BackgroundTo counteract microgravity (µG)-induced adaptation, European Space Agency (ESA) astronauts on long-duration missions (LDMs) to the International Space Station (ISS) perform a daily physical exercise countermeasure program. Since the first ESA crewmember completed an LDM in 2006, the ESA countermeasure program has strived to provide efficient protection against decreases in body mass, muscle strength, bone mass, and aerobic capacity within the operational constraints of the ISS environment and the changing availability of on-board exercise devices. The purpose of this paper is to provide a description of ESA’s individualised approach to in-flight exercise countermeasures and an up-to-date picture of how exercise is used to counteract physiological changes resulting from µG-induced adaptation. Changes in the absolute workload for resistive exercise, treadmill running and cycle ergometry throughout ESA’s eight LDMs are also presented, and aspects of pre-flight physical preparation and post-flight reconditioning outlined.ResultsWith the introduction of the advanced resistive exercise device (ARED) in 2009, the relative contribution of resistance exercise to total in-flight exercise increased (33–46 %), whilst treadmill running (42–33 %) and cycle ergometry (26–20 %) decreased. All eight ESA crewmembers increased their in-flight absolute workload during their LDMs for resistance exercise and treadmill running (running speed and vertical loading through the harness), while cycle ergometer workload was unchanged across missions.ConclusionIncreased or unchanged absolute exercise workloads in-flight would appear contradictory to typical post-flight reductions in muscle mass and strength, and cardiovascular capacity following LDMs. However, increased absolute in-flight workloads are not directly linked to changes in exercise capacity as they likely also reflect the planned, conservative loading early in the mission to allow adaption to µG exercise, including personal comfort issues with novel exercise hardware (e.g. the treadmill harness). Inconsistency in hardware and individualised support concepts across time limit the comparability of results from different crewmembers, and questions regarding the difference between cycling and running in µG versus identical exercise here on Earth, and other factors that might influence in-flight exercise performance, still require further investigation.

Physical training has been conducted on the International Space Station (ISS) for the past 10 yr as a countermeasure to physiological deconditioning during spaceflight. Each member space agency has developed its own approach to creating and implementing physical training protocols for their astronauts. We have divided physical training into three distinct phases (preflight, in-flight, and postflight) and provided a description of each phase with its constraints and limitations. We also discuss how each member agency (NASA, ESA, CSA, and JAXA) prescribed physical training for their crewmembers during the first 10 yr of ISS operations. It is important to understand the operational environment, the agency responsible for the physical training program, and the constraints and limitations associated with spaceflight to accurately design and implement exercise training or interpret the exercise data collected on ISS. As exploration missions move forward, resolving agency differences in physical training programs will become important to maximizing the effectiveness of exercise as a countermeasure and minimizing any mission impacts.

Spaceflight and exposure to microgravity have wide-ranging effects on many systems of the human body. At the European Space Agency (ESA), a physiotherapist plays a key role in the multidisciplinary ESA team responsible for astronaut health, with a focus on the neuromusculoskeletal system. In conjunction with a sports scientist, the physiotherapist prepares the astronaut for spaceflight, monitors their exercise performance whilst on the International Space Station (ISS), and reconditions the astronaut when they return to Earth. This clinical commentary outlines the physiotherapy programme, which was developed over nine longduration missions. Principles of physiotherapy assessment, clinical reasoning, treatment programme design (tailored to the individual) and progression of the programme are outlined.Implications for rehabilitation of terrestrial populations are discussed. Evaluation of the reconditioning programme has begun and challenges anticipated after longer missions, e.g. to Mars, are considered. Key WordsPhysiotherapy; microgravity; spaceflight; astronaut reconditioning; exercise; low back pain 4 IntroductionThe requirements of the human body, in particular the neuro-musculoskeletal system, are very different in space than on Earth. Interestingly, physiological spaceflight data suggest that it is more difficult to return to gravity than to adapt to microgravity conditions (Payne et al 2007). On Earth, the line of gravity normally passes through the ventral part of the L3 vertebral body (Richter & Hebgen, 2006), ensuring optimal load transfer). In microgravity, musculoskeletal adaptations are appropriate to that environment but this has major effects on muscle function and posture. Astronauts move in a predominantly flexed position and the centre of mass shifts posteriorly (Baroni et al, 2001), with increased recruitment of flexor muscles and a loss of extensors (Fitts et al 2001; Fitts et al 2000). A shift of muscle fibres types from tonic (type 1) to phasic (type 2) occurs (Fitts 2001). Graviceptors, which are sensory receptors that contribute to providing a neural representation of the direction of gravity, with respect to the gravity vector (Binder 2009), no longer function in microgravity.The astronaut therefore receives less information about his/her posture and has to rely on vision and feedback from dynamic receptors.Prolonged microgravity has negative effects on muscle strength and endurance, motor control, coordination and balance (Layne et al, 2001), which may place the astronaut at higher risk of injury. In the spine, primarily lumbar, intervertebral discs absorb more water (hyperhydration) than on Earth (Belavy et al 2016), which can be associated with low back pain (LBP) inflight but is short-lived and has been reported in 70% of astronauts without a history of LBP and 100% of those with a history of LBP (Pool-Goodzwaard et al 2015). The effects of microgravity on the intervertebral disc must be considered to allow safe re-loading of the spine postflight, as the astronaut must readapt...

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