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Occupational exercise training programs can improve overall health and fitness in firefighters, but evidence beyond clinical and performance outcomes is needed before fire departments invest in and successfully adopt health promotion programs.
This mixed methods pilot study sought to pair clinical and performance outcomes with participants’ qualitative feedback (eg, participants’ enjoyment, lifestyle behavior changes, and team structure) with the goal of informing recommendations for future programs.
Professional firefighters participated in a 14-week occupational exercise training program with assessments conducted pre- and posttraining. Clinical outcomes included weight, BMI, body fat percentage, resting heart rate, systolic blood pressure, and diastolic blood pressure. Performance outcomes included the sharpened Romberg balance test, 1-repetition maximum leg press and bench press, graded exercise test (estimated VO2max), knee range of motion, shoulder flexibility, and hamstring flexibility. Self-administered surveys (Short Form-36, International Physical Activity Questionnaire, Barriers Self-Efficacy Scale, and Barriers to Being Active Quiz) were completed. In 3 private focus groups of 3 to 4 participants, firefighters' experiences in the training program and their health behaviors were explored.
Male firefighters (n=14; age: mean 36.4, SD 2.6 years) completed 20 training sessions. There were no significant changes to weight (
A 14-week program of exercise training in firefighters elicited improvements in clinical, performance, and self-reported physical activity outcomes. This occupational exercise training program for firefighters increased time spent exercising, improved team building, and led to physical and mental health benefits. Results from this pilot study set a broad, informed, and meaningful foundation for future efforts to increase firefighter participation in occupational fitness programs.
Heart disease is the number one cause of firefighter fatalities [
Any amount of exercise is beneficial in reducing cardiovascular disease risk, reducing all-cause mortality up to 40% [
One means of improving overall health and fitness in firefighters is through the implementation of departmental or occupational fitness programs [
For firefighter departments to adopt and invest in occupational wellness programs that promote exercise training, evidence of success beyond the exhaustively reported [
Finally, there still exists a gap in understanding how best to intervene in firefighters’ health promotion [
This semiexperimental, community-based participatory intervention research pilot study was approved by the institutional review board of West Virginia University (1812386641). Briefly, a local firefighter captain, concerned about the apparent poor physical fitness of the firefighters under his command, approached faculty in the division of Exercise Physiology about implementing an exercise training program within his 3 companies. The investigators (exercise physiology faculty members at West Virginia University), assisted by trained undergraduate exercise physiology student interns, developed and implemented an occupational exercise training program for the firefighters. Clinical, performance, and survey results were collected before and after a 14-week exercise training intervention. At the end of the intervention, the firefighters participated in focus groups to capture impressions of the intervention. While the captain strongly encouraged all firefighters under his directive to participate, enrollment into the research project was voluntary. Written and verbal consent were obtained from all participants.
The exercise training program ran from mid-January through mid-April 2019. Due to the firefighters’ irregular schedules, training occurred at least once, but usually twice weekly either at the nearest fire station (equipped with a small gym facility) or in the Human Performance Laboratory (a fitness and research facility in the division of exercise physiology) at West Virginia University. Four student interns trained 3 to 4 firefighters each. The student interns developed and prescribed exercises targeted to improving functional outcomes in firefighters (eg, getting in and out of the truck, carrying heavy loads up and down stairs, etc) and which incorporated strength, muscular endurance, cardiovascular, flexibility, and agility exercises.
Participants visited the laboratory for assessments before starting and after completing the 14-week training program. Participants were instructed to arrive in athletic shoes and comfortable clothing as well as to abstain from vigorous exercise for 24 hours and caffeine and tobacco for 4 hours prior to testing. All assessments were conducted pre- and postintervention with the exception of the health history questionnaire, which was completed after consent but before physical assessments.
Before arriving to the laboratory, all participants completed a health history questionnaire to assess information related to disease risk, medication use, and lifestyle behaviors (eg, physical activity, nutrition, stress). Upon arrival, to the laboratory, a resting 12-lead electrocardiogram (ECG) was performed by a trained technician and reviewed by a clinical exercise physiologist for evidence of irregular myocardial contractility or arrhythmia. An experienced technician measured resting seated brachial blood pressure of the right arm using a stethoscope and sphygmomanometer and resting heart rate by palpation at the radial artery. The clinical exercise physiologist reviewed the health history questionnaire and assessment results and followed American College of Sports Medicine safety guidelines to determine whether it was safe for participants to exercise [
Standing height (±0.1 cm) was measured with a stadiometer, and body weight (±0.1 kg) was measured with a calibrated body mass scale with the participant barefoot and in light clothing. Body mass index (BMI) was calculated from height and weight (kg/m2). Percentage body fat was measured with air plethysmography using a BodPod (Cosmed USA Inc).
The sharpened Romberg balance test was administered to participants by a trained technician. Participants stood with feet heel-to-toe, arms crossed over their chest, with eyes open for 60 seconds or until the participant moved one or both feet. If the participant successfully completed 60 seconds without moving, the test was repeated with eyes closed.
Participants warmed up by walking on a treadmill at a self-selected speed before performing lower and upper body maximum strength assessments. Lower body strength was assessed with 1-repetition maximum leg press, and upper body strength was assessed with 1-repetition maximum bench press. For the bench press machine (Body Masters Sports Industries Inc), the handle was lowered to chest level. A repetition began with the handle at the level of the chest with no resistance and was completed when the elbows reached full extension. For the leg press (Body Masters Sports Industries Inc) machine, the participant’s feet were placed on the platform shoulder width apart and with the toes slightly rotated outwards. The platform was then adjusted to produce a 90-degree bend at the knee joints. Repetitions began with the knee flexed with no resistance and ended with the knee nearly completely extended. The 1-repetition maximum was recorded as the heaviest weight lifted only once. In the event that the participant could lift the entire weight stack more than once, they were instructed to perform repetitions until voluntary fatigue and maximal 1-repetition maximum volume was calculated as weight unit × repetitions.
A Cornell graded submaximal treadmill test was administered by trained technicians and supervised by a clinical exercise physiologist. Participants completed the staged protocol until 85% of heart rate reserve or volitional fatigue. A clinical exercise physiologist monitored a 3-lead ECG for evidence of myocardial incontractility or irregular electrical activity during the test. Heart rate, blood pressure, and rate of perceived exertion were measured at each stage to monitor participant safety (data not reported). VO2max was estimated using established equations [
Measurements of maximal knee extension and flexion with a goniometer enabled calculation of knee range of motion (degree of maximal extension–degree of maximal flexion). Knee range of motion was measured with the participant lying supine and the ipsilateral hip and knee extended throughout the examination. The axis of the goniometer was centered on the lateral femoral condyle. The stationary arm was aligned along the femoral shaft toward the greater trochanter, while the moving arm was aligned with the fibula downward toward the lateral malleolus. Knee flexion was measured first by flexing the hip to 90°, and then instructing the participant to draw the heel as close to the buttocks as possible. From this position, the participant actively extended the knee until resistance was felt to measure knee extension.
For shoulder flexibility, participants lay in a prone position on the floor, forehead on the ground, and arms extended holding an 18-inch (45-cm) stick with both hands shoulder width apart. The participants raised the stick as high as possible off the floor while keeping the forehead on the ground and a technician measured and recorded the vertical distance achieved from the best of 3 trials.
A sit-and-reach test was performed to assess hamstring flexibility. Briefly, participants sat on the floor with knees extended and feet against the sit-and-reach box and at right angles to the floor. The participants reached forward as far as possible with knees locked and hands one on top of the other. The maximal reach (distance between the box's zero point and participants' reach point) from the best of 3 trials was recorded.
Self-administered surveys—the Short Form-36 [
The Short Form-36 is a multipurpose, short form, validated health survey of 36 questions. The Short Form-36 has 8 scaled scores; the scores are weighted sums of the questions in each section. Scores range from 0 to 100 with lower scores indicating more disability and higher scores indicating less disability. Sections include vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health.
The IPAQ covers 4 domains of physical activity: work-related, transportation, housework/gardening, and leisure time activity including questions about time spent sitting as an indicator of sedentary behavior. In each domain, the number of days per week and time per day spent in both moderate and vigorous activity are recorded. At work, during transportation and in leisure time, walking time is also included. Moderate intensity was defined as 4 MET (metabolic equivalent task) and vigorous intensity was defined as 8 MET. Outcome measures used were MET hours per week
The Barriers Specific Self-Efficacy Scale is a 13-item questionnaire with 11-point Likert scale response options designed to assess participants’ perceived capabilities to exercise. For each item, participants indicate their confidence about executing their exercise behavior. Possible scores range from a minimum self-efficacy score of 0 to a maximum possible score of 100.
The Barriers to Being Physically Active Quiz is a 21-item measure assessing barriers to physical activity including lack of time, social influence, lack of energy, lack of willpower, fear of injury, lack of skill, and lack of resources. Each domain contains 3 items, with a total score range of 0 to 63. Respondents rate the degree of activity interference on a 4-point scale, ranging from 0 (very unlikely) to 3 (very likely).
Qualitative research methods, including focus groups, can provide rich, descriptive data that can be missed when using quantitative methods. Furthermore, qualitative approaches can enhance collaboration with working people by offering them a forum for discussing the particular problems of their employment and health and for developing feasible intervention programs [
For quantitative data, descriptive statistics summarizing clinical, performance, and numerical questionnaire data were analyzed using Excel (Microsoft Inc). Differences between pre- and postassessments were assessed using independent one-tailed
Grounded theory allows for an inductive theory–building approach, one that does not require a prior theory [
Of 16 men who consented, one participant was excluded from participating because of evidence of myocardial dysfunction. A total of 15 men started the training program, but one withdrew due to an orthopedic injury incurred outside the research study. Therefore, 14 Caucasian males (mean 36.4, SD 2.6 years old) completed 20 training sessions over a total of 14 weeks; 2 participants were taking blood pressure medications, and 6 had a history of orthopedic injuries that did not prohibit their participation. Clinical outcomes are presented in
Clinical outcomes.
Outcome | Pre, mean (SD) | Post, mean (SD) | |
Height (cm) | 179.8 (1.7) | N/Aa | N/A |
Weight (kg) | 96.5 (4.9) | 99.0 ( 4.5) | .20 |
BMI (kg/m2) | 30.1 (1.8) | 31.0 (1.5) | .15 |
Body fat (%) | 31.7 (2.6) | 30.9 (2.3) | .16 |
Systolic blood pressure (mmHg) | 129 (2) | 125 (3) | .12 |
Diastolic blood pressure (mmHg) | 93 (6) | 78 (2) | .04 |
Resting heart rate (bpm) | 80 (2) | 76 (3) | .08 |
aN/A: not applicable.
From the health history questionnaire, average responses to physical activity patterns indicated that participants were mostly sitting or standing at work and that they perceived their levels of physical fitness to be below average. Half of the participants exercised 3-5 days/week for at least 6 months, but half reported no regular exercise. Participants reported the fat content in their diet was slightly above average, 10 out of 14 (71%) participants regularly consumed alcoholic beverages, and 11 out of 14 (79%) regularly consumed caffeine. Most (13/14, 93%) reported average to above average job stress.
Physical performance outcomes are reported in
Physical performance outcomes.
Outcome | Pre, mean (SD) | Post, mean (SD) | |
Romberg balance closed (seconds) | 58.9 (1.1) | 57.0 (2.3) | .24 |
Estimated VO2max (mL/kg/minute) | 55.8 (3.3) | 57.3 (4.0) | .34 |
Left leg knee range of motion (degrees) | 142.1 (2.3) | 141.1 (3.6) | .35 |
Right leg knee range of motion (degrees) | 142.4 (2.9) | 140.5 (3.5) | .31 |
Shoulder flexibility | 14.6 (1.1) | 18.8 (1.2) | <.001 |
Hamstring flexibility | 12.5 (1.0) | 13.3 (0.9) | .14 |
Leg press 1-repetition maximum volume (repetitions × weight unit) | 5896 (1119) | 7710 (1315) | .04 |
Bench press 1-repetition maximum volume (repetitions × weight unit) | 2001 (480) | 2781 (678) | .07 |
Changes in IPAQ responses indicated more time spent doing vigorous physical activity as part of work (METminutes/week—pre: mean 1971, SD 514; post: mean 5920, SD 2105;
Overall, there were no differences in group averages for the Short Form-36 (
Focus group themes are presented in
I wanted to regain some of what I’ve lost over the years.
Many expressed reservations; a few attributed their reservations to disinterest, but most attributed it to nervousness, specifically not knowing what to expect and feeling out of shape.
By the end of the training program, the impressions were positive, and many expressed interest in continuing the program:
I really hope they can keep a program and designated times for that.
It was even recommended that the program be extended throughout the entire firefighting department:
I would like to see the department mandate a time in the shift for PT [physical training]… It would push a lot of guys into physical training.
Firefighters liked having the interns as trainers and appreciated the interns’ preparation but suggested assigning intern trainers specific to participants’ interests (cardiovascular versus strength). They liked the variety of exercises (eg, balance exercises and circuit training) and learning new exercises (eg, planks), but many suggested including more task-specific exercises and training:
Flipping the tire was more incorporative of what we actually do.
Include a routine that would have a fireman drill.
While the firefighters enjoyed training in the fitness facility for “getting out of the station” most felt, compared with training at the station, that it posed difficulties logistically. Other recommendations were to have more training rather than once or twice a week:
I feel like I would have gotten more out of it.
Other than merely receiving exercise programming from the intern trainers, the firefighters reported receiving positive motivation but with different styles of support (eg, cheerleading versus drill sergeant). They felt being divided into groups inspired a bit of competition which helped with team motivation.
In terms of exercising outside of meeting times, some of the interns had prescribed “homework” to their group to encourage the firefighters to exercise on off days; the firefighters that were prescribed outside exercise reported completing it. Many of the younger firefighters reported incorporating extra exercises outside of training times of their own volition, but the older firefighters cited lack of time and motivation as barriers:
Life seemed too busy to be able to do it...
...easier to work out in a group...
Some thought they were more likely to incorporate exercise in the future using what they learned from the intern trainers.
Physical performance of their occupation was improved by increased endurance,
I don’t get as winded when I’m walking or doing things...
and many firefighters noted climbing stairs with their gear was significantly easier. Several reported less mental fatigue citing general tasks felt easier:
Any time I put my gear on you can tell a difference.
Other reported benefits were increased flexibility, better recovery and less soreness from firefighter runs or calls, and “more confidence in skills.”
The firefighters reported improvements around the station including more support and improved attitudes toward fitness. Some firefighters reported improvements in health behaviors among the group, including a noticeable influence on nutrition:
It’s definitely improved with eating better and feeling better.
More fruit instead of sugary foods...
...less soda, more water...
There was more talk around the station about exercise, and many reported improved team building,
...play together, stay together...
...seeing guys from other companies helped change the little bickering between them...
This sentiment was reported by the captain and echoed by the group. Many firefighters noted more positive attitudes in their colleagues, which was also reported outside of work; many had better moods and attitudes:
Normally you leave here cranky, irritated and now I leave here in a good mood.
Outside of work, firefighters reported several wellness benefits including feeling better overall, being more productive, and being more inclined to exercise and eat healthier when away from the station.
Overall, there was an increased affinity for exercise with plans to continue into the summer. All firefighters would recommend this program to other companies because it increased overall exercise time, incorporated accountability and team building, and led to physical and mental health benefits:
It was hard, but you get paid to have a personal trainer.
Focus groups themes.
Topics and themes | Findings | |
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Positive feelings: | Looked forward to gaining fitness |
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Some reservations: | Uncertainty, nervousness, and some disinterest |
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General feeedback: | Liked having interns as trainers and their positive motivation |
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Performance: | Increased endurance |
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Around the station: | Increased support from peers |
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At home and in their personal lives: | Better mood |
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Why they recommend participation: | Increased overall exercise time |
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Specific recommendations: | Implement throughout the department |
While physiological (performance and clinical) outcomes have been widely reported [
Combined interventions have been shown to be most effective in improving cardiovascular health in emergency personnel [
Many clinical and performance measures were unchanged after the intervention, which could be attributed to the small sample size or insufficient exercise stimulus. For example, estimated VO2max was unchanged, perhaps because the exercise stimulus from meeting once or twice a week was insufficient to elicit the necessary physiological aerobic adaptations to improve maximal oxygen consumption. Additionally, outcomes such as knee range of motion and balance were within normal ranges at baseline and would have been unchanged even with a rigorous exercise training program.
Independent of physiological outcomes, participants reported improvements in performance and overall health, including increased vigorous activity and more walking at work as well as reduced sitting time during weekdays. In terms of exercising outside of scheduled training times, the firefighters who were prescribed outside exercise reported completing it, and many of the younger firefighters reported incorporating extra exercise outside of training times of their own volition. These findings were supported by previous qualitative research that found younger firefighters were more health conscious [
In addition to fitness, the firefighters reported improvements in other health behaviors, such as nutrition. Despite the lack of direct measures (eg, pedometers, nutrition intake surveys, etc), these findings are evidence of improvements to lifestyle behaviors suggesting the goal of inciting permanent behavior change was supported. However, survey data indicated a significant decline in overcoming barriers to physical activity in the domains of lack of time (
Participants reported improvements in mood and attitude as assessed by surveys and focus groups. Interestingly, in the focus groups, respondents cited improvements in their own moods and attitudes at work and home as well as improvements in those of their colleagues. Since firefighting has been shown to be associated with considerable psychological stress [
In focus groups, many participants reported improvements to the team environment: the captain felt that “seeing guys from other companies helped change the little bickering between them” and this sentiment was echoed by the group. One unforeseen mechanism driving this influence was the random allocation of firefighters to training groups: training with firefighters outside their unit promoted team building across the company. Additionally, the training sessions inspired a bit of competition among firefighters which helped with team motivation as well. Others [
Impressions of this pilot program were positive and many expressed interest in continuing the program, even requesting more days per week of training. The design of the program, including having the interns as trainers and the variety of exercises, were received favorably. A primary outcome of this study was to inform recommendations for future programmatic implementation of occupational firefighter fitness programs. All firefighters would recommend this program to other companies because it increased overall exercise time, incorporated accountability and team building, and led to physical and mental health benefits. The participants recommended that the program be extended throughout the entire firefighting department, but many suggested including more task-specific exercises and training as well as limiting training to the fire stations rather than outside training facilities.
While the findings of this pilot study suggest support for the feasibility of this occupational exercise training program, the study is not without limitations. This project was implemented in a relatively urban setting within Appalachia, and because the individualized exercise programs were implemented by students as part of their coursework, this personal training was free to the firefighters. Also, because the fire captain specifically requested this occupational exercise program, it was a community-based participatory research study. Therefore, the findings of this study may not be generalizable to other settings such as rural areas with limited resources, minority populations, or fire companies that lack leadership commitment to the program. Additionally, a significant limitation of this pilot study was the small sample size, which can be associated with low reproducibility [
The novelty of this pilot program was the qualitative participant feedback including participants’ enjoyment, lifestyle behavior changes, and team structure with the goal of informing recommendations for future programs. We found improvements in overall health, endurance, flexibility, and mood, as well as improvements to team environment and the health behaviors around the station suggesting that the implementation of this fitness program was well received by participants.
Moving forward, this project will be expanded throughout the city’s fire department, offering free personal training from university exercise physiology students to all firefighters. While this study found favorable outcomes among participants, it is a feasibility study, and future research is warranted. In particular, qualitative feedback from fire department leadership that captures barriers to department-wide exercise training programs is needed before permanent programs can be implemented. Additionally, this study trained professional firefighters, but similar work could be evaluated in volunteer firefighters. The outcomes presented here are used to attempt to understand how best to intervene in firefighters’ health promotion [
The 14-week exercise training program improved clinical (diastolic blood pressure and resting heart rate) and performance (1-repetition maximum leg and bench press) outcomes, as well as self-reported physical activity (more vigorous activity and walking, less sitting time). Improvements in overall health, endurance, flexibility, and mood as well as improvements to team environment and the health behaviors around the station were reported; however, a decline in overcoming barriers to physical activity was also found. Overall, the impressions of this pilot program were positive because it increased time spent exercising, improved team building, and led to physical and mental health benefits. Recommendations moving forward are to extend the program throughout the fire department and to include more task-specific exercises and training.
Barriers Self-Efficacy Scale
Barriers to Being Active Quiz
electrocardiogram
International Physical Activity Questionnaire
metabolic equivalent task
None declared.