99:59 in one second intervals. You may also program your computer to count down from a set value by using the UP and DOWN buttons. If you continue exercising once the time has reached 0:00, the computer will begin beeping, and reset itself to the original time set, letting you know your workout is done. SPEED: Displays your workout speed in miles per hour. DISTANCE: Displays the accumulative distance traveled during each workout up to a maximum of 99.9 miles. The distance will be displayed in tenths of a mile. CALORIES (approximate): Your computer will estimate the cumulative calories burned at any given time during your workout. Calorie expenditure on your computer is based on realistic expectations; however, your computer is not individually programmable for all necessary variables to accurately monitor actual calories burned. The computer will count up in 0.1 increments. After the display value

Buttons and Definitions

ENTER: This button allows users to select the Program, Time, Distance, Age, Calories, (Target Heart Rate Program 8 only). START: This button allows the user to STOP or START exercising. (By holding this button for two seconds the user can reset all values to 0). The computer will turn off automatically after approximately 4.5 minutes of non use. All values will then be reset to 0.

(continued on next page)

UP BUTTON: This button allows the user to increase the values of the Tension Level, Time, Distance, Calories, Age and Program. DOWN BUTTON: This button allows the user to decrease the values of the Tension Level, Time, Distance, Calories, Age and Program.
be able to keep your heart rate close to the target beats per minute. When used properly, the heart rate pulse sensors and display monitor provide a reasonably accurate estimate of your actual heart rate. This estimate is not exact and persons with medical conditions and/or a specific need for accurate heart rate monitoring should not rely on the estimations provided. Important: You must keep your hands on the pulse sensors throughout the entire workout when using Programs 8 through 11. Important: Be sure to set your actual age when using these programs.

LCD Workout Graphics

This system offers 15 programs that you can preset the workout time and will divide the time by 10 intervals. If you do not preset the workout time the system will count up the workout time in one-second increments.

Programs 1-7:

See LCD Workout Graphics on next page. STEP 1 Begin by pressing the START button for over two seconds. This will clear any other chosen function. STEP 2 The PROGRAM selection will be flashing. Use the UP and DOWN buttons to select a program. Then press the ENTER button - the TIME selection should now be flashing. Use the UP and DOWN button to set the time you want to exercise for. Then press the ENTER button - the CALORIE selection should now be flashing. Use the UP and DOWN buttons to set the target amount of calories you would like to burn during your workout. Then press the ENTER button - the AGE selection should now be flashing. Use the UP and DOWN buttons to select your age. Press the START button to begin exercising. NOTE: If you do not want to set TIME, CALORIES, or AGE you can just select the program you would like and press the START button. All numbers will count up from zero. If you do set numbers for multiple selections, such as CALORIES and TIME, the computer will beep and stop when the first goal gets to zero. In this example if you still had 3 minutes left on the time, but the calories reached zero the workout would be done. Once you begin exercising, your preset workout interval will be flashing. You can also increase or decrease your workout resistance by pressing the UP or the DOWN buttons. To PAUSE your exercising program, press the START button, then to resume, press the START button again.

LCD Contrast Calibration

The contrast of the screen can be adjusted by the following steps: During the STOP mode, press and hold the ENTER and UP buttons together for over two seconds. You will hear a faint beep. This will open the LCD contrast calibration mode. Then press the UP or DOWN button to adjust the contrast of the screen. Press START button to set the desired level of contrast. There are 16 levels of contrast.
NOTE: The workout course will automatically be saved as soon as you press the START button.
Heart Rate Chest Strap and Receiver
Your 9.5e comes with a wireless Heart Rate Chest Strap. Wearing the chest strap during exercise will allow you to have a heart rate reading regardless of hand placement. The receiver that plugs into the computer (next to the book holder) is the Heart Rate Receiver. It must be plugged into your computer so it can receive the wireless signal from the Chest Strap. Follow the instructions in the wireless chest strap package for direction on how to use the Wireless Chest Strap while exercising.
EXERCISE GUIDELINES IMPORTANT
Please review this section before you begin exercising.

IMPORTANT:

If you are over 35 and have been inactive for several years, you should consult your physician, who may or may not recommend a graded exercise test. If you are just beginning your exercise program, your target heart rate range should be roughly at 60% of your maximum heart rate. As you become more conditioned (or if you are already in good cardiovascular shape) you can increase your target heart rate to 70%-85% of your maximum heart rate. Remember, your target heart rate is only a guide. You should also consult your physician if you have the following: High blood pressure High cholesterol Asthma Heart trouble Family history of early stroke or heart attack deaths Frequent dizzy spells Extreme breathlessness after mild exertion Arthritis or other bone problems Severe muscular, ligament or tendon problems Other known or suspected disease If you experience any pain or tightness in your chest, an irregular heartbeat or shortness of breath, stop exercising immediately. Consult your physician before continuing. Pregnant Balance Impairment Taking medications that affect heart rate

KNOWING THE BASICS

Physical fitness is most easily understood by examining its components, or "parts". There is widespread agreement that these five components comprise the basics of physical training: CARDIORESPIRATORY ENDURANCE the ability to deliver oxygen and nutrients to tissues, and to remove wastes, over sustained periods of time. Using your New Balance 9.5e will improve this. MUSCULAR STRENGTH the ability of a muscle to exert force for a brief period of time. Upper body strength, for example, can be measured by various weight-lifting exercises. MUSCULAR ENDURANCE the ability of a muscle, or a group of muscles, to sustain repeated contractions or to continue applying force against a fixed object. Push-ups are often used to test endurance of arm and shoulder muscles. FLEXIBILITY the ability to move joints and use muscles through their full range of motion. The sit-and-reach test is a good measure of flexibility of the lower back and backs of the upper legs. BODY COMPOSITION often considered a component of fitness. It refers to the makeup of the body in terms of lean mass (muscle, bone, vital tissue and organs) and fat mass. An optimal ratio of fat to lean mass is an indication of fitness, and the right types of exercises will help you decrease body fat and increase or maintain muscle mass. To help track your progress we have provided Workout Progress Charts on pages 21 and 22.

WHEN TO EXERCISE

The hour just before the evening meal is a popular time for exercise. The late afternoon workout provides a welcome change of pace at the end of the work day and helps dissolve the day's worries and tensions. Another popular time to work out is early morning, before the work day begins. Advocates of the early start say it makes them more alert and energetic on the job. Among the factors you should consider in developing your workout schedule are personal preference, job and family responsibilities, availability of exercise facilities and weather. It's important to schedule your workouts for a time when there is little chance that you will have to cancel or interrupt them because of other demands on your time. You should not exercise strenuously during extremely hot, humid weather or within two hours after eating. Heat and/or digestion both make heavy demands on the circulatory system, and in combination with exercise can be an over-taxing double load.
MEASURING YOUR HEART RATE

(see chart on page 17)

Heart rate is widely accepted as a good method for measuring intensity during running, swimming, cycling, and other aerobic activities. Exercise that doesn't raise your heart rate to a certain level and keep it there for 20 minutes won't contribute significantly to cardiovascular fitness. The heart rate you should maintain is called your Target Heart Rate. There are several ways of arriving at this figure. One of the simplest is: maximum heart rate (220 - age) x 70%. Thus, the target heart rate for a 40 year-old would be 126. In this example for this 40 year old to get a cardiovascular effect the
AEROBIC EXERCISE: HOW MUCH? HOW OFTEN?
Experts recommend that you do some form of aerobic exercise at least three times a week for a minimum of 20 continuous minutes. Of course, if that is too much, start with a shorter time span and gradually build up to the minimum. Then gradually progress until you are able to work aerobically for 20-40 minutes. If you want to lose weight, you may want to do your aerobic workout five times a week. It is important to exercise at an intensity vigorous enough to cause your heart rate and breathing to increase. How hard you should exercise depends to
individual would need to keep their heart rate at or above 126 beats per minute to get a cardiovascular effect. Note: Although 70% was used in this example, the heart rate range needed to achieve results falls between 60% and 85% of your maximum heart rate. If you are just beginning your exercise program, your target heart rate range should be roughly at 60% of your maximum heart rate. As you become more conditioned (or if you are already in good cardiovascular shape) you can increase your target heart rate to 70%-85% of your maximum heart rate. Remember, your target heart rate is only a guide. When checking heart rate during a workout, take your pulse within five seconds after interrupting exercise because it starts to go down once you stop moving. Count pulse for 10 seconds and multiply by six to get the per-minute rate. Remember, your New Balance 9.5e Elliptical Trainer also comes with pulse sensors located on the swing arms. When used properly, the unit pulse sensors can help you to determine your estimated heart rate. To do so: a) Push the START button on your computer. b) Gently grab both metal pulse sensors on both swing arms. Wait 6 seconds. c) Your estimated heart rate range will be displayed on screen. Check the chart on the following page to see if you are within your range according to your age. When used properly, the heart rate pulse sensors and display monitor provide a reasonably accurate estimate of your actual heart rate. This estimate is not exact and persons with medical conditions and/or a specific need for accurate heart rate monitoring should not rely on the estimations provided. By using the chart on page 17 you can see where your heart rate falls in the minimum and maximum target zones. The above are guidelines, people with any medical limitations should discuss this formula with their physician.

CLOTHING

All exercise clothing should be loose-fitting to permit freedom of movement, and should make the wearer feel comfortable and self-assured. Never wear rubberized or plastic clothing, such garments interfere with the evaporation of perspiration and can cause body temperature to rise to dangerous levels. We recommend wearing a workout shoe with a rubberized sole unless instructed otherwise.

TIPS TO KEEP YOU GOING

1) Adopt a specific plan and write it down. 2) Keep setting realistic goals as you go along, and remind yourself of them often. 3) Keep a log to record your progress and make sure to keep it up-to-date. See pages 21-24. 4) Include weight and/or percent body fat measures in your log. Extra pounds can easily creep back. 5) Upgrade your fitness program as you progress. Your New Balance 9.5e provides 15 different workout programs to keep your workouts challenging. 6) Enlist the support and company of your family and friends. 7) Update others on your successes. 8) Avoid injuries by pacing yourself and including a warm up and cool down period as part of every workout. See page 15. 9) Reward yourself periodically for a job well done!
HEART RATE TARGET ZONE FOR CARDIOVASCULAR FITNESS

TABLE 1

75 70% Target 80 Zone 123 85% Target Zone Maximum Attainable Heart Rate
Heart 160 Rate (Beats/ 150 Min)

AGE (YRS)

TABLE 2
Exercise Week Warm Up Period THR% Minutes Cool Down Period Total Time Sessions Per Wk. Total Time Per Wk.
&1 & 2 &3 & 4 &5 & 6 &7 & 8 & 9 & 10 &11 & 12

min min min min min min

60-65% 65-70% 70-75% 70-80% 70-85% 70-85%

-8 -10 -15 -20 -25 -25

105 105
WARM UP & COOL DOWN STRETCHES
Stretches can help improve flexibility and relieve the tightness in muscles that results from repetitive sport movements that require a limited range of motion, like elliptical striding. 10 to 12 minutes of daily stretching is recommended. This can be done when warming up or cooling down. When performing these stretches, your movements should be slow and smooth, with no bouncing or jerking. Move into the stretch until you feel a slight tension, not pain, in the muscle and hold the stretch for 20 to 30 seconds. Breathe slowly and rhythmically. Be sure not to hold your breath. Remember that all stretches must be done for both sides of your body.

1. Quadriceps Stretch

Stand close to a wall, chair or other solid object. Use one hand to assist your balance. Bend the opposite knee and lift your heel towards your buttocks. Reach back and grasp the top of your foot with the same side hand. Keeping your inner thighs close together, slowly pull your foot towards your buttocks until you feel a gentle stretch in the front of your thigh. You do not have to touch your buttocks with your heel. Stop pulling when you feel the stretch. Keep your kneecap pointing straight down and keep your knees close together. (Do not let the lifted knee swing outward.) Hold the stretch for 20 to 30 seconds. Repeat for the other leg.
2. Calf and Achilles Stretch
Stand approximately one arms length away from a wall or chair with your feet hip-width apart. Keeping your toes pointed forward, move one leg in close to the chair while extending the other leg behind you. Bending the leg closest to the chair and keeping the other leg straight, place your hands on the chair. Keep the heel of the back leg on the ground and move your hips forward. Slowly lean forward from the ankle, keeping your back leg straight until you feel a stretch in your calf muscles. Hold for 20 to 30 seconds. Repeat for the opposite leg.
3. Overhead/Triceps Stretch
Stand with your feet shoulder width apart and your knees slightly bent. Lift one arm overhead and bend your elbow, reaching down behind your head with your hand toward the opposite shoulder blade. Walk your fingertips down your back as far as you can. Hold this position. Reach up with your opposite hand and grasp your flexed elbow. Gently assist the stretch by pulling on the elbow. Hold for 20 to 30 seconds. Repeat for the opposite arm.

4. Back Stretch

Stand with your legs shoulder length apart and your knees slightly bent. Bend forward from your waist with your arms extending loosely in front of your body. Gently bend from the waist flexing your body as far forward as it will go. Hold for 20 to 30 seconds. Straighten up and repeat.
5. Standing Hamstrings Stretch
Stand with your legs hip-width apart. Extend one leg out in front of you and keep that foot flat against the ground. With your hands resting lightly on your thighs, bend your back leg and lean forward slightly from your hips until you feel a stretch in the back of your thigh. Be sure to lean forward from the hip joint rather than bending at your waist. Hold for 20 to 30 seconds. Repeat for the opposite leg.

6. Buttocks, Hips and Abdominal Stretch
Lay flat on your back with your hips relaxed against the floor. Bend one leg at the knee. Keeping both shoulders flat on the floor, gently grasp the bent knee with your hands and pull it over your body and towards the ground. You should feel a stretch in your hips, abdominals and lower back. Hold for 20 to 30 seconds and release. Repeat for opposite side.

7. Inner Thigh Stretch

Sit on the floor and bend your legs so that the soles of your feet are together. Place your elbows on your knees. Lean forward from the waist and press down lightly on the inside of your knees. You should feel a stretch in the muscles of your inside thigh.

8. Arm Pullback

Stand with your feet shoulder width apart and toes pointing forward and with your knees slightly bent. Let your arms hang relaxed on either side of your body. Expand your chest and pull your shoulders back. Bend your elbows slightly and clasp your hands behind your back. Slowly straighten your arms as you lift your hands upward. Raise your hands upward until you feel mild tension in your shoulder and chest region. Hold for 20 to 30 seconds. Lower your arms to their original position and bend your elbows. Release your hands and return them to your sides.
CARE & STORAGE OF YOUR NEW BALANCE 9.5e

Care For Your Unit

Your New Balance 9.5e Elliptical Trainer has been carefully designed to require minimum maintenance. However, we recommend the following to keep your unit operating smoothly. Unplug your unit when it is not in use. Use your unit indoors only. Wipe all perspiration from your elliptical trainer with a soft, clean cloth after each use to prevent an accumulation of sweat and dirt. Clean your elliptical trainer on a regular basis to prevent a build-up of dust. Use Windex or an alcohol based cleanser on a clean cloth. Do not use any abrasive cleaners and/or polish as these will damage the surface. Store your equipment in a dry area away from children and high traffic areas. Regularly check the tightness of nuts and bolts.
Instructions For Moving Your Unit
Your elliptical trainer is portable. If you need to change the location of your unit, please follow the steps below. Stand behind the unit and grasp the Stabilizer Bar located at the rear of the unit. Lift up using your legs - not your back. Tip the machine forward until it is resting on the front transportation wheels/front rollers. Wheel the machine to its new location and carefully lower the unit back down to the floor.

MILITARY MEDICINE, Vol. 175, August Supplement 2010
understand how I can make sure that warriors and their families can lead their lives to the fullest. I have challenged the scientists to think holistically and to provide our 21st century leaders with 21st century denitions of tness, health, and resilience. Inevitably in war, some men and women pay the ultimate sacrice. For those surviving members of their families and those who have served beside them I am obligated to provide opportunities for them to meet whatever challenges they face in the future. For those who continue to serve, I must make sure they stand t and ready to face whatever missions they are called to execute. For those who move into the civilian world, I believe we owe them our full support for a successful transition toward a life that is as rich and fullling as it can possibly be. Most importantly, for the families who have sacriced so much, I fully embrace my role as a defender of their rights. Total force tness is more than a physical tness. It is the sum total of the many facets of individuals, their families, and the organizations to which they serve. It is not something someone achieves twice a year for a test. It is a state of being. To the scientists and health care providers who read this issue of Military Medicine, I issue this call: Help me help our troops and their families. Give us the tools to know when to intervene. Provide us with scientic measures of total force tness. Give our people the guidance and support they need. Keep your minds open to creative new concepts and possibilities. Critically evaluate the role of complementary and alternative medicine.10,11 Add to our understanding of the connections between physical tness and aging.12,13 And nally, explore the anecdotal evidence regarding total force tness and then develop scientic protocols to put these observations to objective tests. In return, I will defend your efforts, advocate for your cause, and ght any bureaucratic hurdles that may pass in your way.

REFERENCES

1. Sun Tzu: The Art of War. Translated by Samuel B. Grifth. Oxford University Press, 1971. 2. Ekeland E, Heian F, Hagen KB, Abbott J, Nordheim L: Exercise to improve self-esteem in children and young people. Cochrane Database Syst Rev 2004; (1):CD003683. 3. Dutta-Bergman MJ: Primary sources of health information: comparisons in the domain of health attitudes, health cognitions, and health behaviors. Health Commun 2004; 16(3): 27388. 4. Strong KA, Parks SL, Anderson E, Winett R, Davy BM: Weight gain prevention: identifying theory-based targets for health behavior change in young adults. J Am Diet Assoc 2008; 108(10): 170815. 5. Aarnio M, Winter T, Kujala U, Kaprio J: Associations of health related behaviour, social relationships, and health status with persistent physical activity and inactivity: a study of Finnish adolescent twins. Br J Sports Med 2002; 36(5): 3604. 6. Su KP: Biological mechanism of antidepressant effect of omega-3 fatty acids: how does sh oil act as a mind-body interface? Neurosignals 2009; 17(2): 14452. 7. Parker G, Gibson NA, Brotchie H, Heruc G, Rees AM, Hadzi-Pavlovic D: Omega-3 fatty acids and mood disorders. Am J Psychiatry 2006; 163(6): 96978. 8. Joseph S: Client-centred therapy, post-traumatic stress disorder and posttraumatic growth: theoretical perspectives and practical implications. Psychol Psychother 2004; 77(Pt 1): 10119. 9. Calhoun LG, Tedeschi RG, Park CL: Posttraumatic growth: positive changes in the aftermath of crisis. Lawrence Erlbaum Associates, 1998. 10. Levin JS, Glass TA, Kushi LH, Schuck JR, Steele L, Jonas WB: Quantitative methods in research on complementary and alternative medicine. A methodological manifesto. NIH Ofce of Alternative Medicine. Med Care 1997; 35(11): 107994. 11. Aickin M: The importance of early phase research. J Altern Complement Med 2007; 13(4): 44750. 12. Hardy S, Grogan S: Preventing disability through exercise: investigating older adults inuences and motivations to engage in physical activity. J Health Psychol 2009; 14(7): 103646. 13. Colcombe SJ, Kramer AF, McAuley E, Erickson KI, Scalf P: Neurocognitive aging and cardiovascular tness: recent ndings and future directions. J Mol Neurosci 2004; 24(1): 914.

MILITARY MEDICINE, 175, 8:3, 2010
ABSTRACT Fitness and health care have traditionally had a major focus in the military and will continue to be an important focus for the medical community throughout the 21st century. The challenges of meeting comprehensive mental and physical care for service members are many, especially in this era of persistent conict. We must clearly dene what those tness components will be, how they will be assessed as an individual measure, as well as how it will be applied to the community at large. How will it be trained and who determines and what is the end state are only some of the tasks ahead. The Department of Defense (DoD) will be an active participant in these discussions as we forge ahead. Effective, well-informed guidance from our senior leaders is paramount to the success of this initiative and ensures that it becomes integrated into the entire life cycle of our service members.
CURRENT DEPARTMENT OF DEFENSE GUIDANCE FOR TOTAL FORCE FITNESS Fitness and health care have traditionally had a major focus in the military and will continue to be a important focus for the medical community throughout the 21st century. Today, the challenges of meeting comprehensive mental and physical care for our service members are many, especially in this era of persistent conict. One must ask two questions: What is military tness? What and who determines what qualities are components of total force tness? We have focused much of our attention on enhancing physical health and equating that to tness, but we must look beyond this singular focus for all. Going back to 2006, the Uniformed Services University of the Health Sciences held a conference for more than 80 attendees from several Department of Defense (DoD) and service-level organizations on this subject. Entitled Human Performance Optimization (HPO) in the Department of Defense, this conference set out toward a goal of initiating the development of an overall strategic plan for human performance optimization for the military. The nding of this conference was subsequently published in Military Medicine in 2007.1 This conference recognized that there was a capability gap regarding HPO, and even today it continues to be so. One important initiative that evolved from that meeting was the development of a dedicated human performance ofce within Force Health Protection in the Assistant Secretary of Defense Ofce (Health Affairs). This ofce has been an active partner within the DoD on all issues arising in the area of HPO. Other related efforts at the DoD Health Affairs level to highlight tness and performance can be found in the Military Health System Strategic Plan. A Healthy, Fit and Protected Force is one of the four components of the mission of the MHS and Optimizing Human Performance is further specied in mission element 2: Fit, Healthy and Protected Force.2 The importance of tness is also recognized in the most current version of the Joint Force Health Protection Concept of Operations dated July 2007, as a Joint Force Health Protection capability.3 Senior leadership further

FIGURE 1. Mission tasks can be separated into the four different components. Training these components while using injury prevention strategies can result in well-balanced, uninjured, physically t service members.
tive tasks at a lower relative work load; patrolling 10 miles will become easier. Endurance is aerobic training which is dependent on the bodys ability to take in and utilize oxygen, VO2max. The American College of Sports Medicine (ACSM) and the American Heart Association recommend a minimum of 30 minutes of moderately vigorous aerobic activity for a minimum of 5 days a week for adults under the age of 65.10 However, participation in physical activity above the minimum and within the guidelines will increase the health benets.10,11 Since the military requires service members to perform challenging physical tasks, they should perform more than the minimum duration and frequency of aerobic training. Examples of endurance training are long-distance running, swimming, foot marching, cycling, low-weight, high-repetition strength training, and stairmaster. Distance, duration, repetition number, and speed need to be increased gradually to reduce the risk of injury and increase performance. A very general example would be increasing the distance run only 10% per week. Mobility Mobility is the ability to move the body in space with the precision necessary to negotiate an obstacle, such as entering a window. Mobility training is designed to increase the service members speed, balance, jumping, and ability to change direction. Anaerobic training can improve mobility. This involves training with tasks that take no more than 5 minutes. Examples of mobility training include jumping, sprinting, and climbing. Plyometrics (jumping exercises) have been shown to be effective in increasing vertical jump height more than strength training alone.1214 Speed (sprint) training over 11 weeks with 34 sets of 3 sprints of 10 m increasing to 50 m has been shown to increase jump height, jump power, jump length, squat strength, sprint speed, and agility.15
It is important that speed training incorporate changes in direction as well. If a service member is training to accomplish running tasks that require quick directional changes, the principle of specicity of training should be applied; namely, train by sprinting in a straight line as well as with multiple directional changes. Using only straight sprint training results in increases in straight speed but not change-of-direction speed and vice versa.16 Therefore, a combination of the two training techniques is needed.17 Strength The purpose of strength training is to increase the service members ability to generate force and power, thus lowering the relative work required to complete mission tasks. Muscle strength is the maximum force created by a muscle, muscle endurance is the ability to create a force repetitively or sustain it, and power is the ability to create force quickly across distance. Hence, strength is required to lift a 40-lb box, while power is the ability to move the box 4 feet in 1 second. Many weight training regimes are based on a one-repetition maximum (1 RM). This is simply the most weight that the service member can lift once. Novice individuals should begin with 6070% of their 1 RM for 812 repetitions and 23 sets.18 However, once a service member has been strength training for 6 months or more, 80% of 1 RM is needed to continue to increase ones strength and 85% has been shown to be most effective in athletes.18 It is important to remember that even though 80% is stated to be the most successful, this effectiveness is maximized when incorporated into a periodized weight training program.19 Periodization is a phased training program using a variety of sets, repetitions, weights, and exercises. The strength program goal always needs to be considered. For maximum strength to increase, one of three things must happen: (1) the load must increase, (2) repetitions must increase, or (3) rest periods must be lengthened.18 For muscle endurance to increase, repetition speed should be increased and rest time reduced.18 If the goal is to increase power, light loads (060% 1 RM for lower body and 3060% 1 RM for upper body) are used with fast repetitions.18 The amount of rest time between sets varies, depending on the goal of the weight lifting program.19 If the goal is for maximum one-time strength, such as lifting a heavy casualty, then the rest periods between sets need to be longer, at least 23 minutes and often up to 5.20,21 If the goal of the program is to increase endurance, such as lifting more boxes, then the rest period should be shorter, less than 1 minute for sets of 1015 repetitions and 12 minutes for 1520 repetition sets.22,23 For power, such as pushing up out of the prone, rest periods should be 35 minutes between sets.18 Ballistic exercises use very fast explosive movements and are most effective when training power.18 It is important to remember that maximum strength, muscle endurance, and power are all inter-related and a general program should include aspects of each one. ACSM recommends that weight lifting be performed 34 days a week.18 It is important

Any prescription drug misuse is dened as the nonmedical use of prescription-type amphetamines/stimulants (including any use of methamphetamine), tranquilizers/muscle relaxers, barbiturates/sedatives, or pain relievers. Nonmedical use of prescription-type drugs is dened as any use of these drugs, either without a doctors prescription, in greater amounts or more often than prescribed, or for any reasons other than as prescribed, such as for the feelings they caused. Outcomes/Benets of the Fitness Domain and Components The primary outcome for this domain should be the near elimination of illicit drug use by active duty personnel, including reduction of inappropriate use of ones own or others prescription medication. Secondary outcomes include reduction in lowered functioning and in illness and accidents resulting from illicit drug use. Metrics Drug use can be determined in three ways: self-report, other report, and drug testing. Self-Report of Illicit Drug Use Obviously, few active duty members will reveal illicit drug use to the command. However, anonymous reports have been obtained in the HRB survey (although there is likely some under-reporting). Other Reporting Although a useful source of information for the command, there are no reports on frequency of co-workers reporting drug use for their peers. Drug Testing By far, the most effective method of controlling illicit drug use is random drug testing. When conducted frequently, randomly, and properly to ensure accuracy of sample and analysis, this approach appears to be the most effective means of controlling drug use. It is neither effective for drugs not included on the panel (e.g., muscle relaxants, sleep aids, and some street drugs) nor for inappropriate use of ones own prescription drugs. Strength of Evidence for Domain and Component The HRB Survey has shown clear evidence of lowered use of illicit drug use over the years.2,3 In general, military rates are lower than those found in the civilian community, but the consequences in the military are often more grave, given the duties facing active duty personnel. Comparing the HRB Survey, an anonymous survey, with nonanonymous surveys shows an expected discrepancy in accuracy when identiable reporting is required. Treatment programs for illegal drug use have modest results, at best.
How This Fitness Domain Is Being Addressed With Current Programs Random drug testing clearly has been a benecial program for reducing illegal substance use and prescription drug use in those not holding a current prescription for that drug. Existing severe penalties for illegal drug use are a useful deterrent. However, repercussions for abuse of ones own prescription drugs are rarely severe, at least for initial detection. Substance abuse subcomponents, desired outcomes, metrics, current policies, and recommendations are summarized in Table II. BEHAVIORAL HEALTHPSYCHOPHYSICAL FACTORS Although psychological factors play an important role in military tness, this component is considered elsewhere in this supplement. Here, we will focus on weight and sleepprimary psychophysical behavioral factors that inuence tness for duty. Other behaviors such as eating and exercise affect weight, and psychological factors (anxiety, depression, stress), substances (caffeine, alcohol), or biological factors (snoring, sleep apnea, hormonal changes) may lead to sleep problems. Sleep function is associated with quality of performance and quality of life and affects up to 85% of deployed service members.43 Weight is directly addressed by the military, whereas sleep, although no less important, is given far less attention. Weight Overweight among military personnel is a growing concern, and it affects both immediate performance and eventual health consequences.44 Excess weight and obesity cost DoD an estimated $1.1 billion in medical care costs annually.1 Fortunately, behavioral interventions, such as regular physical activity and proper weight control, can reduce the risks of coronary heart disease, can prevent or help control high blood pressure, and are important for weight control.4548 Physical activity can also reduce depression and anxiety.49,50 Being overweight in the military has both health and career consequences. The military has generally set a body mass index (BMI) <25 as acceptable weight standards (as determined by height and weight), assessed during twice annual physical tness tests. Surpassing this threshold can lead to enrollment in a diet and tness program, a disciplinary report in ones record, and discharge if weight remains out of standards, especially during recruit training.51 Individuals can experience health consequences of being overweight as well. Approximately 70% of the relative risk for heat during basic training has been associated with exceeding body fat standards.52 Similar to civilian society, weight levels have been increasing in the military, but there have been recent improvements. From 1995 to 2005, the percentage of personnel under 20 years of age with a BMI 25 rose from 28% to 45%, but in

Daily energy expenditures of various military populations performing mission duties in a range of environments. (Source: Tharion et al., 2005)
Personnel performing ground defense, engineering/construction duties, or general support duties have energy requirements of approximately 1315 MJ/day (3,2003,700 kcal/day).16 Even lower total energy expenditures (1011.7 MJ/day or 2,2002,800 kcal/day) have been measured in military women, in part because of their small total body and lean mass. Reference databases that include the energy requirements of individual military tasks, and those that present average daily energy expenditures of military personnel performing a variety of mission-specic tasks, such as those described above, can be used to estimate the energy requirements of a given military population.16 Online calculators are also available for estimating the energy expenditures from activity diaries (e.g., http://www.shapeup.org/interactive/phys1.php, http://www. mypyramidtracker.gov/). Similar tools are available for estimating water and electrolyte requirements.15,56 Individual AssessmentFood Choices and Knowledge The adequacy of individual food choices can be assessed by survey or direct observation or inferred by measuring specic physiologic biomarkers. The Department of Defense regularly conducts a large scale survey assessing military lifestyle; the most recent survey included several questions related to dietary practices.57 The California Dietary Practices Survey is an example of a more robust survey tool that could be used by the military to assess dietary behaviors, (http://cdph.ca.gov/
programs/cpns/pages/californiastatewidesurveys.aspx). Food frequency questionnaires, such as the Block Dietary Data Systems Assessment Survey (http://www.nutritionquest.com) and the Dietary History Questionnaire (http://riskfactor.cancer.gov/ DHQ) provide information on the adequacy of individuals usual intakes for meeting their recommended nutrient intakes. Direct observation of both the acceptability of individual items and the quantity of the rations that warriors eat is used by the combat feeding directorate to develop new menus and food components for ration packs such as the Meals, Ready to Eat (MREs) and First Strike Rations. Physiologic biomarkers of nutritional tness include body mass and percent body fat, as well as analytes from blood, saliva, or other cellular samples that are reective of specic nutrient adequacy. Tools for assessment of nutritional knowledge are also available. The Diet and Health Knowledge Survey (http:// ars.usda.gov/services) and the Nutrition Knowledge Questionnaire (http://www.ucl.ac.uk/hbrc/resources.html) are two examples. The latter has been validated and has a scoring system, enabling both between- and within-group comparisons. DIETARY PRACTICES AND NUTRITION KNOWLEDGETHE STATUS QUO Relatively few military personnel are eating a diet that meets the recommended dietary guidelines for Americans (DGA) (see Table I) or achieve Healthy People 2010 objectives for

Exceptional Spiritual Experiences
Central to Judaism, Christianity, and Islam is the command to believe in and love God as well as to love your neighbor as yourself. Eastern philosophies and religions such as Buddhism highlight the importance of transcending a limited view of the self as an isolated, self-sufcient entity. The ideal view is one that sees all humanity as interdependent and interrelated, and therefore naturally replaces insatiable drives to fulll individual interests with a prosocial and compassionate attitude that cherishes the well-being and happiness of others, even more than personal happiness. These values point
Exceptional Human Experiences (EHEs) touch on areas outside the common sense reality of our everyday world, e.g., a sense of enlightenment or certainty, a feeling of unity.44,45 This is a psychospiritual term including both spiritual experiences (e.g., mystical experiences) and psychological experiences (e.g., Maslows peak experience category). Spiritual experiences can be either interpretive or direct. Interpretive spiritual experience is spiritual not because of any unusual features of the experience itself, but because it is viewed in the light of a prior [spiritual] interpretive framework.46 Spirituality allows the individual to nd spiritual meaning in all sorts of situations, enhancing positive experiences
and mitigating negative ones through cognitive reframing of events as implicitly spiritual experiences. In addition to interpretive spiritual experiences, a number of directly spiritual experiences are now well established in the psychiatric literature as normal, benecial, and common. These are bereavement visits (perceived visits by the deceased)4754 and near-death experiences.50,55,56 These experiences are associated with the death of someone emotionally close or ones own close brush with death. These situations are especially common in combat, so these experiences may be expected to be especially prevalent in the military during conict. These experiences are salutogenic, changing potentially traumatic events into occasions of growth and consolation. Before the 1970s, these experiences were consistently viewed as pathological hallucinations, but contemporary psychiatric textbooks describe them as normal and conducive to psychological health. Both experiences reduce fear of death and encourage prosocial growth.56,57 Unfortunately, despite progress in the published psychiatric literature, both clergy and health care providers still often misinterpret reports of such experiences as psychiatric symptoms. Though positive, these experiences can produce anxiety if experiencers cannot speak about them openly and receive social support.53 In the military, where perceived stigma reduces utilization of mental health services, it is especially important that care and support personnel understand these experiences and help to create an environment that facilitates their positive effects and avoids the negative effects of stigma. Outcomes/Benets of Spiritual Fitness

Sense of Coherence Questionnaire (SOC) Measures the important salutogenetic construct sense of coherence, which consists of the three subdimensions manageability, comprehensibility, and meaningfulness.111 High consistency (Cronbach a for SOC-13 ranges from 0.74 to 0.91) and considerable stability (e.g., 0.54 over a 2-year period).112 High level of content, face, and construct validity.112

(Continued )

TABLE III. Continued
Options for Metrics Benets of Component, Including Referenced Evidence Where Appropriate
Freiburg Mindfulness Inventory (FMI) Short, 14-item version measures mindfulness as a one-dimensional construct that is associated with regular meditative practice.116 Internal consistency high (Cronbach a = 0.86).25 Can be used in subjects without previous meditation experience. FMI correlates well with relevant constructs (self-awareness, dissociation, global severity index, meditation experience in years).116 Daily Spiritual Experience Scale (DSES)119 A 16-item unidimensional instrument designed to measure frequency of positive spiritual experiences. Assesses the perception of the connection with the transcendent as well as moments of interactions with the transcendent in daily life. Items focus on experience rather than beliefs or behaviors. Can be used to measure vertical transcendence. Cronbachs = 0.95; testretest reliability a = 0.92.119,120 Interpersonal Support Evaluation List (ISEL)87 Two domains of the ISEL measure belonging and perceived isolation. Can measure horizontal transcendence. Index of Core Spiritual Experiences (INSPIRIT) 7-item scale measuring the occurrence of experience that convinces a person God exists and evokes feelings of closeness with God, including the perception that God lives within.124 Not specic to exceptional experiences, but clearly would include them.125 Exceptional Experiences Questionnaire (EEQ): Measures the frequency and evaluation of exceptional experiences as a multidimensional construct. Factors: positive spiritual experiences, experiences of ego loss, psychopathological experiences, visionary dream experiences.105
Self-awareness: Reection and Introspection

Transcendence

Ability to reframe positively the stressors of deployment and recover more quickly from mental and psychological stress.74 Allows leaders to adapt to the external environment, potential adversaries, allies and local populations; to shift gears quickly, transitioning quickly from ghting in one moment to relating peacefully with the local community in the next; to access information from a wider variety of channels; and to display greater accuracy and more objectivity in gathering information.74 Improved attention and self-regulation.23 Increased efciency of the executive attentional network leading to better task performance.113 Enhanced attentional stability, reduced mean reaction time, improved target detection times, and increased efciency by reducing task effort.114 Protection against functional impairments in working memory capacity, which is used in managing cognitive demands and emotion regulation.24 Increased control over distribution of limited brain resources, which is signicant in the dynamic, high-stress, and resource-scarce combat environment.115 Reduced risk of physical, psychological, and spiritual injury. Charitable or seless actions and behaviors. Well-being. Feeling of connection/belonging. Absence of loneliness/isolation. Leaders who promote a vision of transcendent service41,42,117 in their units can transform something mundane to something vibrant, where individual and collective spirituality are valued and reinforced, and spiritual development becomes a cultural expectation of the group for mission accomplishment for the greater good.118

Reduced death anxiety.56,93,121,122 Association between bereavement visits and healthy faster resolution of grief.4648,53 Avoidance of anxiety and potential interpersonal conict produced by conventional stigmatization of such experiences as pathological. Increased life purpose and satisfaction, a health-promoting attitude. Decreased frequency of medical symptoms.123
82 TABLE IV. Operationally Relevant Outcomes and Metrics
Recommended Metric for Each Variable Connor Davidson resilience Scale (CD-RISC) Distinguishes between those with greater and lesser resilience. Has been used in military populations. The two-item version of the Connor-Davidson Resilience Scale (CD-RISC2) takes less than 30 seconds to complete and asks about ones abilities to adapt to change and recover from illness or hardship, and distinguishes between those with greater and lesser resilience.61 CD-RISC2 has demonstrated validity, good test-retest reliability, and signicant correlation with the full, 25-item version of the CD-RISC.62 Related Variables Other related variables and metrics: Post-deployment reintegration Symptoms of depression

Operational Outcome

Resilience and Recovery From Key variable and metric: Deployment- and Combat-Related Resilience Trauma
Well-being Key variable and metric: Risk factors for moral injury and spiritual resilience
Post-Deployment Readjustment Inventory (PDRI)60 Patient Health Questionnaire (PHQ-2) Included in the Post-Deployment Health Assessment and Re-Assessment (PDHA/ PDHRA) is the Pateint Health Questionnaire (PHQ-2), a 2-item depression instrument with high construct and criterion validity.80,81 Veterans RAND 12-Item Health Survey VR-12 Derived from the SF-36, the gold standard used by the VA to measure health related quality of life.82 Deployment Risk and Resiliency Inventory (DRRI)83 Created with DoD and Veterans Affairs support to assess key deployment-related risk factors unique to contemporary warfare that can negatively impact service members health and well-being.84 The DRRI scales assess: Prewar factors such as prior stressors and early life experiences. Deployment and war-zone factors such as stereotypical warfare experiences, ones sense of preparedness and safety in the combat zone, and exposure to nuclear-biological-chemical agents and consequences of combat. Postwar factors such as the extent of social support and stressful life events post-deployment.85 Knowledge questionnaire/test following training session on this topic. Existence of pre-deployment facilitated discussions with chaplains, including scenario building, role playing, etc.

MILITARY MEDICINE, 175, 8:97, 2010
ABSTRACT The Department of Defense (DoD) is exploring the holistic construct of total force tness for individual service members. This exploration provides an opportunity to understand tness concepts in the context of military families. Currently, there are no developed operational denitions or integrated models for the concept of total family tness. This article used the U.S. Navy experience with family programs to begin the discourse of family tness and identify potential family tness-related metrics. A proposed denition of family tness was developed from the conservation of resources theory and a model of family resilience. This article identies eight dimensions of family functioning: problem solving, communications, family roles, affective responsiveness, affective involvement, behavior control, global health, and spiritual support. Four potential instruments are identied that could provide metrics for these family dimensions.
INTRODUCTION There is increasing awareness that military children and families are signicantly affected by a parents combat-related mental health problems and physical injuries, as well as the wear and tear of multiple wartime deployments.1,2 Given that over 50% of U.S. service members are parents, a large number of military children and families are at risk and may benet from targeted preventive services.3 Specic high-risk groups include parents with active symptoms related to post-traumatic stress or other mental health conditions. Psychological injuries and symptoms can interfere with parenting, family functioning, and child adjustment.2,46 Another high-risk group are the families of the over 31,000 combat-injured service members. Combat and operational injuries, whether psychological or physical, in a military parent are likely to disrupt family roles, sources of care, and instrumental support.7,8 These factors underscore the urgent national public health need to provide family-centered, evidence-based prevention services to military children and families who have been affected by multiple wartime separations and parental combat-related psychological and physical injury. Despite ongoing advances in the availability of traumainformed resources for consumers and providers (e.g., Sesame Streets Talk, Listen, Connect: Helping Families During Military Deployment, Military OneSource web-based materials), important gaps remain in the provision of evidenceinformed interventions and services for children and families of military members and veterans who are contending with combat-related mental health problems, physical injury, and loss. Military families facing these challenges are an identied risk group who could benet from evidenced-based coping skill building interventions and services adapted for military culture.

CONCLUSIONS In tandem with the development and adoption of a toolkit containing the elements and metrics for the military-wide commitment to total force tness, a rigorous method of evaluation will provide not only a framework to show that total force tness programs are successful, but also the basis for continuous process improvement. It is vital that such methods be harnessed to deliver TFF programs now when the need is urgent, and that they can yield timely results that are relevant to the line, producing actionable evidence of effectiveness and efcacy and the evaluation of the facilitators and barriers to successful implementation, expansion, and replication. The proposed mixed-methods program evaluation will enable leaders to understand why and how a program was or was not successful to tailor the next effort thoughtfully and on the basis of scientic information. Conducting structural, process, and outcomes evaluation will provide the results required to justify spending precious resources on TFF programs, guide the allocation of resources to those with evidence-based success, and will ultimately yield a catalog of TFF programs suitable for implementation at various locations among troops with a variety of needs. For the assessment of efcacy, group randomization trial design, a comprehensive, scientically rigorous and operationally meaningful variation on program evaluation has been described. Because universally applied programs may demonstrate small treatment effect sizes, the information obtained through program evaluation, including such things as feasibility, replicability, subjective value ratings, cost analysis, and cultural/environmental t may be the determining factors in deciding which program(s) to implement. Importantly, the pragmatic methodology, in which programs are studied as they are actually implemented in real-life, brings the research function into closer alignment with the needs of the line and ensures that research lessons can be cycled into practice more efciently. At a time when stress-related illness and dysfunction are exacting a heavy toll on our military communities, the need for identifying holistic programs that work both in principle and in fact is vital. ACKNOWLEDGMENTS
1. Zoroya G: Militarys health care costs booming. USA Today, April 22, 2010. 2. Jonas W, Lewith G: Toward standards of evidence for CAM research and practice. In: Clinical Research in Complementary Therapies, Ed 2. Edited by Lewith G, Jonas W, Walach H. Littleton, NH, Churchill Livingstone, 2010 (in press). 3. Jonas W: The evidence house: how to build an inclusive base for complementary medicine. West J Med 2001; 175(2): 7980.

health and well-being. The Wellness Inventory is part of a vestep process in which users complete the assessment, receive personal wellness and satisfaction scores, and identify areas of strength and areas with motivation to change. This is followed by creating a personal wellness plan with simple action steps in areas the user is motivated to change and utilizing an array of tools (e.g., online wellness resource and study centers, a personal wellness journal) designed to help users successfully implement each step. Users are able to continually update their personal wellness plans and monitor progress by retaking the assessment every 6 months. Users receive wellness action steps in regular e-mail reminders, use an edit tool to regularly update action steps, and use a test comparison feature to track progress. Authors of the Wellness Inventory see it is an educational tool as well as an assessment. In accord with selection criteria, the Wellness Inventory is written in English, measures the wellness of individuals, and is computer-based and interactive, giving immediate feedback linked to creation of an action plan so that the user can improve his/her whole person wellness. It is multidimensional, measuring 12 key aspects of physical, emotional, behavioral, nutritional, spiritual, and social wellness. Specically, the Wellness Inventory measures: self-responsibility and -love, breathing, sensing, eating, moving, feeling, thinking, playing and working, communicating, intimacy, nding meaning, and transcending. It was chosen as an exemplar because in addition to meeting all the inclusion criteria, it is very comprehensive in nature, is adaptable, and has a strong focus on health rather than disease. Index Development The original version of the Wellness Inventory was authored by John W. Travis, MD, MPH, an early pioneer in the eld of wellness. While serving with the U.S. Public Health Services Division of Health Services Research, Dr. Travis was a protg to Dr. Lewis Robbins, creator of the rst Health Risk Appraisal (HRA). In 1975, Dr. Travis gave up the practice of sick care to open up one of the worlds rst wellness centers, Wellness Resource Center, in Mill Valley, California. The same year he personally created the Wellness Inventory as a way to assist individuals in gaining personal insight into their state of wellness and transforming their awareness into long-term sustainable change. The Wellness Inventory incorporates Dunns concepts of highlevel wellness,3 and Prochaskas Transtheoretical Model (TTM) of behavior change, also known as Stages of Change.6 The Wellness Inventory has been used by individuals and groups in a variety of populations and settings across the United States and abroad, including healthcare workers, patients, students, teachers, administrators, and veterans at worksites, schools, colleges, clinics, and hospitals. Today, the online, interactive Wellness Inventory is provided through HealthWorld Online, an Internet network for wellness and healthy living (www.wellpeople.com). Index Validation The Wellness Inventory was evaluated with a population of 141 full-time college students and determined to be a psycho112

Medical History, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814.
military hospitals existed in some garrisons later in the empire. The Romans obtained and maintained their army in a systematic manner entirely on the basis of empirical evidence.1 From the fall of Rome to the Renaissance, European armies came and went, but none were organized, trained, or maintained on the scale or in the detail of those of Imperial Rome. As the modern nation-state began to emerge in the late 15th century and with it the continuing development of gunpowder weapons, standing armies were created on the continent. Through the 16th and 17th centuries the organizational structurerecruiting, training, paying, and supplyingof these armies became more complex. The development of the tercioa military formation of about 1,750 pikemen and arquebusiers organized by companiesby the Spanish army improved tactical efciency and strength. Later Dutch military reforms increased tactical strength and exibility once again through routine drill, an established chain of command, and the development of company grade ofcers. The Swedish army under Gustavus Adolphus II pioneered the idea of a combined arms approach on the battleeld. Standing European armies were living, breathing organisms of the state. They cost money to train and maintain, and therefore the loss of soldiers through injury or illness was a nancial loss to the state. Keeping losses to a minimum catalyzed the establishment of formal military medical services, created new responsibilities for a commander, and a new relationship between commanders and the physicians and surgeons serving a force whether on land or sea began to develop. EMPIRICALLY BASED FITNESS The opinion of the military physician and military surgeon began to matter. Those opinions reected the scientic progress, numerous military ventures, and the medical experiences of European colonial expansion of the 17th century. Disease causation as proposed by Thomas Sydenham and John Locke was based upon the relative potencies of contagion, miasmas generated from the decomposition of organic matter, and
Military Hygiene Enters the 21st Century
the epidemic constitution of the atmosphere. During their voyages, soldiers and sailors contracted new fevers and developed what are now dened as dietary deciency diseases. Efforts to prevent these diseases increased during the 18th century and, while empirical, some preventive modalities were evidenced based. Aboard the HMS Salisbury during the War of Austrian Succession, James Lind conducted the rst case-control study using oranges and lemons in the treatment of scurvy.3 Although he proved the value of citrus fruit as a treatment and preventive for the disease, it would take another 50 years before his ndings were implemented by the Royal Navy. Disease rates were also found to decline if sailors were made to change their clothes regularly and wear shoes aboard ship, sensible suggestions that were implemented. Smallpox inoculationrubbing smallpox scabs into a small incision hopefully to induce a mild case of the diseasewas another evidence-based intervention, which gained acceptance in the 18th century. From midcentury the British Army in North America practiced voluntary inoculation in the face of epidemics, but when smallpox threatened to destroy our army at Morristown in the winter of 1777, General Washington ordered that the entire army be inoculated. It was a bold move considering the dangers of inoculation, and to ensure this modality did not generate a smallpox outbreak, soldiers were segregated from nonimmunes and others who were sick. Segregating those with similar maladies was found to be benecial later in our war for independence by James Tilton. He designed smaller, well-ventilated hospitals and found less hospital transmission of camp fevers that we recognize today as typhus, streptococcal infections, and respiratory disease. The 18th century also saw a concerted effort on the part of medical ofcers to educate line commanders. John Pringle, MD, who rst dened jail, ship, and hospital fevers as all one disease, what we know today as epidemic typhus, wrote the rst English military medicine text in 1752. My chief intention, he stated, was to collect materials for tracing the remoter causes of military distempers, in order that whatever depended upon those in command, and was consistent with the service, might be fairly stated so as to suggest measures for preventing or palliating such causes in any future campaign.4 Pringles text and the good relationship the medical establishment had with line ofcers had a positive effect on soldier health during the Seven Years War, in which smallpox, scurvy, and dysentery were the main disease threats. This desire to educate line ofcers concerning soldier health continued in 1764 with the publication of Richard Brocklesbys Oeconomical and Medical Observations5 and Donald Monros An Account of the Diseases which were most Frequent in the British Hospitals in Germany with advice on military hospitals and soldier health. Monros book included specic instructions concerning clothing and diet in various climates, treating cold injury and avoiding heat injury on campaign, and maintaining cleanliness aboard troopships.6

Specialization blossomed during this era; the American Medical Association (AMA) gained power and prestige. Medical corps ofcers began to identify with these organizations, exchange knowledge, and work with civilian colleagues more routinely than in the past. By the time the Axis Powers declared war on the U.S., the Division of Medical Sciences of the National Research Council in conjunction with its military liaisons created seven primary committees to answer the militarys burgeoning number of questions across the whole eld of medicine. COL James S. Simmons, Chief, Preventive Medicine Division for the Surgeon General, established the Board for the Investigation and Control of Inuenza and Other Epidemic Diseases in the Army. Consisting of distinguished civilian scientists and medical department ofcers, the board known today as the Armed Forces Epidemiological Boardworked in coordination with their respective research facilities to solve major disease problems affecting the army. However, military preventive medicine was not military hygiene. COL George Dunham, MC, USA wrote Military Preventive Medicine, but it was never intended as a guide for line ofcers as Munsons had been. No discussion of rations, clothing, equipment weight, marching, or hot and cold climates was included.21 Modern medicine, which had improved the general tness of the armed forces through rational recruiting standards, immunizations, and the sulfa drugs, only broadened the educational and social gap between line and medical ofcers. This, to some extent, disengaged the medical ofcer from critical staff planning and the mundane health problems of an army on campaign. From this situation, lessons from the First World War notwithstanding, occurred some of the more memorable blunders affecting performance, endurance, and resilience during World War II. LESSONS UNLEARNED As General MacArthur went on the offensive in the Southwest Pacic area following the Battle of Midway in summer 1942, the power of the malaria parasite was given low priority. The capture of Dutch Indonesia in 1942 gave Japan control of the worlds largest supplies of chinchona. The U.S. armed forces reserved quinine for treatment only, but had no appropriate dosing schedule for Atabrine and no malaria discipline on the ghting line. On Guadalcanal, 1223% of the 1st Marine Division was ineffective from malaria between August and November.22 At the same time on New Guinea, the inadequately trained, poorly supplied, and poorly led 32nd Infantry Division was being pummeled by mosquitoes, the Japanese, and dysentery until LTG Robert Eichelberger assumed command. Eichelberger instilled leadership and discipline, straightened out logistics problems, and by January 1943 had helped the Australians beat the Japanese. However, the heavy toll of Plasmodium falciparum and vivax malaria on Allied forces had to stop.23 In March 1943, MacArthur put tropical disease control on his agenda by establishing a combined advisory committee, which reported directly to him, under the direction of COL Neil Fairly. Their recommendations received