Program Considerations and Modification

In this topic, we focus on the tools used in program design and their importance when working with special populations. You will learn:

• The importance of the pre-screening process
• Pre-screening tools available to assist in safe client stratification and program design
• Fitness testing for special populations
• Acute and chronic responses to exercise
• Program considerations for special population clients.

Terminology and vocabulary reference guide

As an allied health professional, you need to be familiar with terms associated with basic exercise principles and use the terms correctly (and confidently) with clients, your colleagues, and other allied health professionals. You will be introduced to many terms and definitions. Add any unfamiliar terms to your own vocabulary reference guide.

Activities

There are activities throughout the topic and an end of the topic automated quiz. These are not part of your assessment but will provide practical experience that will help you in your work and help you prepare for your formal assessment.

Pre-screening implies a preliminary step taken in order to identify any potential risks of the reason for exclusion when undertaking an exercise routine, similar to a job interview in the sense you would be asked a series of questions to determine if you are the right candidate for the role. Within exercise, you would pre-screen your client to determine:

• If your client is medically and physically safe to exercise and if so, further determine the appropriate intensity and other variables within the FITT principle
• If medical referral and or clearance is required
• If you are a suitable professional to safely, and effectively, meet their medical and exercise needs.

It is important to provide an initial screening of all participants in order to determine risk factors and or disease limitations prior to embarking on an exercise routine. This is to ensure the safety of the clients during exercise testing and to effectively contribute towards as suitable, sustainable, and safe exercise program.

Pre-screening is a two way process, in the sense that, you should use this stage to determine not only if your client is a suitable candidate for exercise but also if the needs of your client falls within your scope of practice, i.e. are you qualified to safely guide them through their exercise needs. If not, do not be a hero, ask for further advice from your gym manager, a more experienced personal trainer or refer to an allied health professional such as a G.P or Exercise Physiologist for more medically comprehensive screening and exercise supervision.

All health and fitness professionals conduct a pre-screening session to:

• optimise safety
• develop sound and effective exercise prescription
• identify individuals with disease symptoms and risk factors for disease development who should receive medical clearance before starting an exercise program
• identify and exclude individuals with medical contraindications to exercise
• identify individuals with other special needs.

Obtaining accurate client information and provide appropriate exercise prescription is of upmost importance for all clients, this will put you in the best possible position to significantly reduce both the likelihood and severity of causing a serious incident or injury as a result of your professional advice. It is recommended that client screening is conducted as an essential component of all exercise prescription and, can often be of significant support during any legal cases surrounding concerns regarding personal injury possibly sustained during an exercise session or program design, should such situations arise.

A sound and approved method for gathering this information would be to include the Physical Activity Readiness Questionnaire (PAR-Q) in your pre-screening session. This questionnaire, created by British Columbia Ministry of Health and the Multidisciplinary Board and Exercise, adopted directly from the American College of Sports Medicine (ACSM) Standards and Guidelines for Health and Fitness Facilities, contains relevant questions in the necessary detail for you to be able to determine if your client is medically fit to exercise and any parameters you may need to work around when planning and conducting your exercise program together. The key focus of this questionnaire is to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice concerning the most suitable type of activity.

What should be captured in a pre-screening form?

You may find that health and fitness providers adapt the format of the questionnaire to suit their needs, however, the underlying key information is still contained within. The PAR-Q for you use should, at a minimum, must contain the following:

• Medical history questions – injury, disease, or condition (past or present) and medications
• Questions that allow you to judge “risk stratification”
• Medical clearance- should risk stratification require medical clearance
• Lifestyle evaluation – diet, recreational activities, exercise history (and current), availability, personal commitments etc.​
• Things that can also be included:
  • Informed consent and commitment statement (signed)​
  • Exercise & Biometric testing – Baseline data.

Let us look further into some of these components.

Medical history

You should require your clients to complete a comprehensive medical history questionnaire that includes questions concerning personal and family health history.​ When reviewing medical history, you should carefully focus on conditions that require medical referral. If any of these conditions are noted, refer your client to their GP for medical clearance prior to exercise testing or starting an exercise program.

Important – keep a copy of this in your client file, confidentially, for your own records to refer to.

Medication

It is also important to note the types of medication being used by the client and to ascertain what effects (if any) these will have on their ability to train. ​Drugs such as digitalis, beta-blockers, diuretics, vasodilators, bronchodilators, and insulin may alter the individual’s heart rate blood pressure, ECG, and exercise capacity., you should be aware of these and incorporate this knowledge into your program and progression approach.

If your client reports a medical condition or drug that is unfamiliar to you, make sure you consult medical references or a GP to obtain more information before conducting any exercise tests or allowing the client to participate in an exercise program.

Lifestyle evaluation

Planning a well-rounded fitness program for a client requires that you to first find out information about their living habits. ​The lifestyle assessment provides useful information regarding the individual’s risk factor profile.

Factors such as smoking, lack of physical activity, and diets high in saturated fats or cholesterol increase the risk of CVD and hypertension and therefore increase the risk of participation in vigorous activity. These may also have an effect on blood pressure readings, perceived rate of exertion or lung capacity resulting in exercise being more demanding on these clients.

The lifestyle evaluation component should also gather information on drug and alcohol use, past and present physical activity levels along with the psychological stress levels of the individual. ​These factors can be used to pinpoint patterns and habits that need modification and to assess the likelihood of the client’s adherence to the exercise program.

It is also useful to know the client's weekly schedule in terms of work and other commitments so you know what you will have to be working around, for example, understanding they work 5 days a week and have only weekends available will enable you to design a program that suits their weekend availability. Exercise type and location preferences are also worth noting as these will aid you in making the program engaging and achievable for your clients.

Goals and motivations

It is important to find out why the client has decided to embark on an exercise programme now, is there a specific event they wish to train for?​ Are they working towards achieving their goals by a particular date such as a birthday, anniversary or wedding day?

Discuss your client’s goals and record them following the SMARTER process. Click on each of the following components to learn more.

Informed consent

Prior to conducting any physical fitness tests or exercise programs, you should see that each participant signs an informed consent. ​ This form explains the purpose and nature of each physical fitness test, any inherent risks in the testing, and the expected benefits of the tests, client awareness and consent are essential.

Important- If your client is underage (under 18 years of age), a parent or guardian must also sign the informed consent.

Consultation with other professionals

It is not possible for you to know every facet of every condition, or the effects that exercise will have on each condition, therefore you need to ensure that you consult with the medical professionals involved with your client. ​Remember each client will have different needs and goals (so no blanket approach).

Like you would for any client, consider the type, duration, intensity, frequency, and progression of exercises which are appropriate for your special need client.

After conducting the pre-screening process with your client, you will have all the information you require to design a safe and effective program. The next stage to this process would be to conduct a fitness test (or tests) to determine what your client’s “baseline” measurements are, i.e. their starting levels before any exercise has been undertaken. Fitness testing should be specific to their training and or health goals.

As a minimum, all clients must have their resting heart rate (RHR) and blood pressure (BP) measured. These are standardised tests which should be performed on all clients. Any further tests you decide to conduct for your client should be specific to their goals for example:

• Flexibility: sit and reach test.
• Body composition: skinfold testing (three or seven sites), waist to hip ratio, individual limb measurement (thigh, bicep, chest).
• Cardiovascular endurance: beep test or a modified version to support clients who present with a health condition, 3 minutes step-up test, 400m (2.4Km) run.
• Muscular endurance: 1-minute sit-up/push up test.
• Balance: standing stork test – standing on one leg with the foot of the other resting on the inner thigh and measuring how long the individual can maintain their balance for.
• Muscular strength: 1 rep max (1RM) test, sub max test (performing as many reps as they can with a lighter than maximum weight).

When to perform fitness testing?

Fitness testing is not a one-time event, during your training program these should be retested to evaluate both the effectiveness of the training and the improvements in your client’s baseline measurements.

In order to be accurate and also repeated effectively, it is important to conduct the standardised (typically the Gold Standard) method of the testing protocol, rather than amending and making tweaks where you see fit. This ensures that the results are accurate and also, should you work with another allied health professional or your client has come to you from another trainer or, begins to work with another trainer, the tests can be replicated in the same way achieving both consistency and validity of results.

Fitness testing does not have to be complicated, it should, however, be an accurate reflection of the clients' initial measurements, prior to undertaking any fitness training, and correlate to their goals, i.e. there is little point in measuring their cardiovascular fitness if their goal is to increase their muscular strength.

When performing an exercise, many changes occur within the body to meet the new demands been placed on it. ​These can be considered either acute or chronic with acute being further subdivided into desirable or undesirable responses.

The term acute implies those responses which are present during the exercise session itself, also referred to as short term. Acute responses typically reflect an immediate response by or more of systems of the body, such as elevated heart rate which occurs during warm-up or an increase in blood pressure during resistance training or and increased breathing rate as exercise intensity increased from a resting state. Acute responses can be further either positive or negative with negative responses being considered as undesirable responses.

When working with special populations, in particular, it is important to be aware of any signs or symptoms which may indicate adverse effects of training which may be displayed before, during, and after a training session, i.e. the acute responses. In order to do this effectively, we must ensure we monitor our client’s both during and after each session to ensure our client enjoying themselves and, most importantly, is safe!

Chronic responses, on the other hand, last for a longer time and typically reflects the benefits an individual receives as a result of long-term exercising if the exercise regime is maintained.

It is important to note, that some benefits such as increased stroke volume, increased tidal volume, and increased cardiac output along with others, depending on the context, can be placed in both categories as typically and an individual will experience an increase in both stroke volume and cardiac output during a session in order to complete the session however these would more typically be seen as a chronic response as this would be a lasting result in response to adhering to a regular, well-designed training program.

Both acute and chronic training responses can be further sub-categorised as physiological and psychological responses which can be further subdivided into both negative and positive. Before we explore acute responses in more depth, let us take a brief look at what would be deemed as a physiological and psychological chronic response.

Let us take a deeper look into acute training responses and better equip ourselves with the knowledge needed to keep the clients safe, fit and happy.

Acute training responses

Acute training responses, whilst they can range from redness of the face to decreased temperament, can be an invaluable method for both the client and the trainer to identify if the F.I.T.T. variables, such as type of exercise, frequency, intensity and duration of the session are well balanced or require adjustment along with factors such as the environment of the training session. These can all be variable which can either positively or negatively impact both the physiological and psychological responses everyone will demonstrate before, during and after a training session. Let us look at each of these to be better equipped to identify these within our clients.

Physiological responses

When exercise or physical activity is undertaken, the body will respond by attempting to meet the requirements of the demands of the training or activity. This typically requires all 11 systems of the body to step up and contribute appropriately to effectively support the body. This also results in greater fuel demands (carbohydrates, protein, and fats), with the level of the response being typically dictated by the duration, type, and intensity of the exercise.

Positive

• Increased heart rate- number of beats of the heart per minute
• Increased stroke volume- the volume of blood ejected by the left ventricle per each beat
• Increased cardiac output (Q)- the amount of blood pumped by the heart per minute
• Increased venous return- the volume of blood being returned to the heart per minute
• Increased breathing/ respiratory rate (breaths per minute) – due to increased requirement of metabolic waste removal and requirement for oxygen
• Increased ventilation rate- how much air is breathed in and out per minute
• Increased tidal volume – the volume of air taken up per each breath
• Increased gas exchange between the lungs and the blood – uptake of oxygen and removal of carbon dioxide
• Increased blood pressure- due to increased flow and volume of blood passing through the arteries
• Increased temperature of skeletal muscles – occurs because of chemical reactions occurring during activity and exercise
• Increased hormone release- such as testosterone, growth hormone, and endorphins just to name a few
• Redness in the face
• Sweating.

Negative

• Sore or in pain
• Tiredness or exhaustion
• Dizziness
• Dehydration
• Difficulty completing programmes or exercises
• Closed body language
• Nausea
• Injury
• Shortness of breath- excessively increased breathing
• Excessive sweat
• No sweat at all
• Unconsciousness or death.

Psychological responses

Often the physiological benefits of exercise are emphasised, with the psychological being more of an afterthought. The psychological, however, can be just as important for some individuals, and therefore it is important for it to receive equal importance.

Exercise, as well as decreasing the waistline, can have significant positive impacts on mental health in areas such as anxiety, depression and ADHD just to name a few. It is important to recognise that not every client begins training simply to look better or fit into smaller pants, many have goals such as the following positive psychological aspects of training. These too can be achieved through adjustments of the F.I.T.T principle variables, such adjustments will likely, but not always, be different from those applied to achieve physiological aspects of training. It is, however, equally as important, to be clear on both the positive and negative implications of training to ensure your client's mental health is positively impacted and adjustments being made where applicable to ensure a safe, appropriate and effective training program for each individual.

Positive

• Increased mood
• Improved focus and concentration
• Reduced stress
• Increased feeling of accomplishment
• Improved body image
• Improved appetite.

Negative

• Negative towards workout
• Decreased mood
• Disengaged
• Avoidance- not responding to your calls or texts in regard to training, possible not showing up for sessions.

How to respond to acute training responses

It is important to remember that whilst a client is in your care, i.e. before, during and after the session, you have a duty of care, which aligns with the minimum ethical standards, to identify any signs of negative physiological and or psychological outcomes as a result of training. Should you feel that the client is displaying any signs of the negative effects of training, decide which of, or combination of the following steps would be applicable is supporting your client.

• Be prepared with water​
• Ask our client how exercises are feeling – RPE?
  • Do they need a longer rest period?
  • Do they need a regression of exercise?
  • Do they need to take layers off?
  • Are they hungover?
  • Have they had a long night of work, how tired are they?
  • Have they had a change in their medication?
• Reassure them – two-way communication, let the client know you are listening, and that their feedback is welcome​
• Lower the intensity​
• Education on session preparation​
• Change location
• Fanning them/cooling them down
• Altering the session based on the clients’ state
• Stop the session
• Recovery position
• Administer first aid Better screening process
• Refer to Dr/Physio or relevant allied health professional.

What could this look like in practice?

During a session with your client, you notice they are unable to hold a conversation through their rest periods. This is an example of an acute response to exercise, breathlessness due to working at a higher intensity. To manage this, provide your client with a longer rest period so they were fully recovered before continuing with the workout. You could also consider decreasing the intensity and regressing the exercises, for example, the jump squat could be amended to be an air squat, physiologically similar to a decreased intensity for your client.

When working with clients with differing medical and special needs, it is op the upmost importance to plan every aspect of your program and session design thoroughly. As a health and fitness professional, your aim is to ensure you avoid complications to the best of your ability, ensuring you adhere to your own code of practice and work within your scope of practice at all times. This can be done by following a minimum level of duty of care.

Broad recommendations to reduce complications during exercise

The following points cover the minimum that should be considered when planning for safety and consideration.

Ensure medical clearance and follow up

Medical clearance is essential for:

• Men over 45 years and women over 55 years who display two or more risk factors or one or more symptoms of heart disease
• Those who have diagnosed metabolic disorders, cardiac or respiratory diseases and you are contemplating effort of over 65%HR.

If necessary, establish an emergency plan

• Trainers should be equipped to deal with musculoskeletal injury and cardiovascular complications.​
• This may include performing CPR, attending to injuries, and if necessary stabilising the subject for transport to a medical centre
• Knowledge of medications and how and when to administer them is vital as well as when to ring an ambulance (especially of clients prone to seizures).

Educate your clients of their HR range for exercise and ensure they know how to accurately take their pulse

As a health and fitness professional, it is your responsibility to ensure all clients are:

• Aware of their prescribed Heart Rate range for training. They should know how to take their pulse accurately and the appropriate work rates they should be working at to achieve their aerobic needs.
• Aware of how to use the perceived rate of exertion (PRE) as a guideline for during sessions
• Should be strongly encouraged to remain at or below the prescribed intensity and to discontinue exercise and seek medical advice if any major warning symptoms occur (chest pain, lightheadedness, abdominal discomfort, extreme shortness of breath or unusual fatigue…).

Educate your clients on how to determine how hard they are working – the perceived rate of exertion (PRE)

As a fitness professional, it is important to give your client the tools they need to exercise safely and effectively both in your presence and when they train independently. One key tool is known as the perceived rate of exertion, often referred to as PRE (or RPE- rate of perceived exertion) or the Borg scale. This tool is a subjective tool in which your client can let you know how they feel during training but rating themselves on a scale of typically, 1-10 (you will also see scales which range from 6-20, these are used in the same fashion as 1-10 scales).

When working with your client, you can use extra information they provide you such as how they appear, are they flushed in the cheeks are they are able to speak in full or part sentences, to gauge their PRE appropriately. Use the following scale to help both you and your client determine how hard they are training. This tool is useful for general population clients also however is of particular use when working with special population clients.

Perceived rate of exertion

1: Resting

• No exertion e.g. sitting, watching TV

2-3: Light activity

• Minimal exertion – feels like it can be maintained for hours.
• Easy to breathe and carry on a conversation e.g. household chores.

4-6: Moderate activity

• Feels like you can exercise for hours.  
• Breathing heavily. Can hold a conversation, but sentences become shorter.

7-8: Vigorous activity

• On the verge of becoming uncomfortable
• Short of breath, can speak a short sentence

9: Very hard activity

• Very difficult to maintain the set exercise intensity
• Can barely breathe and speak in short, aggravated, words.

10: Maximal activity

• Feeling almost impossible to keep going
• Completely out of breath, unable to talk.

Start slowly and build intensity and exercise length gradually

It is advisable you encourage mild to moderate activity levels in the initial stages with your special population clients as:

• The lower the intensity, the less likely it is for a complication to arise
• Victims of exercise-related sudden death often have a history of poor compliance with their prescribed HR training range. Many mortalities occur in the initial stages of a programme
• Exercise leaders should recognise that excessive frequency (>5 x weekly) and duration (>45mins) often offer little additional aerobic gain yet increase orthopaedic injury substantially.

Emphasise appropriate warm-up and cool-down procedures before and after vigorous workouts

This is encouraged because:

• A disproportionate number of cardiovascular complications have been reported during the warm-up and cool down components of cardio workouts
• Progressive warmups are vital in preparation for vigorous activity and should include stretches as well as low-intensity cardio-respiratory activity
• Cool-downs enhance recovery and also reduce post-exercise hypotension episodes.

Maintain supervision in recovery

Duty of care implies:

• You should remain on-site for up to 10 minutes post-activity session as you are the health and fitness professional who has just asked your client to take part in the exercise which you have designed and complications can arise after exercise in the vulnerable tapering off period as post-training. It is therefore of great value to the health of your client, let alone the reputation of your skills and services, that you remain with your client to ensure their health and safety prior to departing.

Consider the weather/environmental effects

As the health and fitness professional, you should be aware of environmental impacts the chosen location may bring:

• Dynamic exercise in cold conditions is relatively safe provided appropriate clothing is worn. Cold air may increase stroke volume and heart work, as vasoconstriction of blood vessels to retain heat create greater peripheral resistance for the heart to work against
• Exercising in hot or humid conditions can pose extra problems for those with diagnosed cardiac conditions. In 24 ̊C or over, heart rate increases 1 bpm for every degree increase in heat, this places more stress on the heart and may lead to working in an inappropriate HR zone
• Hot and humid conditions could also pose issues for asthmatics, it is advisable to plan ahead and check the weather on the day, if you have concerns, discuss this with your client prior to attending the session, if the session is to proceed as planned, you may wish to advise your client to bring their inhaler in the event of any bronchospasms and perhaps you have one in your kit for emergencies.

Recreational needs of special population clients

In terms of needs gained from exercises, special needs clients have the same needs as general population clients, they may, however, place greater importance on some and have greater levels of difficulty obtaining others compared with general population clients, for example:

• Social interaction​
• Health​
• Challenge​
• Competition​
• Creative expression​
• Achievement and mastery​
• Education​
• Self-fulfilment​
• Fun.

Your role as an exercise professional when working with special population clients

Your objective is not to learn everything there is to know about all the specified populations but to learn how and when to apply a clear process that will enable you to research various conditions to help ensure the safety of your clients with special needs.

In this topic, we focused on the tools used in program design and their importance when working with special populations. You learnt about:

• The importance of the pre-screening process
• Pre-screening tools to assist in safe client stratification and program design
• Fitness testing for special populations
• Acute and chronic responses to exercise
• Program considerations for special population clients.