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ACE Personal Trainer Manual 5th Edition
Chapter 14: Exercise and Special PopulationsLesson 14.1
© 2014 ACE
• After completing this session, you will be able to: Explain the impact of exercise on special populations and the
importance of documentation. Discuss the following special populations and recommendations for
exercise programming: o Cardiovascular disorderso Hypertensiono Strokeo Peripheral vascular diseaseo Dyslipidemiao Diabeteso Metabolic syndromeo Asthma
LEARNING OBJECTIVES
© 2014 ACE
EXERCISE GUIDELINES FOR SPECIAL POPULATIONS
• Clients with health conditions should follow a low- to moderate-intensity program that gradually progresses.
• Many clients have comorbidities that will also impact their program.
• The program must be individualized: Specific client characteristics Appropriate modifications Safe and effective
• A personal trainer has a responsibility to expand his or her knowledge and skills and communicate with healthcare professionals when training clients with health conditions or special considerations.
© 2014 ACE
WORKING WITH CLIENTS WHO HAVE HEALTH PROBLEMS
Do you feel comfortable working with clients who have health problems?
Given that the overall population is aging and becoming increasingly overweight and that with aging and/or obesity often comes an increased prevalence of health disorders, personal trainers must consider that their services will be offered to clients who are dealing with health challenges.
• Are you prepared to work with clients who have special health and fitness issues?
• How will you increase your knowledge in this important area?• Is there a specific population with which you would like to work? • How will you promote your services to this clientele?
© 2014 ACE
• Documentation is important to appropriately adjust each client’s program and prepare communication to the health provider:
Client encounters Health status Progress
• The SOAP note is commonly used to document progress:
S – Subjective: The client’s own observations (e.g., status report, symptoms, challenges, and progress made)
O – Objective: Measurements (e.g., vital signs, height, weight, age, posture, exercise, and test results) and exercise and nutrition log information
A – Assessment: A brief summary of the client’s current status based on the subjective and objective observations and measures
P – Plan: A description of the next steps in the program based on the assessment
DOCUMENTATION AND SOAP NOTES
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CARDIOVASCULAR DISORDERS
• 80.7 million Americans have one or more types of cardiovascular disorders:DyslipidemiaCoronary artery disease (CAD)Congestive heart failure (CHF)HypertensionStrokePeripheral vascular disease
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CVD SIGNS AND SYMPTOMS
• Abnormal signs or symptoms that necessitate delaying or terminating the exercise session: Angina Dyspnea Lightheadedness or dizziness Pallor Rapid heart rate
• Teach clients to recognize signs and symptoms that indicate they should stop exercising and contact their physician.
© 2014 ACE
EXERCISE RECOMMENDATIONS FOR CVD
Condition Mode Intensity Frequency Duration CommentsCoronary artery disease
Low-intensity endurance: low-impact aerobics, walking, swimming, stationary cycling, or other erg use.
Low-risk, stable CAD clients starting exercise should begin at 40 to 50% of HRR or an RPE of 9 to 11 (6 to 20 scale) or at an HR 20 to 30 beats over resting heart rate.
Low-risk, stable CAD clients who are already exercising may progress to 60 to 85% of HRR or an RPE of 11 to 14.
Three to five days per week of aerobic training.
Two days per week of resistance training.
Total duration gradually increased to 30 minutes or more of continuous or interval training.
Gradually progress to moderate-intensity exercise using interval-type training. Be aware of medications that may alter heart rate response to exercise. Use RPE and careful client observations.
© 2014 ACE
HYPERTENSION
• Hypertension is sometimes referred to as the “silent killer” and is defined as: Systolic BP ≥140 mmHg Diastolic BP ≥90 mmHg Or taking antihypertensive medication
• Prehypertension is defined as: Systolic BP of 120−139 mmHg Diastolic BP of 80−89 mmHg
© 2014 ACE
HYPERTENSION AND EXERCISE
• Personal trainers should use the following guidelines: Obtain the physician’s release, guidelines, and recommendations Be aware of the client’s medications and potential impact on exercise Teach clients to pay careful attention to hydration, especially in warm
environments and if taking diuretics Teach clients to use RPE to monitor exercise intensity, change positions
slowly, and follow exercise with a gradual and prolonged cool-down period
Avoid isometrics and inverted exercises; emphasize technique and breathing
Include yoga or tai chi to add variety and promote relaxation Measure the client’s pre- and post-exercise blood pressure:
o Monitor blood pressure during exercise initially, and possibly long-termo Discontinued if the SBP or DBP rise to 250 mmHg or 115 mmHg,
respectively, or if the SBP fails to increase with increasing workload or drops ≥20 mmHg
© 2014 ACE
EXERCISE RECOMMENDATIONS FOR HYPERTENSION
Condition Mode Intensity Frequency Duration CommentsHypertension
Endurance exercise: low-impact aerobics, walking, cycling, using ergometers, and swimming.
Weight training: low resistance and high repetitions.
Mind-body exercise: to promote strength, flexibility, and relaxation.
An RPE of 9 to 13 (6 to 20 scale), especially for those clients on heart rate–altering medications.
Four to seven days per week.
Ideally strive for daily exercise due to the acute hypotensive effect of exercise.
Gradual warm-up and cool-down periods lasting longer than five minutes.
Gradually increase total exercise duration to as much as 40 to 60 minutes per session, continuously or intermittent.
Exercises with a significant isometric component should be avoided.
Exercise training performed at lower intensities appears to lower blood pressure as much as, if not more than, exercise at higher intensities.
© 2014 ACE
STROKE
• Hemorrhagic stroke: a blood vessel in the brain bursts• Ischemic stroke: blood supply to the brain is cut off
Approximately 80% of all strokes are ischemic• Strokes dramatically reduce a client’s quality of life and can
lead to metabolic disorders and an increased risk of recurrent stroke and myocardial infarction.
• Risk factors for stroke include: High blood pressure Smoking Heart disease Previous stroke Physical inactivity Transient ischemic attacks
© 2014 ACE
STROKE AND EXERCISE
• Personal trainers should be aware of the warning signs of a stroke:Sudden numbness or weakness of
the face, arms, or legsSudden confusion or trouble
speaking or understanding othersSudden trouble seeing in one or
both eyes Sudden walking problems, dizziness,
or loss of balance and coordinationSudden severe headache with no
known cause
© 2014 ACE
EXERCISE RECOMMENDATIONS FOR STROKE
Condition Mode Intensity Frequency Duration Comments
Stroke Walking, cycling, upper- extremity ergometers, and water exercise.
Include balance and light resistance training.
As conditioning improves, cognitive challenges can be added as the client exercises.
Light to moderate.
Five days per week, though many may need to begin with three days and gradually progress to five.
Clients should begin with short bouts of activity—three to five minutes—and gradually build to 30 minutes over time, or use intermittent exercise as needed.
Be aware of and stop exercise with:
Sudden numbness or weakness of the face, arms, or legs; sudden confusion or trouble speaking or understanding others; sudden trouble seeing in one or both eyes; sudden walking problems, dizziness, or loss of balance and coordination; sudden severe headache with no known cause.
© 2014 ACE
PERIPHERAL VASCULAR DISEASE (PVD)
• PVD is caused by atherosclerotic lesions in one or more peripheral arterial and/or venous blood vessels:
• Peripheral artery occlusive disease (PAOD): results from atherosclerosis of the arteries of the lower extremities; most common form of PVD
• Peripheral vascular artery disease (PVOD): characterized by muscular pain caused by ischemia, or lack of blood flow to the muscle.
• PVD risk factors are similar to those of CAD: Hyperlipidemia Smoking Hypertension Diabetes Family predisposition Obesity Stress
© 2014 ACE
SUBJECTIVE GRADING SCALE FOR PVD
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RECOMMENDATIONS FOR PVD
Condition Mode Intensity Frequency Duration CommentsPeripheral vascular disease (PVD)
Non-impact endurance exercise: swimming, cycling, and other ergometer use.
Aerobic exercise: low to moderate, gradually increasing as capacity improves.
Weightbearing activities such as walking should be carried out to the point of moderate to intense pain (grade II to grade III on the claudication pain scale).
Daily exercise is recommended initially.
As functional capacity improves, frequency can be reduced to four to five days a week.
Longer and more gradual warm-up and cool-down periods (longer than 10 minutes).
Gradually increase total exercise duration to 30 to 60 minutes.
Close attention should be paid to the client’s feet, especially if the client is diabetic, and encourage proper footwear.
Clients with PVD should avoid exercising in cold air or water to reduce the risk of vasoconstriction.
© 2014 ACE
PVD AND EXERCISE
• People with PVD may also have underlying CAD. • Some clients may develop CAD symptoms as walking
distance and/or speed increases: Stop the exercise session The client must be evaluated by his or her physician and
released back to activity• Proper foot care is essential:
Pay close attention to the client’s feet, especially if diabetic Encourage proper footwear
• Avoid exercising in cold air or water to reduce the risk of vasoconstriction.
© 2014 ACE
DYSLIPIDEMIA
• The highest correlation to CVD involves: Elevated total cholesterol
levels Elevated LDL levels Suboptimal HDL levels Elevated triglyceride levels
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CHOLESTEROL CLASSIFICATION
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DYSLIPIDEMIA AND EXERCISE
• Exercise and dietary modification: Considered effective in managing
high serum cholesterol and triglyceride levels
Particularly effective in elevating low HDL levels
• The impact of exercise on blood lipid profiles is most profound with corresponding decreases in body fat.
• Therefore, exercise, when combined with dietary changes that lower body weight, is an effective means of improving lipid profiles.
© 2014 ACE
EXERCISE RECOMMENDATIONS FOR DYSLIPEDEMIA
Condition Mode Intensity Frequency Duration Comments
Dyslipidemia Aerobic activities: walking, jogging, cycling, and swimming.
Resistance training: twice a week using light to moderate weights at 10 to 12 repetitions.
Low to moderate intensity with a focus on duration.
Some clients may be able to progress to short bouts of vigorous-intensity exercise.
Five days per week.
Begin workouts at 15 minutes and build to 30 to 60 minutes per day.
The goal is to exercise for a total of 150 to 200 minutes each week.
Programming for clients who have abnormal lipid levels, but who are free of other health conditions, can be developed utilizing the general age-specific guidelines.
© 2014 ACE
DIABETES
• Diabetes: a fasting blood glucose level of ≥126 mg/dL• Prediabetes: a fasting blood glucose level between 100 and 125
mg/dL• Causes abnormalities in the metabolism of carbohydrate,
protein, and fat• If inadequately treated, results in chronic disorders or death• Type 1 diabetes: develops when the body’s immune system
destroys pancreatic beta cells responsible for producing insulin• Type 2 diabetes: typically presents as insulin resistance, a
disorder in which the cells do not use insulin properly; the pancreas gradually loses the ability to produce insulin
• Gestational diabetes: glucose intolerance that occurs during pregnancy
© 2014 ACE
DIABETES CONTROL AND EXERCISE
• The primary treatment goal for diabetes control: Normalize glucose metabolism Prevent diabetes-associated complications
and disease progression• Proper management requires a team
approach: Physicians Diabetes educators Dietitians Exercise specialists The client with diabetes
• The personal trainer’s role: Assist with client motivation Program regular physical activity Provide feedback regarding progress and
responses to the team
© 2014 ACE
EXERCISE RECOMMENDATIONS FOR DIABETES
Condition Mode Intensity Frequency Duration Comments
Diabetes
Walking, cycling, swimming, and recreational sports.
Resistance training:twice per week, eight to 10 exercises at eight to 12 repetitions.
Moderate intensity:
Type 1 – RPE of 11 to 14 (6 to 20 scale)
Type 2 – RPE of 11 to 16 (6 to 20 scale)
Five to six days per week, though some clients may need to start out with several shorter daily sessions.
The initial goal is to establish a “regular” pattern of physical activity and then gradually progress to higher levels of activity.
Type 1 – gradually work up to 30 minutes or more per session
Type 2 – 40 to 60 minutes
It is essential to utilize gradual warm-up and cool-down periods.
Recognize the signs and symptoms of hypoglycemia and hyperglycemia.
Ingest additional carbohydrate if glucose levels are <100 mg/dL pre-exercise.
Do not exercise if glucose levels are >300 mg/dL or >250 mg/dL with the presence of ketosis pre-exercise.
Focus on careful foot hygiene and proper footwear.
© 2014 ACE
METABOLIC SYNDROME
• Metabolic syndrome (MetS) is identified as the presence of 3 or more of the following components: Elevated waist circumference Elevated triglycerides Reduced HDL cholesterol Elevated blood pressure Elevated fasting blood glucose
• MetS is also characterized by abdominal obesity, and a prothrombotic and pro-inflammatory state.• MetS has been associated with: Physical inactivity Excessive caloric intake Genetics Aging
© 2014 ACE
METABOLIC SYNDROME
• The primary treatment objective for MetS: Reduce the risk for developing cardiovascular disease Reduce the risk for developing type 2 diabetes
• Lifestyle interventions are typically the initial strategies implemented: Weight loss Increased physical activity Healthy eating Tobacco cessation
© 2014 ACE
EXERCISE RECOMMENDATIONS FOR METABOLIC SYNDROME
Condition Mode Intensity Frequency Duration Comments
Metabolic syndrome
Low-impact activities: walking, elliptical training, and low-impact aerobics.
Non-weightbearing activities (e.g., water exercise and cycling) for obese clients and those with musculoskeletal challenges.
Twice-a-week resistance training using eight to 10 exercises at eight to 12 repetitions.
An RPE of fairly light to somewhat hard (11 to 13 on the 6 to 20 scale) or 30 to 75% of VO2R.
Begin at a low intensity and gradually progress as conditioning improves and weight loss occurs.
Initially work on increasing duration rather than intensity to optimize caloric expenditure.
At least three to five days per week, preferably daily.
Target a total weekly accumulation of 200 to 300 minutes using a gradual progression.
Intermittent short exercise bouts (10 to 15 minutes) accumulated throughout the day may be easier and more beneficial for some individuals in maximizing weight loss.
Individuals with MetS should be encouraged to develop an active lifestyle by looking for opportunities to expend energy throughout their daily routines.
© 2014 ACE
ASTHMA
• A cascade of events set off by environmental triggers activating an inflammatory response
• This inflammatory response leads to: Constriction of smooth muscle around the airways Airway hyper-responsiveness and airway obstruction Swelling of mucosal cells Increased secretion of mucus
• Exercised-induced asthma (EIA) An asthma attack during and/or after physical activity Occurs after breathing dry, cold air with allergens or pollutants Severity depends on exercise intensity and environmental
conditions Happens during or after vigorous activity, or by sudden intense
activity
© 2014 ACE
EXERCISE AND ASTHMA
• Exercise can help to reduce the ventilatory requirement, making it easier for clients with asthma to participate in any activity.
• EIA is brought on by hyperventilation: Clients should perform gradual and
prolonged warm-up and cool-down periods.• This allows clients to utilize the
refractory period to lessen the bronchospastic response during subsequent higher-intensity exercise.
© 2014 ACE
EXERCISE RECOMMENDATIONS FOR ASTHMA
Condition Mode Intensity Frequency Duration Comments
Asthma Walking, cycling, ergometer use, and swimming.
Younger, more highly conditioned individuals may also be able to jog and/or run.
Swimming may be beneficial due to inhaling moist air just above the surface of the water.
Exercises such as arm cranking, rowing, and cross-country skiing may not be appropriate because of the higher ventilation demands.
Low- to moderate-intensity dynamic exercise.
Begin easy and gradually increase intensity during the session.
The peak exercise intensity should be determined by the client’s state of conditioning and asthma severity. Clients should reduce the intensity if asthma symptoms begin to occur.
At least three to five times per week.
Some clients may benefit from intermittent exercise (two or three 10-minute sessions, or interval training).
Gradually progress total exercise time to 30 minutes or more.
Longer, more gradual warm-up and cool-down periods (10 minutes or more) are recommended.
Clients with asthma should have rescue medication with them at all times.
Avoid asthma triggers during exercise and consider moving indoors on extremely hot or cold days or when pollen counts and/or air pollution are high.
Personal trainers should closely observe the client for early signs of an asthma attack and respond immediately.
People with asthma often respond best to exercise in mid-to-late morning.
© 2014 ACE
SUMMARY
• Personal trainers may work with one or more clients that have a chronic condition.
• It is important that the trainer work closely with the client’s medical team to establish a safe and effective exercise program.
• The personal trainer must be careful not to step beyond the defined scope of practice and always obtain physician clearance and program recommendations prior to working with clients who have health limitations.
