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Unique Aspects of Competitive Weightlifting

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 Sports Med 2012; 42 (9): 769-790
REVIEW ARTICLE 0112-1642/12/0009-0769/$49.95/0

Adis 2012 Springer International Publishing AG. All rights reserved.

Unique Aspects of Competitive

Weightlifting
Performance, Training and Physiology
Adam Storey and Heather K. Smith
Department of Sport and Exercise Science, The University of Auckland, Auckland, New Zealand

Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770
2. Literature Reviewed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
3. Weightlifting Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
3.1 The Snatch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
3.2 The Clean and Jerk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
4. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774
4.1 Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774
4.2 Annual Training Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774
4.3 Application and Variation in Training Load . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775
4.4 Metabolic Cost of Weightlifting and Nutritional Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
4.5 Influence of Body Weight Changes on Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
5. Anthropometric Characteristics of Weightlifters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
6. Physiological Responses and Adaptations to Weightlifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777
6.1 Skeletal Muscle Structure and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778
6.1.1 Fibre Type Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778
6.1.2 Neuromuscular Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778
6.1.3 Sex- and Age-Related Differences in Neuromuscular Function . . . . . . . . . . . . . . . . . . . . . . 779
6.2 Bone Mineral Density. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780
6.3 Cardiovascular Structure and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780
6.4 Endocrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781
6.4.1 Testosterone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781
6.4.2 Testosterone : Cortisol Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781
6.4.3 Growth Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 782
7. Recommendations and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 782

Abstract Weightlifting is a dynamic strength and power sport in which two, multi-
joint, whole-body lifts are performed in competition; the snatch and clean
and jerk. During the performance of these lifts, weightlifters have achieved
some of the highest absolute and relative peak power outputs reported in the
literature. The training structure of competitive weightlifters is characterized
by the frequent use of high-intensity resistance exercise movements. Varied
coaching and training philosophies currently exist around the world and fur-
ther research is required to substantiate the best type of training programme
for male and female weightlifters of various age groups. As competitive
770 Storey & Smith

weightlifting is contested over eight male and seven female body weight ca-
tegories, the anthropometric characteristics of the athletes widely ranges. The
body compositions of weightlifters are similar to that of athletes of compar-
able body mass in other strength and power sports. However, the shorter
height and limb lengths of weightlifters provide mechanical advantages when
lifting heavy loads by reducing the mechanical torque and the vertical dis-
tance that the barbell must be displaced. Furthermore, the shorter body di-
mensions coincide with a greater mean skeletal muscle cross-sectional area
that is advantageous to weightlifting performance. Weightlifting training
induces a high metabolic cost. Although dietary records demonstrate that
weightlifters typically meet their required daily energy intake, weightlifters
have been shown to over consume protein and fat at the expense of adequate
carbohydrate. The resulting macronutrient imbalance may not yield optimal
performance gains. Cross-sectional data suggest that weightlifting training
induces type IIX to IIA fibre-type transformation. Furthermore, weightlifters
exhibit hypertrophy of type II fibres that is advantageous to weightlifting
performance and maximal force production. As such, the isometric peak
force and contractile rate of force development of weightlifters is ~1520%
and ~1316% greater, respectively, than in other strength and power athletes.
In addition, weightlifting training has been shown to reduce the typical sex-
related difference in the expression of neuromuscular strength and power.
However, this apparent sex-related difference appears to be augmented with
increasing adult age demonstrating that women undergo a greater age-related
decline in muscle shortening velocity and peak power when compared with
men. Weightlifting training and competition has been shown to induce sig-
nificant structural and functional adaptations of the cardiovascular system.
The collective evidence shows that these adaptations are physiological as
opposed to pathological. Finally, the acute exercise-induced testosterone,
cortisol and growth hormone responses of weightlifters have similarities to
that of following conventional strength and hypertrophy protocols involving
large muscle mass exercises. The routine assessment of the basal testoster-
one : cortisol ratio may be beneficial when attempting to quantify the adaptive
responses to weightlifting training. As competitive weightlifting is becoming
increasingly popular around the world, further research addressing the phys-
iological responses and adaptations of female weightlifters and younger (i.e.
17 years of age) and older (i.e. 35 years of age) weightlifters of both sexes is
required.

1. Introduction This review details the unique performance

Weightlifting has been a longstanding part of the
modern Olympic Games and has wide and growing
international participation. During the performance
of the two competitive lifts, the snatch and the clean
and jerk (C&J), weightlifters are required to gen-
erate extremely high peak forces and contractile
rates of force development and, consequently, high
peak power outputs and contractile impulses.[1-6]
and training requirements of competitive weight-
lifters with particular emphasis on the movement
demands, training intensities and commonly adopt-
ed nutritional practices of these athletes. Further
attention is directed towards descriptions of the
physiological responses and adaptations of the
musculoskeletal, cardiovascular and endocrine sys-
tems to weightlifting training and competition. Fi-
nally, as weightlifting is becoming increasingly

Adis 2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (9)
Competitive Weightlifting Performance, Training and Physiology
popular with females, and younger and older in-
dividuals, we highlight potential areas for future
research that will enable the development of safe and
effective training guidelines for these populations.
2. Literature Reviewed
The search for scientific literature relevant to
this review was conducted using the US National
Library of Medicine (PubMed), SPORTDiscus
and Google Scholar databases. Key search terms
of Olympic weightlifting, weightlifter/s, snatch,
clean and jerk, muscular strength and muscular
power were used. Further literature was obtained
from electronic related articles searches and by
manually screening the reference lists of included
studies. The inclusion criteria for all articles were;
(i) refereed articles published in English language
journals and books from the 1970s until February,
2012; and (ii) the terms weightlifter and weight-
lifting had to be in context with the sport of
competitive weightlifting as opposed to general
weight/resistance training.
3. Weightlifting Performance
The snatch and C&J are complex whole-body
movements encompassing a series of high-intensity
muscular contractions. During these lifts, weight-
lifters achieve power outputs unmatched by any
other athletes.[1] Since 1998, the recognized body
weight classes are: men 56 kg, 62 kg, 69 kg,
77 kg, 85 kg, 94 kg, 105 kg and >105 kg; and
women 48 kg, 53 kg, 58 kg, 63 kg, 69 kg,
75 kg and >75 kg. Athletes must weigh-in during
a 1-hour window that begins 2 hours before the
start of their competition session. The athletes
placing within their respective body weight class is
determined by their competition total, which is
the sum of their highest recorded snatch and C&J.
3.1 The Snatch
The snatch requires the weighted barbell to be
lifted from the floor (using a wide grip) to an
overhead position in one continuous movement.[7]
The snatch includes six phases (figure 1). The first
pull is initiated when the lifter extends their knees
Adis 2012 Springer International Publishing AG. All rights reserved.
771
to raise the barbell off the platform to a position
just below knee level. A transition period (also re-
ferred to as the double-knee bend) follows whereby
the knees are re-bent and are moved under the
barbell whilst the lifters trunk is moved to a near
vertical position.[8-10] The double-knee bend
allows the lifter to take advantage of a stretch-
shortening cycle during the subsequent second
pull.[10] The second pull requires the lifter to maxi-
mally accelerate the barbell by simultaneously
shrugging the shoulders and extending the hips,
knees and ankles. During the performance of near
maximal to maximal full snatch attempts, the ver-
tical velocity of the barbell during the second pull
can range between 1.65 m/sec and 2.28 m/sec.[4,11-16]
During submaximal attempts and snatch-related
movements (i.e. power snatch), barbell velocities
may exceed 3.00 m/sec.[17,18] As the barbell rises
in the vertical plane to ~6278% of the lifters
height,[11,13-15] the lifter begins to pull their body
underneath the barbell; this phase is referred to as
the turnover. The lifter then catches the barbell in
a straight-arm overhead position whilst flexing at
the knee and hip into a full squat position. The
lifter then recovers out of the full squat to a
standing position whilst maintaining the barbell
overhead. The duration of effort from the start of
the first pull until the competition referees signal
a successful lift is ~35 seconds. Each athlete is
entitled to three snatch attempts in competition.
3.2 The Clean and Jerk
The C&J is a two-part lift that enables heavier
loads (~1820% greater) to be lifted than during
the snatch. The clean requires the barbell to be
raised from the floor (using a shoulder width grip)
to the front of the shoulders in one continuous
movement. There are six phases of the clean
(figure 2). The mechanical principles behind the
first three phases (first pull, transition/double-
knee bend and second pull) are the same as those
of the snatch. During the second pull of near
maximal to maximal attempt cleans, the vertical
velocity of the barbell can range from 0.88 m/sec
to 1.73 m/sec.[3,4] However, during submaximal
attempts and clean-related movements (i.e. power
clean), barbell velocities may exceed 2.50 m/sec.[19,20]
Sports Med 2012; 42 (9)
772
a b
d e
Fig. 1. The six phases of the snatch: (a) first pull; (b) transition to the start of the second pull; (c) completion of the second pull; (d) turnover;
(e) catch; (f) recovery.
As the barbell rises in the vertical plane to ~5565%
of the lifters height,[21] the lifter initiates the turn-
over phase. The lifter then catches the barbell on
their shoulders and descends into a full squat posi-
tion. The lifter then recovers from the full squat
position to prepare for the jerk.
The jerk also has six phases (figure 2): (i) start;
(ii) dip; (iii) jerk drive; (iv) unsupported split
under the bar; (v) supported split under the bar;
and (vi) recovery. During the start phase, the lifter
and the barbell must become motionless. The lifter
then begins to dip down by flexing at the knee
and hip, with the barbell held across the should-
ers. At the lowest point of the dip, the lifter makes
the transition to the jerk drive where they are re-
quired to accelerate the barbell in the vertical
plane. During this transition period, the athlete
may be exposed to a downward force equivalent
Adis 2012 Springer International Publishing AG. All rights reserved.
Storey & Smith
c
f
to 17 times their body mass.[22] Reported power
outputs during maximal attempt jerk drives
range from 2140 watts (W) for a lifter in mens
under 56 kg class to 4786 W for a lifter in
the mens 105 kg+ class.[1] At the completion of the
jerk drive, the barbell is vertically driven off the
shoulders and the lifters feet leave the ground.
This phase represents the unsupported split
under the bar. Once the lifters feet are in contact
with the ground and the barbell is held overhead
with fully extended arms, the lifter is in the sup-
ported split under the bar phase. The lifter must
then recover and is required to stand motionless
with their feet parallel to one another. The dura-
tion of effort from the start of the first pull to
the signal of a successful lift is ~812 seconds.
Each athlete is entitled to three C&J attempts in
competition.
Sports Med 2012; 42 (9)
Competitive Weightlifting Performance, Training and Physiology 773

a b c

d e f

g h i

j k l

Fig. 2. The twelve phases of the clean and jerk: (a) first pull; (b) transition to the start of the second pull; (c) completion of the second pull;
(d) turnover; (e) catch; (f) recovery from the clean; (g) start position for the jerk; (h) jerk dip; (i) jerk drive; (j) unsupported split under the bar;
(k) supported split under the bar; (l) recovery from the jerk.

Adis 2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (9)
774
4. Training
There is limited evidence comparing the perfor-
mance and physiological responses arising from
different weightlifting training programmes.[23-26]
However, the English language coaching literature
and empirical evidence suggests that numerous
and varied practices exist amongst internationally
competitive weightlifters.[21,25-28]
4.1 Exercises
The two competitive lifts form the basis of
the training programmes for junior and senior
weightlifters. Complementary exercises that have
movement patterns similar to the competitive lifts
(e.g. hang/power snatch, hang/power clean, snatch
and clean pulls, front and back squats) and sup-
plementary exercises (e.g. overhead presses, back
extensions and abdominal work) that target sy-
nergistic muscle groups are also used. The com-
plementary exercises are also incorporated into
the training programmes of other power ath-
letes[24,29-31] as follows: (i) kinematic similari-
ties exist between the propulsive phases in both
weightlifting and jumping movements;[32-37] and
(ii) significant relationships exist between weight-
lifting ability and power output during jumping
(r = 0.59 to 0.93) and sprinting (r = -0.52 to
-0.76)[33,37-40] and tests of agility (-0.41).[37]
However, despite commonalities in the mode
of exercise and other acute variables, the training
programmes of weightlifters differ, particularly in
the frequency and volume of high-intensity loads,
from that of other power athletes (refer section 4.3).
The collective differences in the competitive de-
mands and the required physiological adaptations
of other various athletes may account for these dis-
crepancies. Furthermore, due to the technically and
physically demanding nature of the snatch and
C&J, modified versions are often employed by other
athletes for the enhancement of muscular power.
4.2 Annual Training Structure
Broad descriptions of variations in weightlift-
ing training variables have been offered in the
literature.[21,23-26,28,41] More specific details are
rarely outlined. Due to the success of many
Adis 2012 Springer International Publishing AG. All rights reserved.
Storey & Smith
Eastern European teams, in particular the former
Soviet Union and Bulgaria, a number of the worlds
training programmes are variations of the general-
ized training models established by these nations.[27]
However, Western coaches were required to make
modifications to these training methods pre-
sumably due to the higher prevalence of anabolic
steroid use amongst Eastern Bloc teams;[10,42,43]
since the 1970s, competitive weightlifters have
been subjected to random drug testing[42] that can
include both urine and blood assays.
The training programmes from the former
Soviet Union were based upon the classic period-
ization model[25] consisting of a preparatory phase
(generalized and specific conditioning), competition
phase (specific training mimicking the demands of
competition), and a transition phase (generalized
conditioning at the end of a training cycle). A wide
variety of exercises at varying intensities and vol-
umes were incorporated into these programmes
with the belief that this would prevent athletes
reaching a state of overtraining due to movement
pattern monotony.[27] Although international-level
weightlifters would typically perform 20 00025 000
multijoint exercise repetitions per year, only
1535% of those repetitions were competition lifts
performed at 8090% of their one-repetition max-
imum (1RM) with an additional 47% being per-
formed at 90% of 1RM.[21,25,44]
In contrast, the Bulgarian training approach
is characterized by frequent, near-maximal to
maximal-intensity loading[21,27,44-46] and is more
closely aligned with the demands of competition.
It has been reported that Bulgarian lifters per-
formed between 1400 and 4000 maximal attempts,
and 450 and 460 failed supramaximal attempts
each year in training.[21,44] Approximately 10% of
the total training time is devoted to warm-up ex-
ercises, 45% to competition lifts, 40% to comple-
mentary strength exercises, 3% to supplementary
exercises and 2% to other sports and cross-training
activities.[21] There is very little variation in train-
ing intensity, by comparison with the training
programmes of the former Soviet Union. How-
ever, fluctuations in training volume are applied.
The training follows a repeated pattern of 23 weeks
of increased loading followed by 1 week of reduced
loading. This cyclic pattern of overload and
Sports Med 2012; 42 (9)
Competitive Weightlifting Performance, Training and Physiology
recovery is believed to contribute to subsequent
long-term improvements in performance.[41,47]
Although the competitive performances of
weightlifters continue to improve, as evident by
increases in national and world records, further
research needs to be directed towards several as-
pects of weightlifting programme design. These
aspects include (i) effective coaching strate-
gies for novice weightlifters; (ii) the influence of
exercise volume and intensity on physiological
and performance variables in female and youth
weightlifters; and (iii) the efficacy of variations in
training techniques (e.g. the incorporation of ec-
centric-only exercises).
4.3 Application and Variation in Training Load
International-level weightlifters perform two
or more high-intensity resistance exercise (HIRE)
[80% 1RM] sessions per day, of the same major
muscle groups, 6 or 7 days per week.[21,25-28] An
extreme example of this high-frequency of train-
ing was demonstrated by the Greek weightlifting
team during preparations for the 1996 Olympic
Games. Across a 6-day training week, the Greek
team performed 13 snatch, 11 C&J, 11 back squat
and 9 front squat sessions.[21] In senior weight-
lifters, dividing a given training volume across
two sessions that are performed on the same day
produces significantly greater increases in muscu-
lar strength, hypertrophy and maximal neural ac-
tivation of the trained musculature.[48,49] However,
as the majority of the exercises that are performed
by weightlifters are the competitive lifts and similar
multijoint movements, a large number of muscle
contractions are performed by the same major
muscle groups within each training session.
Thus, the frequency of HIRE performed by
weightlifters exceeds evidence-based recommenda-
tions for improving muscular strength and power
in advanced trained adults. For example, the
American College of Sports Medicine (ACSM)
propose (i) a training frequency of 46 sessions
per week; and (ii) training different muscle groups
during subsequent strength and power sessions to
allow for adequate recovery.[50,51] Previous evi-
dence has also shown that repeated HIRE bouts
of the same muscle group/s result in the persistent
Adis 2012 Springer International Publishing AG. All rights reserved.
775
suppression of key anabolic mediators, prolonged
inflammatory signalling and decrements in muscu-
lar performance.[52-56] In contrast to these findings,
weightlifters demonstrate both acute and long-term
improvements in competitive lifting performance
in response to their frequent HIRE training
structure.[21,57-60]
Although little evidence exists to suggest that
weightlifting training, under proper supervision,
is more injurious to children or adolescents when
compared with other sports,[61-63] considerable
controversy still surrounds the use of weightlifting
exercises in younger populations (i.e. <17 years of
age). As such, definitive biological and/or training
age appropriate weightlifting training guidelines
have yet to be established. The training age of
a weightlifter greatly influences their ability to
positively adapt to the frequent use of HIRE.
Over a 10-week training period in competitive
junior (1720 years of age) weightlifters, moderate
volumes of high-intensity (>90100% 1RM) load-
ing produced significantly greater strength gains
(10.5% improvement in C&J and 9.5% improve-
ment in back squat) when compared with low
(3.0% improvement in C&J and 5.3% improve-
ment in back squat) and high (6.9% improvement
in back squat performance only) volumes of sim-
ilarly high-intensity loading.[23] Furthermore, it
has recently been demonstrated that performing
additional high-intensity training sessions within
the same day does not lead to significantly greater
performance improvements in young weightlift-
ers.[64] In comparison, international-level senior
weightlifters (2035 years of age) demonstrate a
greater ability to tolerate and adapt to higher
volumes of high-intensity loading.[6,21,26,27] How-
ever, masters weightlifters (35 years of age) ex-
hibit significant declines in training ability and
weightlifting performance,[65-68] which is in accor-
dance with the well documented impaired adaptive
responses to resistance exercise with increasing
adult age.[69-71] On the basis of these findings, we
propose that an inverted U-shaped relationship
exists between competitive age and the volume
of high-intensity loading that leads to enhanced
weightlifting performance (figure 3).
During ballistic activities such as bench throws
or jump squats, absolute peak power output (PP)
Sports Med 2012; 42 (9)
776 Storey & Smith

High penditures incurred by the athletes. For example,

Volume of a mean caloric expenditure of 39.5 kJ/min was

high-intensity Moderate recorded in male weightlifters during a 1 week
loading
preparatory phase of training characterized by a
Low moderate- to high-volume of moderate- to high-
intensity lifts.[91] This value is comparable with
the metabolic cost incurred by high-volume cir-
r

s
io

io

r
te
n

n
Ju

Se

as cuit-style resistance exercise.[92] Furthermore, the

M

Fig. 3. Proposed relationship between the volume of high-intensity

training stimulus alone produced a weekly energy
(90100% of one-repetition maximum) loading that leads to enhanced expenditure of 16 456 kJ.[91] The reported mean
weightlifting performance and competitive age. Junior: 17 to 20 years daily energy intakes of male weightlifters range
of age; senior: >20 to 35 years of age; masters: 35 years of age.
between 13 212 kJ and 19 307 kJ,[93-97] which are
consistent with the values recommended for hard
has been shown to occur between training loads
training male athletes (14 70023 100 kJ/day).[98]
of 3050% of 1RM.[72-77] However, more recent
As expected, the corresponding relative daily en-
research suggests that the load required to elicit
ergy intakes values of 134244 kJ/kg/day[93,95-97]
PP during jump squats may even be as low as
are comparable with those of other strength and
body mass only.[19,78,79] Therefore, the prescrip-
power athletes.[93,95,97,99] In regards to macro-
tion of relatively low-intensity (i.e. 060% 1RM)
nutrient consumption, it is reported that weight-
resistance exercise (inclusive of complementary
lifters consume a greater number of daily servings
weightlifting exercises) is often recommended to
of protein-rich sources when compared with
improve muscular power and dynamic athletic
other athletes.[93,94,100] As a result, the protein in-
performance.[51,74,80-85] For example, the lighter
take of male weightlifters has been reported to
relative training loads used for the power snatch,
range between 1.6 g/kg/day and 3.2 g/kg/day,[95,96]
power clean and various pulling movements result in
which is high when compared with the recom-
a greater maximum barbell vertical velocity, con-
mended 1.21.7 g/kg/day for resistance train-
tractile impulse and thus a greater PP when com-
ing athletes.[60,93,95,101] Furthermore, weightlifters
pared with maximal competition lifts.[18-20,36,86,87]
derive approximately 4044% of their daily energy
During the snatch and/or C&J, PP has been shown
intake from dietary fat,[93,95,96,102] which is also
to occur with loads of 7080% of 1RM[19,30,86,88]
well above the acceptable range for health and
demonstrating that the high-intensity training of
athletic performance of 2035%.[103,104] This is
weightlifters results in improved PP under high-
a possible consequence of their greater intake of
load conditions. Therefore, weightlifters will fre-
protein-rich animal products. Conversely, the
quently train for the competitive lifts at intensities
reported carbohydrate intakes in weightlifters of
70% of 1RM.[21,25-28] Athletes who are required
2.96.1 g/kg/day[93,95,105] are insufficient according
to generate high PP against heavy external loads
to the current recommended levels of 78 g/kg/day
(e.g. wrestlers, bobsledders and rugby union/league
for athletic individuals.[106] Combined, these reports
players) are likely to benefit from high-load
suggest that the dietary habits of male weightlifters
weightlifting training.[19,24,35,37,89,90] However, at
may not yield the desired training gains and/or
present there is a paucity of research examining
health benefits due to the emphasis placed on
the efficacy of power training with high- versus
protein consumption (with high fat) at the ex-
low-load weightlifting exercises in trained strength
pense of adequate carbohydrate ingestion. As the
and power athletes.
training and competition demands of weightlifters
differ to those of other strength and power ath-
4.4 Metabolic Cost of Weightlifting and
Nutritional Practices letes, further research is required to (i) document
the current dietary habits of competitive weight-
The metabolic demands of weightlifting train- lifters; and (ii) identify the optimal macronutrient
ing are reflected in the relatively high energy ex- balance for weightlifting performance.

Adis 2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (9)
Competitive Weightlifting Performance, Training and Physiology
4.5 Influence of Body Weight Changes on
Performance
Athletes participating in weight-restricted events
will often train at a body mass that is 510% above
their required competition weight class.[98] In the
week leading up to competition, a minor reduc-
tion in body mass (e.g. a loss of 12 kg) might be
achieved by restricting fluid intake and consuming a
low residue diet.[101] To make weight and to avoid
the loss of lean muscle mass, it is common for
weightlifters to rapidly reduce total body water con-
tent prior to competition weigh in. This is achieved
via passive methods including self-limited fluid in-
take, acute heat exposure and/or the use of (banned)
diuretic agents.[107] Whilst the detrimental effects of
hypohydration on endurance performance are well
documented,[108-110] less evidence exists regarding
the effects of hypohydration on muscular strength
and power. Evaluations of the effects of short-term
hypohydration on maximal force production, mus-
cular endurance and PP have demonstrated a de-
crease[111-115] or no change[116-119] in these variables.
Where mild hypohydration (i.e. 2% reduction in
body mass) techniques have attenuated neuromus-
cular performance, rapid rehydration interventions
over a short period of time (i.e. over a 2 hour period
as done in competition) have effectively restored
performance variables.[111] However, an athletes
ability to overcome the detrimental effects of dehy-
dration is severely affected when hypohydration-
induced reductions in body mass reach 34%.[107,114]
It is thus tenable that severe hypohydration
would impair weightlifting performance. For weight-
lifters opting to train at a body mass 3% above
their competition weight, minor dietary modifica-
tions should be introduced in the weeks leading up
to competition to achieve a body mass of 2% above
that desired/required for competition. Mild hypo-
hydration techniques may then be implemented
24 hours prior to competition weigh-in, followed by
effective rehydration strategies afterwards.
5. Anthropometric Characteristics of
Weightlifters
The anthropometric characteristics of male
weightlifters have been documented extensive-
ly.[10,120-125] Light- to middle-weight male weight-
Adis 2012 Springer International Publishing AG. All rights reserved.
777
lifters (i.e. 56 kg to 85 kg) are somatotyped as
predominately ectomorphic or mesomorphic[124]
with body fat percentages of 510%.[10,122,123,125]
These compositional characteristics are comparable
to weight restricted wrestlers and athletes com-
peting in the sprinting and jumping events of
athletics.[10,126,127] Conversely, weightlifters in the
heavy to unlimited weight classes (i.e. 94 kg to
>105 kg) tend to be more endomorphic meso-
morphs[124] with corresponding body fat percentages
of 17%.[10,121,125] These individuals possess similar
body compositions to heavyweight wrestlers, pow-
erlifters, discus, shot put and hammer throwing
athletes.[10,127-131] Although the anthropometric data
on female weightlifters is less comprehensive, the
limited data suggest that the body fat percentages of
female weightlifters may be double that of male
weightlifters of a similar body mass.[10,132,133] How-
ever, elite male and female weightlifters exhibit a
lower body fat percentage when compared with
lower level competitors of a similar total body
mass.[122,133] Thus, the resulting differences in lean
body mass becomes a major contributing factor
to the divergent neuromuscular responses seen
between male and female and elite versus non-
elite weightlifters (refer section 6.1.3).[122,133-140]
In comparison to other strength and power
athletes of a similar body mass and composition,
weightlifters have proportionally shorter arm span
and tibial lengths, larger biacromial breadths and
are shorter in height.[120,122,125,136] Such anthro-
pometric characteristics provide two mechanical
advantages when lifting maximal loads: (i) the
mechanical torque that is required to lift a given
load is less due to shorter lengths of the resistance
lever arms; and (ii) the amount of muscular work
required to lift a given load is decreased via a
reduction in the vertical distance that the barbell
must be displaced.[129] Furthermore, the shorter
body dimensions coincide with a greater mean
skeletal muscle cross-sectional area, which is ad-
vantageous to weightlifting performance.[134]
6. Physiological Responses and
Adaptations to Weightlifting
The complexity, intensity and brevity of weight-
lifting impose great challenges when attempting
Sports Med 2012; 42 (9)
778
to obtain valid and meaningful physiological
data from competitive weightlifters. Furthermore,
it is onerous and/or inappropriate to apply sim-
ilar exercise protocols in non-weightlifters due to
the technically demanding nature of the specific
movements. As such there is limited data on the
acute neuromuscular, cardiovascular and endo-
crine responses that occur (especially in female
weightlifters) during weightlifting training and
competition. Furthermore, few studies have ex-
amined the adaptations of the neuromuscular
and endocrine systems that arise from moderate
(weeksmonths) to long-term (monthsyears) peri-
ods of weightlifting-specific training. However, in-
vestigations into the physiological responses and
adaptations of masters weightlifters do provide
some insight into the long-term benefits of weight-
lifting training.
6.1 Skeletal Muscle Structure and Function
6.1.1 Fibre Type Composition
The force-velocity properties of a muscle are in
part determined by the relative proportions of
fast-twitch (type IIA and IIX; formerly identified
as IIB) and slow-twitch (type I) muscle fibres.[34,141]
Strength and power athletes, including weight-
lifters, exhibit mean percentages of fast-twitch
fibres in the vastus lateralis ranging from 53% to
65%.[60,142-148] Although similar percentages have
been reported in untrained adults,[144,149,150] the
cross-sectional areas of type II fibres are con-
siderably larger in weightlifters.[143,144,147,148] Such
a structural difference is advantageous to force
production as type II fibres possess a greater ca-
pacity to generate power per unit cross-sectional
area when compared with type I fibres.[141,151-153]
Both the proportion of type IIA fibres and the
relative myosin heavy chain IIA isoform content
have been shown to be greater in weightlifters when
compared with recreationally active adults.[143] In
addition, weightlifting performance is strongly cor-
related to type IIA percent content (r = 0.94) and
type IIA percent fibre area (r = 0.83).[143] Thus,
evidence from cross-sectional studies suggests that
the frequent high-intensity training of weight-
lifters results in hypertrophy of type IIA fi-
bres.[143,144,147,148] Evidence from longitudinal
Adis 2012 Springer International Publishing AG. All rights reserved.
Storey & Smith
HIRE studies in non-weightlifters indicates that
there may also be a concomitant IIX to IIA fibre-
type transformation.[154-158] Conversely, a restora-
tion of type IIX content has been shown to occur in
other athletes (i.e. swimmers, runners and cyclists)
during pre-competition tapers, which involve a
planned reduction in training volume.[159-163] How-
ever, the existence of a tapering-induced reshift in
the fibre-type composition of competitive weight-
lifters has yet to be quantified.
6.1.2 Neuromuscular Function
Maximal voluntary isometric peak force (PF)
and PP are strongly related to weightlifting per-
formance.[164-168] During isometric conditions, PF is
reached in the vicinity of 300400 msec.[164,169-171]
However, during dynamic weightlifting movements,
weightlifters achieve PF, PP and maximum barbell
velocities in <260 msec.[4,12,14,172] Thus, the maximal
contractile rate of force development (RFD) in
the early phase of muscle contraction is of great
importance to these athletes.[164,173,174]
Improvements in both PF and contractile RFD
have been reported in male and female weight-
lifters following moderate- to long-term periods
of training.[23,60,132,145] These findings demonstrate
that the frequent high-intensity training used by
weightlifters (refer to sections 4.2 and 4.3) effec-
tively increases muscular strength and power con-
currently.[165,175] As a result, the isometric PF and
peak RFD of male weightlifters is ~1520% and
~1316% greater, respectively, when compared
with other strength and power athletes (i.e. football
players, sprinters, throwers and jumpers).[176-179]
This improved muscular function may arise due
to an enhanced voluntary and/or reflex-induced
neural activation of motor units[48,49,60,169] and/
or a selective recruitment of fast-twitch motor
units.[180,181]
During the performance of the snatch and
C&J, weightlifters have demonstrated some of
the highest absolute and relative PP reported in
the literature.[1,2,4,5] For example, during the
second pull of maximal snatch and C&J attempts,
values as high as 5442 W and 6981 W, respect-
ively, have been reported in male weightlifters.[3,5]
Furthermore, the corresponding relative PP for
male and female weightlifters range from 53 W/kg
Sports Med 2012; 42 (9)
Competitive Weightlifting Performance, Training and Physiology
to 56 W/kg and 38 W/kg to 40 W/kg, respective-
ly.[4,5] As a comparison, during maximal bench
press and deadlift exercises performed by male
strength athletes, absolute PP of 415 W and 1274 W,
respectively, have been reported[4,5] with relative
PP ranging from ~4-12 W/kg.[1,5] In addition, during
exercise tests that incorporate the lower body (i.e.
clean pulls and various jumps) the reported PP of
male weightlifters is ~1336% greater when com-
pared with other power athletes.[131,178,179,182] How-
ever, during upper body only exercise, no differences
in absolute or relative PP were shown to exist
between weightlifters and handball players.[73]
These findings highlight the important contribu-
tion that the lower body makes to power devel-
opment in weightlifters. Furthermore, they may
be explained by the specificity of training, as hand-
ball players are required to perform repeated high-
intensity upper body movements (i.e. throwing)
in competition.[73,183] Conversely, the upper body
musculature of a weightlifter plays a relatively
lesser role, in comparison to the legs, during the
snatch and C&J.[73,184]
6.1.3 Sex- and Age-Related Differences in
Neuromuscular Function
To compare performances across the different
body weight classes, Sinclair scores, based upon
current world record totals and adjusted each
Olympic year, are used.[185] The lifters actual
competition total is multiplied by the appropriate
Sinclair coefficient. The resulting score is a projec-
Table I. Sex- and age-related differences in the under 69 kg world recordsa
Category Lift Male
Youth Snatch 142
C&J 172
Total 310
Junior Snatch 158
C&J 190
Total 346
Senior Snatch 165
C&J 197
Total 357
a Current world records as of November, 2011.
C&J = clean and jerk.
Adis 2012 Springer International Publishing AG. All rights reserved.
779
tion of the total the lifter would theoretically achieve
if they were in the super heavy-weight class with the
same lifting ability. Various other allometric scaling
formulae have been derived.[134,186-188] However,
many tend to yield either an overestimation or
underestimation for certain body weights.
In untrained and/or recreationally trained males
and females, reported sex-related differences in
absolute neuromuscular strength and power range
from 31% to 48% and 17% to 46%, respective-
ly.[139,189-192] However, when comparing the cur-
rent under 69 kg (the only common body weight
class between sexes) world record lifts for youth,
junior and senior male and female weightlifters,
there is a consistent sex-related difference of
1520% (table I). Thus, it is evident that although
long-term weightlifting training minimizes the sex-
related difference in neuromuscular function, fac-
tors such as the distribution and total amount of
lean body mass in male and female weightlifters will
ultimately influence the expression of strength and
power across all age and weight categories.[67,134]
As competitive weightlifting is becoming in-
creasingly popular in masters athletes, a number
of studies have investigated the influence of in-
creasing age on competitive weightlifting perfor-
mance and neuromuscular function.[65-68,193,194]
Pearson et al.[65] demonstrated that, on average,
masters weightlifters (aged 4087 years) were able
to generate 32% more isometric knee extensor
force and lower body explosive power when
compared with age-matched, healthy, untrained
Female Percentage of the male record Mean SD (%)
obtained by a female
117 82.4 83.7 1.2
145 84.3
262 84.5
123 77.8 80.0 2.4
157 82.6
275 79.5
128 77.6 79.2 1.4
158 80.2
286 79.9
Sports Med 2012; 42 (9)
780 Storey & Smith

adults. It is likely that neural factors contributed greater age-related declines in muscle shortening
to this enhanced functionality in older weightlifters velocity and PP than men, which is likely due to a
as no significant differences in lean lower-limb decreased neural drive and a combination of
volume existed between groups.[65] Furthermore, muscle fibre loss and atrophy.[201,202]
the maximal motor unit discharge rates in the
rectus femoris of masters weightlifters have been 6.2 Bone Mineral Density
shown to be ~20% greater than in untrained, age-
The skeletal structures of weightlifters undergo
matched adults.[195] Therefore, it appears that long-
significant adaptations in response to the large
term weightlifting training and competition has the
compressive and shear forces that are encountered
potential to attenuate the age-related decline in
during training and competition.[5,22,36,203] Bio-
motor unit size, number and/or function that be-
chemical indicators of bone formation are elevated
comes apparent after the age of 60 years.[196,197]
by up to 35% in actively competitive weight-
A significant reduction in type II fibre size and
lifters when compared with age-matched, healthy
content is associated with increasing age[198-200]
adults.[204] Furthermore, greater site-specific in-
and is likely to contribute to the annual decline of
creases in trabecular and cortical bone densities
~11.5% in PP and competitive performance that
have been reported in the vertebrae (1342%), fem-
has been reported in masters weightlifters.[65,66]
oral neck/trochanter (1224%), tibia (912%) and
According to Anton et al.,[68] the rate of decline in
radius (10%) of competitive weightlifters when
competitive performance is markedly greater in
compared with untrained and recreationally trained
women across all weight classes.[68] These pre-
adults.[205-209] Following ~30 years of retirement
vious findings are confirmed when comparing the
from weightlifting, former weightlifters aged be-
current under 69 kg male and female world records
tween 50 and 64 years have been shown to exhibit
across all age categories (figure 4). Interestingly, no
a significantly greater bone mass when compared
such sex-related difference with increasing age has
with age-matched controls.[209] However, between
been reported during the expression of maximal
the ages of 6579 years, no differences in bone
strength in competitive powerlifting.[68] Therefore,
mass existed between groups.[209] Thus, it is evi-
it was concluded that only the ability to perform
dent that weightlifters must maintain an adequate
complex and explosive power-type exercises de-
level of physical activity past the age of 65 in order
clines at a greater rate in women.[68] These findings
to attenuate age-related declines in bone mass.
are in accordance with previous investigations,
which have demonstrated that women undergo 6.3 Cardiovascular Structure and Function

60 High-intensity resistance exercise increases

peripheral vascular resistance, thereby stimulating
Sex-related difference (%)

50
concentric left ventricular (LV) hypertrophy.[210,211]
40 The increase in myocardial wall thickness arises due
30 to the parallel addition of new myofibrils and is a
R2 = 0.90 compensatory attempt to reduce LV wall stress and
20
systolic pressure.[211,212] A number of studies have
10 examined the ventricular morphology and function
in competitive weightlifters.[121,213-227] Some investi-
0
gations have reported that the absolute LV mass (g)
9

9
h

or

or
3

6
ut

of weightlifters may be ~1330% larger than that of

ni

ni
Yo

35

40

45

50

55

60

65
Ju

Se
M

age-matched healthy and/or sedentary control sub-

Age category (years)
jects.[214,219,222,228,229] However, in most instances,
Fig. 4. The sex-related differences as a function of age (years) the increased LV mass exhibited by weightlifters is
between male and female world record totals in the under 69 kg
category. World record totals as of November, 2011. M = masters;
proportional to their total body mass, body surface
R2 = coefficient of determination. area and/or lean body mass, thereby indicating a

Adis 2012 Springer International Publishing AG. All rights reserved. Sports Med 2012; 42 (9)
Competitive Weightlifting Performance, Training and Physiology
physiological as opposed to a pathological adapta-
tion.[219,222,228,229] This is of importance as LV hy-
pertrophy is categorized as an independent risk
factor for cardiovascular morbid events.[211] Con-
versely, other studies have shown no significant
differences in absolute or relative measures of car-
diac morphology between weightlifters and healthy
adults.[215,218,221,224,226] The lack of difference in
these results may be explained by (i) the experi-
mental groups being more evenly matched for
body dimensions;[215,218] (ii) differences in the
training history of the control subjects (e.g. se-
dentary/untrained vs recreationally trained);[226]
and (iii) possible sex-related differences in cardiac
hypertrophy as only one study has examined
cardiac morphology in female weightlifters.[218]
In light of these findings, the consensus of opi-
nion is that weightlifting does not induce a true
concentric enlargement of the left ventricle as
seen in pathological conditions.
The cardiorespiratory function of competitive
male weightlifters,. as determined by maximal oxygen
consumption (VO2max), has been reported to range
between 42.0 and 50.7 mL/kg/min.[121,226-228,230,231]
As expected, these mean values are similar to those
of other athletes involved in short-duration high-
intensity/power activities.[121] Short-term (8 weeks)
weightlifting-style training in active adults has
been
. shown to increase both absolute and relative
VO2max by ~67%.[227] However, annual evalua-
tions over the course of 3 years of specific weight-
lifting training in competitive weightlifters revealed
significant
. reductions in both absolute and relative
VO2max of ~4% and 11%, respectively.[232] With
regards to resting haemodynamics, reported values
for mean heart rates range between 60 beats per
minute (bpm) and 81 bpm, systolic blood pres-
sure between 115 mmHg and 153 mmHg, and
diastolic blood pressure between 71 mmHg and
93 mmHg.[214,221,222,226-228,231,233] These data classi-
fy weightlifters as being normal or stage 1 hyper-
tensive as per the ACSM guidelines.[234]
6.4 Endocrine
Evidence of endocrine responses and adapta-
tions in weightlifters and/or related to weightlifting
performance are predominately limited to anabolic
Adis 2012 Springer International Publishing AG. All rights reserved.
781
and catabolic hormones for the large part in young
male weightlifters. Here we include where sub-
stantial data have been obtained, the responses of
testosterone, cortisol and growth hormone.
6.4.1 Testosterone
Testosterone is a potent androgenic-anabolic
hormone that is considered to be a major pro-
moter of muscular hypertrophy, strength and
power.[235,236] The reported basal serum total tes-
tosterone concentrations in male weightlifters range
from ~14.4 nmol/L to 27.7 nmol/L,[60,176,237-241]
which is within the normal range for young, healthy
untrained men (12.134.7 mol/L).[240,242,243] Short-
term exercise-induced increases in total serum tes-
tosterone of ~1730% have been reported in male
weightlifters in response to acute weightlifting
training sessions of moderate to high intensity and
volume.[97,176,241] In addition to the influence of ex-
ercise type, volume and intensity, the training age of
an individual also affects the exercise-induced tes-
tosterone response. Elite junior weightlifters with >2
years training experience exhibit significantly great-
er exercise-induced increases in serum testosterone
when compared with those with 2 years train-
ing experience.[241] Combined, these results demon-
strate that weightlifting training elicits a response
similar to that reported for conventional strength
and hypertrophy protocols involving large muscle
mass exercises.[244-247]
The available data pertaining to the testosterone
response to competition and competition-like set-
tings is limited to salivary measures.[57,248] During
official and simulated weightlifting competitions,
Passelergue et al.[248] reported no significant changes
in salivary total testosterone. From this limited
data, it appears that competition settings fail to
meet the exercise volume threshold that is required
to induce a significant testosterone response in
weightlifters.[236] This is in accordance with previous
investigations that have demonstrated no significant
changes in total testosterone following high-
intensity, low-volume, moderately long rest period
duration, resistance exercise protocols.[245,247,249,250]
6.4.2 Testosterone : Cortisol Ratio
The basal testosterone : cortisol (T : C) ratio is
often used to represent the physiological strain
Sports Med 2012; 42 (9)
782
imposed by a training programme,[251-253] as it
generally exhibits an inverse relationship with ex-
ercise volume.[132,238,254-256] For example, across
a 5-week training period in elite female weight-
lifters, a 37.0% reduction in training volume elici-
ted a mean increase of 72.5% in basal T : C
ratios.[132] Conversely, Wu et al.[256] demonstra-
ted that a 54% increase in weightlifting training
volume over 2 weeks resulted in a 60% reduction
in the basal T : C ratio. However, weightlifting
training for 1 year and prior exposure to increased
training volumes appears to attenuate this relation-
ship.[59] Furthermore, during extended training
periods (i.e. 1224 weeks) of varying intensity and
volume, experienced weightlifters have demon-
strated a positive association between an increased
basal T : C ratio and maximal voluntary isometric
PF and PP.[132,255,257] Thus, the routine assessment
of the basal T : C ratio may provide an effective
way in which to measure acute and chronic adap-
tive responses to weightlifting training.
In competition settings, the T : C ratio is greatly
influenced by pre-competition anxiety and may
decrease prior to any form of strenuous physical
activity.[248] Furthermore, an official weightlifting
competition has been shown to produce a higher
salivary cortisol response and, thus, a greater
decrease in the salivary T : C ratio, when com-
pared with a simulated competition.[58] However,
competitors with higher pre-competition salivary
cortisol levels also exhibited superior lifting perfor-
mances.[58] In stressful situations, salivary cortisol
levels have been shown to increase by 230% from
basal values.[258] A pre-competition anticipatory rise
in circulating catecholamines[220,259] may stimulate
the release of adrenocorticotropic hormone, which
in turn increases cortisol secretion.[260] As a positive
association exists between increased catecholamine
levels and force production,[259] it is possible that
this mechanism may account for the higher cortisol
levels and the superior lifting performances that
were reported during an official competition.[58]
6.4.3 Growth Hormone
Conventional resistance exercise does not appear
to affect basal concentrations of growth hormone
(GH).[261] In accordance with this contention, sim-
ilar basal GH concentrations have been reported
Adis 2012 Springer International Publishing AG. All rights reserved.
Storey & Smith
in male and female weightlifters[133,176,241,245,254]
and other strength athletes (i.e. bodybuilders and
powerlifters) when compared with recreationally
trained and untrained adults.[242,244,261,262] Sig-
nificant exercise-induced increases in GH occur
similarly in men and women in response to mod-
erate-intensity, high-volume and short rest period
resistance exercise protocols (i.e. hypertrophy
training).[245,261,263] Conversely, only minor in-
creases in GH have been reported following con-
ventional strength and power protocols that use
high loads, low repetitions and long rest peri-
ods.[245,264-266] In contrast to these latter findings,
4.513-fold increases in GH have been reported in
male weightlifters in response to their high-intensity,
high-power training.[176,241,254] However, these con-
flicting results may be explained by (i) the differ-
ences in the training experience of participants that
has been shown to affect the magnitude of GH re-
lease;[244,262,267] and (ii) differences in the absolute
and relative intensity, volume and type of exercise
performed (i.e. isolation vs multijoint exercise) in
each investigation.[261]
7. Recommendations and Conclusions
The high-intensity, explosive nature of weight-
lifting training and competition results in a
number of structural and functional adaptations
of the musculoskeletal and cardiovascular sys-
tems. Of particular interest is that the rapid force
and power generating ability of weightlifters ex-
ceeds that of other strength and power athletes.
Although the use of weightlifting exercises are
becoming increasingly popular across a number
of sports, the frequency of HIRE performed by
weightlifters is unmatched by other athletes and
exceeds the current ACSM recommendations for
strength and power training. As younger and
older individuals of both sexes are being drawn to
the sport of weightlifting, it is imperative that
further research is conducted in these populations
to ensure the development of safe and effective
training programmes. Particular focus needs to
be directed towards understanding the acute
responses and long-term adaptations of female
weightlifters, as the majority of existing research
has solely been conducted in male athletes.
Sports Med 2012; 42 (9)
Competitive Weightlifting Performance, Training and Physiology
Acknowledgements
The authors have no potential conflicts of interest. No
funding was received for this review. The authors would like
to thank Jonathan Milne and our athlete model for their as-
sistance with supplying the photographs for this publication.
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Correspondence: Adam Storey, Department of Sport and
Exercise Science, The University of Auckland, Private Bag
92019, Auckland Mail Centre, Auckland 1142, New Zealand.
E-mail: adam.storey@auckland.ac.nz
Sports Med 2012; 42 (9)