NSCAs essentials of training special populations by National Strength Conditioning Association (Estats Units dAmèrica) Jacobs, Patrick L (z-lib.org)

NSCA’s Essentials of Training Special Populations

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NSCA’s Essentials of Training Special Populations Patrick L. Jacobs, PhD, CSCS,*D, FNSCA Editor

Library of Congress Cataloging-in-Publication Data Names: Jacobs, Patrick L., 1955- editor. | National Strength & Conditioning Association (U.S.), issuing body. Title: NSCA’s essentials of training special populations / National Strength and Conditioning Association ; Patrick L. Jacobs, editor. Other titles: National Strength and Conditioning Association’s essentials of training special populations | Essentials of training special populations Description: Champaign, IL : Human Kinetics, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2017000180 (print) | LCCN 2017001698 (ebook) | ISBN 9780736083300 (print) | ISBN 9781492546290 (e-book) Subjects: | MESH: Physical Fitness | Resistance Training--methods | Disabled Persons--rehabilitation | Population Groups Classification: LCC RA781 (print) | LCC RA781 (ebook) | NLM QT 256 | DDC 613.7--dc23 LC record available at https://lccn.loc.gov/2017000180 ISBN: 978-0-7360-8330-0 (print) Copyright © 2018 by the National Strength and Conditioning Association All rights reserved. Except for use in a review, the reproduction or utilization of this work in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including xerography, photocopying, and recording, and in any information storage and retrieval system, is forbidden without the written permission of the publisher. Note: This publication is written and published to provide accurate and authoritative information relevant to the subject matter presented. It is published and sold with the understanding that no party involved in writing, developing, reviewing, or publishing this book or any forms of this book is engaged in rendering legal, medical, or other professional services by reason of association with this work. Readers are urged to consult with their health care professional regarding any and all drug-related information and gain the appropriate clearance prior to participating in any form of fitness assessment or beginning any form of exercise. Notice: Permission to reproduce the following material is granted to instructors and agencies who have purchased NSCA’s Essentials of Training Special Populations: pp. 18-21, 22-23, 24-25, 26-27. The reproduction of other parts of this book is expressly forbidden by the above copyright notice. Persons or agencies who have not purchased NSCA’s Essentials of Training Special Populations may not reproduce any material. The web addresses cited in this text were current as of March 2017, unless otherwise noted. Acquisitions Editor: Roger W. Earle; Senior Developmental Editor: Christine M. Drews: Managing Editor: Kirsten E. Keller; Copyeditor: Joyce Sexton; Indexer: Susan Danzi Hernandez; Permissions Manager: Dalene Reeder; Senior Graphic Designer: Joe Buck; Cover Designer: Keith Blomberg; Photographer (interior): © Human Kinetics, unless otherwise noted; Photo Asset Manager: Laura Fitch; Visual Production Assistant: Joyce Brumfield; Photo Production Manager: Jason Allen; Senior Art Manager: Kelly Hendren; Illustrations: © Human Kinetics, unless otherwise noted; Printer: Walsworth Printed in the United States of America 10 9 8 7 6 5 4 3 2 1 The paper in this book was manufactured using responsible forestry methods. Human Kinetics Website: www.HumanKinetics.com United States: Human Kinetics Europe: Human Kinetics P.O. Box 5076 107 Bradford Road Champaign, IL 61825-5076 Stanningley 800-747-4457 Leeds LS28 6AT, United Kingdom e-mail: [email protected] +44 (0) 113 255 5665 e-mail: [email protected] Canada: Human Kinetics 475 Devonshire Road Unit 100 Windsor, ON N8Y 2L5 800-465-7301 (in Canada only) e-mail: [email protected] For information about Human Kinetics’ coverage in other areas of the world, please visit our website: www.HumanKinetics.com. E4822

Contents Preface ix Chapter 1 Rationale and Considerations for Training Special Populations 1 Patrick L. Jacobs, PhD, CSCS,*D, FNSCA Bene ts of Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Inactivity and Costs to Individuals and Society. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Why Are People Inactive? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Speci c Exercise Programming for Special Populations . . . . . . . . . . . . . . . . . . . . . . 5 Scope of Practice of Those Working With Special Populations. . . . . . . . . . . . . . . . . 6 Professional Opportunities for Those Training Special Populations . . . . . . . . . . . . . . 7 Expectations in the Training of Special Populations . . . . . . . . . . . . . . . . . . . . . . . . 10 Appropriate Environments for Training Special Populations . . . . . . . . . . . . . . . . . . 11 Chapter 2 Health Appraisal and Fitness Assessments 15 John F. Graham, MS, CSCS,*D, RSCC*E, FNSCA Malcolm T. Whitehead, PhD, CSCS Medical and Health History Appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Fitness Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Fitness Assessment Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 SMART Goal Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Motivational and Coaching Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Chapter 3 Musculoskeletal Conditions and Disorders 67 Carwyn Sharp, PhD, CSCS,*D Disorders of the Spine and Associated Musculature . . . . . . . . . . . . . . . . . . . . . . . 68 Disorders of the Skeletal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Disorders of Joint Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Disorders of the Muscular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Chapter 4 Metabolic Conditions and Disorders 109 Thomas P. LaFontaine, PhD, CSCS, NSCA-CPT Jeffrey L. Roitman, EdD Paul Sorace, MS, CSCS Obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Type 1 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Dyslipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Hypothyroidism and Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 v

vi | Contents Chapter 5 Pulmonary Disorders and Conditions 145 Kenneth W. Rundell, PhD James M. Smoliga, DVM, PhD, CSCS Pnina Weiss, MD, FAAP Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Pulmonary Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Chronic Restrictive Pulmonary Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Chapter 6 Cardiovascular Conditions and Disorders 181 Ann Marie Swank, PhD, CSCS Carwyn Sharp, PhD, CSCS,*D Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Chronic Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Pacemakers and Implantable Cardioverter De brillators . . . . . . . . . . . . . . . . . . . 199 Valvular Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Cardiovascular Surgical Procedures: Coronary Artery Bypass Graft and Percutaneous Transluminal Coronary Angioplasty . . . . . . . . . . . . . . . . . . . . . . 204 Chapter 7 Immunologic and Hematologic Disorders 215 Don Melrose, PhD, CSCS,*D Jay Dawes, PhD, CSCS,*D, NSCA-CPT,*D, FNSCA Misty Kesterson, EdD, CSCS Benjamin Reuter, PhD, ATC, CSCS,*D Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Lupus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Chronic Fatigue Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Fibromyalgia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Sickle Cell Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Hemophilia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Contents | vii Chapter 8 Neuromuscular Conditions and Disorders 267 Patrick L. Jacobs, PhD, CSCS,*D, FNSCA Stephanie M. Svoboda, MS, DPT, CSCS Anna Lepeley, PhD, CSCS Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 Parkinson’s Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Muscular Dystrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Cerebral Palsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Traumatic Brain Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Spinal Cord Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Chapter 9 Cognitive Conditions and Disorders 319 William J. Kraemer, PhD, CSCS,*D, FNSCA Brett A. Comstock, PhD, CSCS James E. Clark, MS, CSCS General Exercise Considerations for Clients With Cognitive Disorders . . . . . . . . . 321 Exercise Recommendations for Clients With Cognitive Conditions and Disorders . . 322 Autism Spectrum Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 Down Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Intellectual Disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332 Dementia and Alzheimer’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Philosophy of Exercise Programming for Clients With Special Needs . . . . . . . . . . 339 Chapter 10 Cancer 341 Alejandro F. San Juan, PhD, PT Steven J. Fleck, PhD, CSCS, FNSCA Alejandro Lucia, MD, PhD Pathology of Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Pathophysiology of Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Speci c Management and Treatment of Individuals With Cancer . . . . . . . . . . . . 343 Common Medications Given to Individuals With Cancer . . . . . . . . . . . . . . . . . . . 347 Effects of Exercise in Individuals With Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . 350 Exercise Recommendations for Clients With Cancer . . . . . . . . . . . . . . . . . . . . . . 355

viii | Contents Chapter 11 Children and Adolescents 367 Avery D. Faigenbaum, EdD, CSCS, CSPS, FNSCA Trends in Youth Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 Bene ts of Physical Activity for Children and Adolescents . . . . . . . . . . . . . . . . . . 369 Growth, Maturation, and Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 Effects of Exercise in Children and Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . 371 Exercise Recommendations for Children and Adolescents . . . . . . . . . . . . . . . . . . 373 Chapter 12 Older Adults 383 Wayne L. Westcott, PhD, CSCS Exercise Recommendations for Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384 Common Medications Given to Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 Effects of Exercise in Older Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 Exercise Recommendations for Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391 Recommended Strategies for Instructing Older Adults . . . . . . . . . . . . . . . . . . . . 396 Chapter 13 Female-Specific Conditions 403 Jill A. Bush, PhD, CSCS,*D Female Athlete Triad. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404 Pregnancy and Postpartum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410 Menopause and Postmenopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 Answers to Study Questions 427 References 429 Index 505 About the Editor 513 Contributors 515

Preface The benefits of engaging in an active lifestyle are factors aside, effective access to exercise opportu- extensive and apply across virtually all popula- nities is commonly limited by a lack of exercise tions. However, many individuals are relatively professionals prepared in the speci c issues related inactive. Some are not active due to personal to exercise with special populations. choices or perceived lack of time or resources or both. However, many individuals who could cer- NSCA’s Essentials of Training Special Populations tainly profit from participation in exercise train- was developed by the National Strength and Con- ing do not do so because of their own particular ditioning Association (NSCA) and was prepared characteristics. These individuals may require by 26 expert contributors to provide speci c modifications to the general exercise recommen- recommendations for professionals regarding the dations for the apparently healthy adult popula- training of persons with conditions that warrant tion. With regard to exercise recommendations speci c programming modi cations. This text is and training, these individuals can be considered an indication of the dedication of the NSCA to members of various special populations. Persons providing appropriate preparatory materials and with these special conditions commonly require training for professionals who work with all mem- specific exercise facility design and particular bers of our society. training equipment. Special populations may also require specific exercise programming supervised NSCA’s Essentials of Training Special Populations by exercise professionals with specialized training. is intended to serve as a primary resource for the It is the purpose of this book, NSCA’s Essentials of Certi ed Special Population Specialist (CSPS) cer- Training Special Populations, to serve as a resource ti cation examination. It can serve as a resource for exercise professionals working with special manual for commercial, community, and corporate populations. health and tness centers with clients who have special conditions. This text was also organized Special populations include individuals with so as to serve as a textbook for university courses chronic disease or disability and individuals who dedicated to the physical training of special pop- differ from the overall population with regard to ulations. recommendations for exercise training. Exercise training recommendations should also be modi- This Essentials text provides evidence-based information on particular training protocols for ed, taking into account age (e.g., youth, persons particular special populations. While the training who are elderly) or speci c conditions related to strategies recommended for special populations sex (e.g., female athlete triad and pregnancy). The are based to a great degree on the established participation of special populations in regular protocols for the general, apparently healthy exercise training is relatively low; this is related to population, speci c training modi cations are de ciency in the access that persons with special warranted for safe and effective training for each conditions have to appropriate training oppor- special condition. This text is organized to provide tunities. Historically, opportunities for exercise the reader with an understanding of the pathology training for persons with special conditions were and pathophysiology of the given condition. The concentrated within clinical settings due to the known effects of various exercise programs in the specialized staf ng in the medical model and the particular special condition are discussed, with lack of appropriate opportunities in general exer- an emphasis on published controlled research cise settings. Special populations should be pro- investigations. Each chapter provides exercise rec- vided opportunities for exercise conditioning in the ommendations particular to the special condition, least restrictive and most accessible and integrated with speci c training modi cations, precautions, settings possible. Limitations in suitable training and contraindications. Each chapter also discusses environments include architectural accessibility the medications commonly prescribed for each and issues with general exercise equipment. Those special condition, with emphasis on the potential effects of the medications on exercise responses ix

x | Preface and adaptations. A case study is provided as an for exercise training. Conditions covered include example of the application of these recommenda- neuromuscular conditions that continue to pro- tions within the given special condition. gress over time, such as multiple sclerosis, Par- kinson’s disease, and muscular dystrophy, as well The following outlines the topics covered in as conditions that generally do not progress, such each chapter. as cerebral palsy, head injury, stroke, spinal cord injury, and epilepsy. Chapter 1 addresses the bene ts of exercise in general and the costs of inactivity at the individual Chapter 9 provides information regarding cog- and societal levels. Particular challenges to exer- nitive disorders in relation to recommendations for cise training in special populations are discussed, exercise training. Developmental disorders covered with an emphasis on the need for appropriately in this chapter include autism spectrum disorder trained exercise professionals. (ASD), Down syndrome, and intellectual disability (ID). The chapter also discusses the neurodegener- Chapter 2 discusses the pivotal procedures ative diseases dementia and Alzheimer’s disease. of health appraisals and tness assessments in regard to special populations. Medical clearance Chapter 10 addresses characteristics of cancer processes are speci cally addressed. and medical treatments. A review of exercise train- ing studies in persons with cancer is provided, Chapter 3 covers common musculoskeletal with professional recommendations for exercise conditions and disorders and the respective rec- training. ommendations for exercise training. Postural and low back pain issues are discussed as well as issues Chapter 11 covers children and adolescents, related to regeneration of muscular, skeletal, and discussing physical development and physical joint structures. activity levels. Age-speci c recommendations for exercise training are provided. Chapter 4 provides exercise recommendations for the most prevalent metabolic conditions and Chapter 12 details the altered physiology with disorders. This chapter addresses some of the most aging and discusses the effects of exercise in older common disease processes, including obesity, dia- adults. Speci c exercise recommendations are betes mellitus, and dyslipidemia. Other conditions provided for exercise professionals working with discussed include hypothyroidism and hyperthy- older adults. roidism, as well as chronic kidney disease. Chapter 13 provides discussions of the physiol- Chapter 5 details pulmonary conditions and ogy of particular female considerations that may disorders that alter exercise recommendations alter recommendations for exercise. Discussions from those for the general, apparently healthy cover the female athlete triad and pregnancy and adult population. Discussions speci cally address postpartum, as well as menopause and postmen- the characteristics of, and exercise recommenda- opause. tions for, persons with asthma, chronic obstructive pulmonary disease, chronic restrictive pulmonary This book is organized with a number of learn- disease, and cystic brosis. ing aids designed to assist the reader. Chapter 6 deals with the characteristics of the • Chapter objectives appear at the beginning most prevalent cardiovascular conditions and of each chapter, providing the reader with disorders. Condition-speci c exercise recommen- an understanding of the expected reader out- dations are provided. comes. Chapter 7 offers recommendations for exercise • Key points summarize the important key con- professionals working with persons who have cepts for the reader. immunologic or hematologic conditions or disor- ders. The chapter provides information on such • Key terms are identi ed throughout the text conditions as rheumatoid arthritis, lupus, chronic in bold font. Each key term is de ned near the fatigue syndrome, bromyalgia, HIV/AIDS, sickle rst use of the term. cell disease, and hemophilia. • Each chapter has one Chapter 8 discusses neuromuscular conditions or more lists of rec- and disorders, with speci c recommendations ommended readings.

Preface | xi Related speci cally to the topics of the given 190 gures, tables, and photos from the text- chapters, these resources should be useful to book, which can be used as an image bank by readers wishing to learn more about a topic instructors who need to customize their pres- in general or speci cally in preparation for entations. Easy-to-follow instructions help the CSPS exam. guide instructors on how to reuse the images within their own PowerPoint templates. The INSTRUCTOR AND presentation package plus image bank is free PROFESSIONAL to course adopters and is available online. For RESOURCES use outside of a college or university course, this presentation package plus image bank To assist instructors and professionals using this may be purchased separately. For access and text, these resources are available: ordering, go to www.HumanKinetics.com/ NSC A sE s s ent i a l sOf Tr a i n i ngSp ec i a l Popu l a • Instructor guide. The instructor guide contains tions. chapter objectives, chapter outlines, and key terms with de nitions. • Test package. The test package includes a bank of 130 multiple-choice questions, from which • Presentation package and image bank. This com- instructors can make their own tests and quiz- prehensive resource, delivered in Microsoft zes. Instructors can download Respondus or PowerPoint, offers instructors and profession- RTF les or les formatted for use in a learning als a presentation package containing over 580 management system. slides to help augment lectures and facilitate class discussions. In addition to outlines and These instructor resources can be found at key points, the resource contains more than www.HumanKinetics.com/NSCAsEssentialsOf TrainingSpecialPopulations.

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Rationale and 1 Considerations for Training Special 1 Populations Patrick L. Jacobs, PhD, CSCS,*D, FNSCA After completing this chapter, you will be able to ◆ discuss the benefits of an active lifestyle, ◆ explain the negative consequences of leading an inactive lifestyle, ◆ list reasons commonly cited for not leading an active lifestyle and discuss which of these could be addressed by an exercise professional, ◆ discuss the characteristics of special populations with regard to exercise training and testing, ◆ explain the Americans with Disabilities Act with regard to exercise training, ◆ discuss the scope of practice of the exercise professional working with special populations, and ◆ describe how the concept of inclusive fitness differs from a traditional model of training special populations (rehabilitation settings).

2 | NSCA’s Essentials of Training Special Populations Participation in structured exercise training is BENEFITS OF EXERCISE known to provide significant physical and psy- chological benefits. Exercise conditioning is now Active lifestyles, particularly those that include considered a viable means to enhance functional regular exercise, have been associated with numer- capacity and independence across different popu- ous important health benefits as well as enhanced lations. Unfortunately, many persons who could functional performance of daily activities. Con- benefit the most from increased daily activity sistent participation in a structured exercise plan do not do so. Various populations, due to their and dietary control are components of most proven inherent characteristics, require specific exercise weight loss and weight maintenance programs. equipment and facility access compared to the Increased activity can assist in the reduction of general population. Because of their particular excessive body weight when applied with reduced characteristics, these persons may also require caloric intake, can help prevent further weight specific exercise programming and therefore spe- gain, and has been shown to help support reduced cially prepared exercise professional supervision. body weight after the initial loss (16). These groups can be considered special popula- tions with regard to their particular requirements Increased physical activity reduces the chances for safe and effective exercise training. Special of developing certain diseases while decreases populations include groups that differ from the in physical activity will increase the risk of dis- overall population with regard to age (e.g., youth eases such as cardiovascular disease, diabetes and people who are elderly) or specific conditions mellitus, obesity, and hypertension (39). Many related to sex (e.g., female triad and pregnancy). disease processes are associated with a number of risk factors, some of which are considered to be Special populations also include many persons modi able and are under an individual’s control. with chronic disease or disability. Treatment of For example, increased levels of physical activity medical conditions has traditionally concentrated may favorably in uence high blood pressure (15) on disease curative efforts with emphasis on sur- and detrimental blood lipid pro les (35), thereby vival and life extension rather than on efforts to reducing the chances of developing heart disease reduce the consequences of the disease processes (39) or having a stroke (29). Metabolic syndrome, (palliative). A shift to a more palliative emphasis which is characterized by (a) overweight or obe- and away from the purely curative approach is sity, (b) undesirable lipid pro les, (c) high blood indicative of an increased emphasis on quality of pressure, and (d) high resting blood glucose levels, life rather than the traditional concentration on is well associated with the overall lack of physi- quantity of life. cal activity (42). In contrast, physical activity, as part of a complete conditioning program, has Members of many special populations may been shown to be quite effective in reducing body wish to engage in exercise training for a variety of weight (16) and blood pressure (15) with improve- reasons, which may be similar to or different from ments in lipid levels (35) and resting sugar levels those of the general, apparently healthy population. (3), thereby reducing the chances of developing Increased physical activity may increase physical metabolic syndrome (42) and diabetes (3). work capacity, thereby enhancing quality of life and independence. Conversely, with a sedentary Improvement in the performance of important lifestyle, the negative consequences of the disease daily activities with increased physical activity is or disability processes may become more profound commonly related to signi cant improvements in over time. Unfortunately, the participation of per- muscular strength and endurance with increased sons with these chronic conditions is quite low cardiovascular tness (1, 5). For example, well- due to a lack of exercise training opportunities for designed exercise programs have been shown to persons with special conditions. Increased exer- signi cantly reduce the risk of falls in the aging cise training opportunities for these individuals and middle-aged populations (8, 32). Reduced necessitates appropriate access to, and supervision health risks tend to result in fewer medical com- within, the exercise training environment. plications, and this, combined with improved

Rationale and Considerations for Training Special Populations | 3 physical capacity, contributes to increased INACTIVITY AND chances of longevity with greater levels of physi- COSTS TO INDIVIDUALS cal activity (6, 39). AND SOCIETY Participation in regular physical activity is also known to provide enhancements in mental health The consequences of an inactive lifestyle are while also increasing physical work capacity. Psy- progressive, with significant consequences. Sed- chological improvements may include improve- entary lifestyles are a leading cause of preventable ments in overall mood with reduced feelings of death, with increasing risk of numerous disease depression and anxiety (22). processes including cardiovascular disease, dia- betes, hypertension, obesity, osteoporosis, and Key Point lipid disorders (41). It appears that the adage “use it or lose it” accurately captures ongoing physi- Increases in physical activity are associated with cal deterioration and declining function of many benefits including enhanced weight loss and physiological systems during extended periods improved weight maintenance, increased ability of physical inactivity (25). In general, the longer to perform important daily tasks, and improved and more complete the period of inactivity, the psychological mood, with reduced chances of greater the degree of systemic dysfunction (25). developing certain disease processes such as Approximately 50% of all U.S. adults have at least cardiovascular disease, diabetes mellitus, obesity, one chronic health condition, and about 25% have and hypertension. two or more of these disease processes (40). It is important to note that active lifestyles, The chronic diseases associated with inactivity speci cally participation in well-designed exer- are becoming increasingly prevalent and produce cise programs, have been shown to provide sig- staggering economic effects. Obesity is now diag- ni cant bene ts across populations regardless nosed in more than one-third of all American of chronological age, sex, training status, and adults and in approximately 17% of children and current health condition. Whereas the bene ts adolescents aged 2 to 19 (31). The medical costs of exercise appear to be consistent across quite associated with obesity were estimated in 2008 at different groups (39), the actual exercise pro- $147 billion annually (12). Approximately 12% of gramming should be speci cally selected or all U.S. adults are now diagnosed with diabetes, developed (or both) relative to the capabilities and another 37% are diagnosed with prediabe- and goals of the individual. Thus, while exercise tes, based on fasting glucose or A1C (glycated training will provide useful health and function hemoglobin) levels (11). The total medical costs advantages to the lives of most people, it is vital associated with diabetes in 2012 were estimated at that the training programming be appropriate $245 billion, which included both direct medical for the safe and effective participation of each costs ($176 billion) and costs related to decreased individual. While the bene ts of an active life- productivity ($69 billion) (21). The average medi- style are apparent and speci c recommendations cal cost for each person with diabetes was calcu- for exercise activity have been developed and lated at $1,429 per year greater than the costs for made readily available, most Americans remain a person of normal weight (17). relatively inactive (13). While the bene ts of an active lifestyle and Key Point the health and functional risks of a sedentary way of life have been well established, the level While the benefits of increased activity levels are of participation in an active lifestyle is relatively evident across sexes, ages, and health status, the quite low. Only 15% to 20% of American adults, training programs should be appropriate for the aged 18 years and above, regularly meet both the particular participant in order to provide safe and aerobic and strength training recommendations of effective outcomes. the 2008 Physical Activity Guidelines for Americans

4 | NSCA’s Essentials of Training Special Populations (non-Hispanic whites, 21.3%; non-Hispanic blacks, the U.S. population aged 65 years and older from 17.2%; Hispanics, 14.4%) (13). 13% in 2010 to approximately 19.3% by the year 2030 (38). This would represent an increase in the WHY ARE PEOPLE 65+ population by about 50% in a 20-year period. INACTIVE? Unfortunately, as persons generally become less active with advancing age, particularly after The benefits of an active lifestyle (16, 39) and the retirement, this population shift is also creating negative consequences of a sedentary lifestyle (41) a dramatic increase in the number of inactive have been well established. However, less than persons (23). one-fifth of all American adults meet basic exer- cise recommendations (13). The lack of activity The decline in physiological status that is has been related to changes in modern societies generally associated with the aging processes is that reduce the physical nature of daily activities. further compounded by reduced activity of the Additionally, sedentary persons commonly report younger segments of our society. Decreased levels similar reasons for their inactive lifestyles, includ- of physical activity in children and young adults ing time issues and a lack of opportunities within limit peak development of bone and lean muscle local communities. mass during critical periods (27). The gradual decline in physiological status with aging may Societal Issues therefore be further compounded by lower peak levels of development. Reduced outdoor play Several primary societal changes appear to have activities and reductions in public school physical contributed substantially to the declining levels education programming often require participa- of physical activity exhibited over the past several tion in private extracurricular programming in decades. Significant technological advancements order to achieve appropriate levels of physical have dramatically reduced the amount of physical activity (4). activity necessary in the performance of many daily tasks (37). Both work-related tasks and per- Individual Issues sonal recreation pursuits (leisure interests) tend to involve less gross physical effort (37). There Reasons commonly reported by individuals for has been a shift from occupational duties rely- not being more physically active include perceived ing on physical efforts of the individual toward lack of time or convenience, lack of motivation or work duties more commonly involving operating interest in exercise, lack of confidence to partici- mechanized equipment. The percentage of non- pate safely, lack of personal management skills farm workers in manufacturing positions was over or support systems or both, and perceived lack 30% of the total U.S. workforce in 1950 but had of suitable resources (10). These reported barriers declined to approximately 10% by 2007 (26). Most to an active lifestyle are frequently cited by many of this shift was matched by increased workers in persons despite their actual capacity and poten- the service sectors. tial to live a more active lifestyle (10). Some of the commonly listed barriers are misperceptions The automobile is now relied upon for virtually based on individuals’ incorrect beliefs concerning all transportation in the United States regardless themselves and exercise. People who have been of the distance involved (7). The shift in commu- physically inactive for extended periods of time nity development from smaller locally based units may feel that their level of physical deconditioning to extended suburban sprawl has dramatically is too advanced to reverse. Others with limited reduced walking and cycling as realistic options exposure to physical exercise activities may not for daily transportation (19). Unfortunately, the have the needed background in this area to under- increased reliance on the automobile has been stand the potential benefits of physical training associated with the increasing incidence of obesity despite their present status. and other secondary medical complications (18). Many of the commonly cited barriers to The maturing of the “baby boomer” generation increased participation in regular physical activity is projected to dramatically increase the segment can be effectively addressed by an exercise profes-

Rationale and Considerations for Training Special Populations | 5 sional who possesses the requisite background specific recommendations for activity in several and knowledge to safely assess, design, and populations known to be less active, including supervise training sessions on an individual basis. children, older adults, women who are pregnant, The exercise professional motivates and educates and persons with chronic disease or disability. clients to guide them toward their speci c goals. These recommendations indicate that these spe- cial populations include individuals who, based Persons with physical disability or chronic dis- on their specific characteristics, require particular ease have long been known to be less active than condition-specific exercise programming in order persons without disability or disease (20). These to receive effective and safe training. individuals may, in addition to the previously discussed perceived barriers to participation in Key Point physical activity programs, face actual substantial barriers to participation (33). For example, indi- Special populations are groups of individuals viduals may encounter limitations or restrictions who, when considered with regard to exercise, in accessibility to exercise opportunities based differ from the general, apparently healthy adult on architectural accessibility issues or equip- population with respect to recommendations for ment selection (or both) in community training exercise programming. These populations may facilities. Accessibility to exercise opportunities exhibit characteristics that require condition- certainly involves appropriate architectural and specific recommendations for exercise as well as equipment issues but also appropriate training appropriate precautions and contraindications supervision. Barriers to participation in exercise to exercise in order to receive effective and safe activities may also be limited by a lack of com- training. munity exercise professionals properly trained in the particular exercise issues related to the Professional recommendations for exercise supervision of persons other than the healthy training of the general adult population are adult client. based on known acute physiological responses to exercise activities as well as the established SPECIFIC EXERCISE chronic adaptations to exercise stresses. Thus, the PROGRAMMING FOR general recommendations for exercise in appar- SPECIAL POPULATIONS ently healthy populations have been established for those individuals in whom the physiological Professional organizations have established gen- systems generally respond in a standard manner. eral activity and exercise recommendations to Changes in physiological functioning will pre- provide guidance in planning and performance sumably result in altered capacities for, and of exercise activities for the general population responses to, exercise in the acute setting, as well without chronic disease or disability. These as potentially affecting the expected adaptations guidelines are based on scientific evidence sup- to exercise training over time. Thus, persons with porting the health and functional benefits of an some degree of physiological dysfunction may be active lifestyle. For example, the U.S. Department considered as members of a special population of Health and Human Services (DHHS) recom- who require speci c programming in order to mends that all healthy adults complete at least receive safe and effective exercise training. 2.5 hours of aerobic exercise weekly or complete at least 1.25 hours of vigorous aerobic exercise The altered physiological functioning exhib- per week (13). Strength training is also recom- ited by special populations may be the result of a mended for all healthy adults at least two times number of factors including chronic diseases and weekly. While these recommendations were set disabilities, as well as certain age- and sex-related forth by the DHHS for the general healthy adult issues. This text provides an overview of some of population, specific recommendations were also the most common special populations, with dis- established for particular populations. The 2008 cussions of the pathology and pathophysiology of Physical Activity Guidelines for Americans sets forth each condition, in order to provide the reader with a basic understanding of the unique physiological

6 | NSCA’s Essentials of Training Special Populations functioning of persons with the given condition the industry-published standards of care and the (with emphasis on how this differs from that particular certi cation process. in the general, apparently healthy population). Speci c recommendations for exercise activities The scope of practice of the exercise profes- as well as precautions and contraindications are sional involves designing and supervising safe provided for each condition. and effective exercise programs in relation to the client’s physiological status and goals. Assessment Exercise training of special populations and training procedures are carried out, as well as requires appropriate expertise and professional provision of education and motivation during the training of the exercise professionals involved, as training process. Exercise professionals must be well as provision of suitable training equipment aware of the limitations of their scope of practice and environments. The exercise professional and refer clients to suitable licensed health care needs to possess the background and education professionals when appropriate. appropriate for the specialized training activities needed by the special population. Thus, this set- The scope of practice of the exercise profes- ting requires specialized knowledge and expertise sional includes performing health appraisals in related to the special population in addition to the order to screen new clients for risk factors and professional pro ciencies used with the general, symptoms of disease. The client should be referred apparently healthy population. to an appropriate health care professional when indicated by the health appraisal. Exercise profes- SCOPE OF PRACTICE OF sionals often encounter newly developed injuries THOSE WORKING WITH or diseases with their existing clients. In such SPECIAL POPULATIONS cases, the health appraisal (e.g., Par-Q) should be reapplied with adjustment of the training Various professions are licensed by governmen- program or referral to a health care professional tal agencies (national, state, or both) in order to where appropriate. carry out the legally permitted procedures and processes. In these cases, the professional scope of Key Point practice is set forth by law. The licensing process involves specific education, experience, and dem- The scope of practice of the exercise profes- onstrated competency. Other professions do not sional includes conducting health appraisals and have a governmental license but have standards physical assessments as well as designing and of practice published by professional associa- supervising exercise training. The exercise pro- tions. Additionally, professional associations may fessional should not engage in any activities that administer specialized certifications that should are presented as physical therapy or counseling also involve specific education and demonstration but rather should refer clients to an appropriate of competency. licensed clinician. The exercise professional is not licensed by a For example, physical therapists commonly governmental agency, and there are no industry- use therapeutic exercise as a means to address wide standards. However, a number of allied pro- an injury or disease in terms of a patient’s func- fessional organizations have published standards tion. The scope of practice of physical therapy of care for the exercise professional. Likewise, includes other interventions such as joint and soft numerous professional exercise associations offer tissue mobilization, neuromuscular education, various certi cations that differ considerably. It gait training, and modalities. So while many of is recommended that all exercise professionals the therapeutic interventions applied in physical ful ll a certi cation that involves assessment of therapy may appear similar to those used by the both scienti c concepts and practice competen- exercise professional, it is vital that exercise pro- cies. Thus, the appropriate scope of practice for fessionals refrain from describing their services as the exercise professional is determined by both physical therapy. Physical therapists are licensed health care professionals who diagnose and treat medical conditions (injuries and diseases) that

Rationale and Considerations for Training Special Populations | 7 limit function or cause pain. It is imperative that needs, preventively, and in collaboration with exercise professionals not present their services healthcare professionals. Special populations as physical therapy or as treating a disease or include those with chronic and temporary injury. Rather, it is recommended that the exer- health conditions. cise professional refer clients who exhibit pain that limits motion, swelling of a joint or muscle, CSPSs design safe and effective exercise or limited range of motion to a medical or allied programs, provide the guidance to help clients health professional for appropriate treatment. achieve their personal health/ tness goals, and recognize and respond to emergency situations. The scope of practice of the exercise profes- Recognizing their own areas of expertise, sional also does not include psychological ser- CSPSs receive referrals from and refer clients vices. Licensed health care professionals, such to other health care providers as appropriate. as mental health counselors and psychologists, have the appropriate background and training PROFESSIONAL necessary for treatment of psychological issues. OPPORTUNITIES FOR Just as it is inappropriate for exercise professionals THOSE TRAINING SPECIAL to describe their services as “treating a disease” or as “injury rehabilitation,” it is not acceptable POPULATIONS for the exercise professional to provide counsel- ing services directly related to disordered eating, The exercise professional with expertise in the body image, or other psychologically based issues. training of special populations (via formal educa- tion and professional certifications) is properly Various populations have characteristics that positioned to meet the growing need for profes- require exercise programming differing from sionals with appropriate background in this area. the recommendations offered for the general Various special populations are expected to grow population (see table 1.1). It is vital that the exer- in size with the increasing rate of inactivity in the cise professional have the necessary knowledge general population compounded with specific base and training to ful ll these responsibilities growth in certain special populations. Almost with each client. Obviously, some clients require one-half of all U.S. adults (117 million) have at greater levels of professional expertise than others least one chronic medical condition (e.g., hyper- based on either their physiological status or their tension, coronary heart disease, stroke, diabetes, training goals. cancer, arthritis), with more than two chronic conditions reported in over one-quarter of adults The professional credential of Certi ed Special (60 million) (40). The current number of Ameri- Population Specialist (CSPS) was established by cans over the age of 65 is calculated at over 40 mil- the National Strength and Conditioning Associa- lion and is expected to increase to approximately tion (NSCA) in order to provide a certi cation 72 million persons by the year 2030. Because process speci c to the exercise professional who chronic conditions increase in prevalence in older seeks documentation of specialized advanced populations, these figures indicate that an over- expertise with special populations. The CSPS whelming number of persons in our society and a certi cation provides the opportunity for the more growing segment of our society will be classified experienced exercise professional to demonstrate, as a part of special populations (9). both to the potential client and to other profes- sionals and institutions in the eld, his advanced Health care costs associated with obesity and background in the area of training special popula- sedentary lifestyles are greater than $90 billion tions. The NSCA de nes the CSPS as follows (from annually in the United States alone (28). These www.nsca.com/Certi cation/CSPS/): escalating costs place undue stress on both indi- vidual and employer health insurance systems. Certified Special Population Specialists The medical system has made dramatic advances (CSPSs) are tness professionals who, using in the care of persons with disease, in particular in an individualized approach, assess, motivate, the area of emergency care. Survival and recovery educate, and train special population clients of all ages regarding their health and tness

Table 1.1 Common Conditions, Disorders, or Diseases of Special Populations Type of condition Condition, disorder, or disease Cardiovascular conditions Myocardial infarction Angina Pulmonary conditions Hypertension Metabolic conditions Peripheral vascular disease (e.g., deep vein thrombosis, peripheral artery disease) Immunologic and Congestive heart failure hematologic conditions Valvular disorders Revascularizations Musculoskeletal or Conduction defects or disorders (e.g., atrial fibrillation, pacemakers) orthopedic conditions Chronic obstructive pulmonary disease (COPD) (e.g., emphysema, chronic bronchitis) Joint disorders or Chronic restrictive pulmonary disease (CRPD) (e.g., fibrosis, sarcoidosis) conditions Neuromuscular Asthma conditions Pulmonary hypertension Diabetes mellitus (types 1 and 2) Overfatness, obesity Metabolic syndrome Thyroid disorders (hypo- or hyperthyroidism) End-stage renal disease AIDS/HIV (acquired immunodeficiency syndrome/human immunodeficiency virus) Chronic fatigue syndrome Fibromyalgia Anemia Autoimmune disorders (e.g., lupus, rheumatoid arthritis) Bleeding or clotting disorders Osteoporosis and other low BMD (bone mineral density) conditions Limb amputations Osteoarthritis Lower back conditions Chronic musculoskeletal conditions (e.g., low back pain) Frailty Joint replacements Sarcopenia Posture conditions Cystic fibrosis Stroke or brain injury Spinal cord disabilities Multiple sclerosis Cerebral palsy Down syndrome Parkinson’s disease Epilepsy Balance conditions Muscular dystrophy 8

Rationale and Considerations for Training Special Populations | 9 Type of condition Condition, disorder, or disease Female-specific conditions Pregnancy and postpartum Female athlete triad Behavioral or Menopausal or postmenopausal psychological disorders Disordered eating patterns Cancer Body image Older adults Depression Children and Chemical dependency adolescents Note: Professionals working with individuals with any of these conditions need to do so within their proper scope of practice. Adapted, by permission, from NSCA, 2012, What is a special population? Available: https://www.nsca.com/Education/Articles/What-is-a- Special-Population/ have signi cantly improved in many conditions sionals with regard to future patients and their considered to have questionable outcomes only a need to engage in purposeful exercise program- few decades ago. This dramatically extended life ming outside of the medical treatment environ- expectancy, from 66 years in males and 71.7 years ment. in females in 1950 to 72.1 years in males and 79.0 years in females in 1990 (24). By the year 2009, Discharge plans from medical care, particularly the predicted life span from birth had grown to physical therapy, usually involve some recommen- 76.0 years for men and to 80.9 years for women dations for activities and exercise strategies for the (2). Thus, during the same period of time in which patient. Patients may have a limited background length of life increased by approximately 10 years, in exercise and active lifestyles, and their only our society became increasingly inactive. This has experience in these areas may be the therapeutic resulted in progressive extension of the length of activities in the rehabilitative setting. Thus, it is life (quantity of life) with signi cant reductions unlikely that they will seek to begin a structured in the level of functional independence during the exercise program with professional support even later years of life (quality of life) (24). if this has been recommended by the clinician. It is recommended that the exercise professional The medical system may be an important refer- establish working relationships with medical ral source of new clients to the exercise profes- professionals in the community. In this way, the sional with expertise with special populations. patient can be directly referred by the medical Chapter 2 of this text provides detailed discus- professional to an associated exercise professional sions of the health appraisal process and the steps who can provide the appropriate guidance and to determine the appropriateness of a medical supervision. clearance for a particular potential client. The medical clearance process establishes a means of Unfortunately, in many situations the reha- communication between the exercise professional bilitation plan must be carried out with time and a licensed health care professional. Medical limitations related to the patient’s medical insur- clearance provides professional authorization ance coverage. The therapeutic plan of care often for exercise testing and training in persons who must concentrate on the most vital skills of daily exhibit particular risk factors. This process may living in order to enhance the level of functional also establish a line of communication between independence in the limited time available. Thus, the exercise professional and the medical profes- many patients are discharged from the reha- bilitation setting in a condition that warrants

10 | NSCA’s Essentials of Training Special Populations continued physical training. Exercise profession- does not create undue nancial hardships. While als with advanced background in training of spe- people commonly view the ADA as legislation cial populations can certainly provide the needed that pertains only to architectural issues, other assessment and training of these discharged concerns relating to programming and staf ng patients, with clearance and recommendations are also addressed. from the clinician. The ADA asserts that as a matter of human EXPECTATIONS IN THE rights, discrimination against persons with spe- TRAINING OF SPECIAL cial needs is not acceptable. All persons are con- sidered to possess certain rights and these rights POPULATIONS can be expressed with respect to opportunities for an active, productive lifestyle. Speci cally, the The benefits of engaging in an active lifestyle are ADA addresses rights of individuals to pursue extensive and apply across virtually all popula- an active lifestyle, including the right to an inte- tions of persons regardless of age, sex, or social grated setting, the right to participate, the right or racial group. As most persons will benefit from to reasonable accommodations, the right to adap- an appropriate exercise training program, it is tive equipment, and the right to an assessment the goal that opportunities for exercise training or evaluation (30). For example, the individual be available to all persons regardless of their par- with a disability has the right to participate in ticular characteristics. any recreation or exercise activity offered to the general public. Participation should be offered Governmental legislation has addressed the in the least restrictive manner possible, and the issues related to the opportunities of persons with opportunity to participate in an integrated set- special needs to successfully enter into a more ting should be made available. The individual active lifestyle. Such legislation generally attempts should be able to participate with family, friends, to address the limitations to participation in exer- and other community members regardless of the cise activities due to barriers and restraints asso- disability. ciated with the exercise environment. The most notable of the legislative efforts is the Americans Traditionally, persons with disability or special with Disabilities Act (ADA). The ADA prohibits needs were limited to exercise activities offered discrimination of many types against persons in the medical rehabilitation setting. While that with disabilities in different settings including the environment usually provides appropriate pro- workplace, transportation, public accommoda- fessional supervision by staff that are familiar tions, and governmental activities. This Act also with the medical issues, the rehabilitation setting addresses issues apparent in public and private may not be integrated. It would be preferable to settings for physical activity and exercise training. provide a more inclusive training environment in Governmental institutions (e.g., county parks) which the exercise activities, not the disabilities, and larger recreation businesses are required by are the common theme. Inclusive tness is a law to comply with the requirements of the ADA, growing approach to exercise training in which while smaller individual recreation businesses are persons with special training needs are able to encouraged to comply to the extent possible that train in mainstream environments rather than in specialized secluded settings. There has been Key Point a shift in program delivery from the medical rehabilitation setting to the community-based The Americans with Disabilities Act (ADA) spe- recreation facility. Similarly, there has been a cifically prohibits discrimination against persons shift from prevention of secondary disabilities with disabilities in the workplace, public accom- in persons with disability to health promotion modations, transportation, and governmental and more recently to increasing physical work activities as well as public and private settings for capacity as a means to enhance function, inde- physical activity and exercise training. pendence, and self-concept (34).

Rationale and Considerations for Training Special Populations | 11 Key Point and commercial exercise facilities (14). Generally, these standards do not affect existing structures Training of members of special populations that are not undergoing new construction or should be carried out in the most inclusive, alterations to existing facilities. However, certain integrated, and accessible settings possible. As topics included in the 2010 Standards but not such, exercise training of special populations speci cally addressed in the original 1990 ADA has shifted program delivery from specialized standards, such as exercise standards, are absolute clinical settings to community-based recreation requirements without any “grandfather” options surroundings, while programming has moved or release from requirements based on limited size from prevention of secondary disabilities to of the business. Thus, all governmental, public, enhancement of physical work capacity as a and commercial exercise facilities must comply means to improve function, independence, and with the 2010 Standards wherever possible. self-concept. Equal access to exercise training in a safe and APPROPRIATE effective environment necessitates appropriate ENVIRONMENTS FOR physical access into and throughout the facility. Special populations may present physical char- TRAINING SPECIAL acteristics that require particular considerations POPULATIONS in order to access the training environment as independently and safely as possible. Standards Appropriate opportunities for all to participate in for acceptable entry into and passage through- exercise activities require appropriate professional out the facility are usually based on the proven supervision and programming, as well as suitable needs of the wheelchair user (14). Access into and training environments, in order to provide equal throughout the exercise training facility must access to exercise training in a safe and effective not limit entry with doors that require grasping environment. It would appear prudent to provide of standard doorknobs or substantial pulling exercise facilities and equipment in accordance forces. Standard accommodations in this area with both the recommendations established for include doorway lever handles and automated the general training environment and also specific door opening systems (motion or large push guidelines for special populations set forth by gov- button switches). A less preferable but acceptable ernmental agencies. Generalized recommendations accommodation would be a staff member assigned for exercise facility design and equipment selection to open doors in a timely manner. Wheelchair have been published in NSCA’s Essentials of Personal users generally require greater space for travel Training (36). The reader is referred to that pub- routes. According to the 2010 Standards, facilities lication for a thorough discussion of the general must provide a continuous path that is at least 36 requirements for exercise facilities and equipment. inches (91 cm) wide, with recommendations for pathways to be at least 48 inches (122 cm) wide. The ADA was enacted in 1990 and addressed Areas for wheelchair turnaround must be at least many issues that can be defined as “public 60 inches (152 cm) in diameter. accommodations.” Similar to other businesses, exercise facilities have access considerations rang- Equal access to an exercise training facility ing from physical access through the front door must include appropriate access to the exercise and throughout the facility to bathroom access. machines for all, regardless of individuals’ particu- However, smaller businesses with fewer than 15 lar needs. Generalized recommendations for space employees are exempt from the requirement of requirements in exercise training areas usually the ADA. In 2010, the U.S. Department of Justice call for 3-foot (0.9 m) distance between all exer- published the ADA Standards for Accessible Design, cise stations (36). Wheelchair users require more which sets forth standards for minimal accommo- space than others, establishing a particular need dations in all new or altered governmental, public, for accessible routes to the exercise stations as well as greater space between exercise stations so that

12 | NSCA’s Essentials of Training Special Populations the wheelchair can safely navigate alongside the straps wrapped around the client and the torso stations. There should be ample clear oor space provides increased stability in a manner similar to allow the wheelchair or other mobility device to that with automobile seat belts and shoulder to be parked next to the exercise station without straps. Other basic adaptations include wrist blocking access for other clients. The 2010 ADA straps and other assistance grasping devices to Standards for Accessible Design stipulates there enable upper body training in clients without a must be an open oor space at least 3 by 4 feet (0.9 strong grasp. by 1.2 m) beside at least one of each type of exer- cise station (14). There may be an overlap between It is expected that persons with special needs stations in open oor space. The exception to the be provided appropriate accessible exercise equip- open access requirements for the parked wheel- ment. The individual should be able to position chair alongside the device are exercise stations that herself in the exercise device and independently allow direct use while in a wheelchair. operate the device without assistance. This may necessitate the use of specialized assistive equip- The 2010 Standards also speci es that an option ment (e.g., lifting straps) or assistance from a staff must be available for each type of training (e.g., member when needed. strength, cardiovascular) for each special popu- lation. For example, if a facility has treadmills It is important, for safety reasons and training and stepper and elliptical exercise machines, ef cacy, that the exercise equipment be appropri- then the facility must provide open access space ately sized for the client. In many cases, exercise next to at least one of each of those types of exer- equipment designed for use by adults is not appro- cise devices. This also means that the exercise priate for training children and persons of smaller facility must provide a means of cardiovascular dimensions. Similarly, general exercise equipment training accessible and usable by all potential may not be suitable when training persons of clients, including those unable to participate in larger than average dimensions. Larger-size indi- cardiovascular training with the legs. Therefore, viduals, such as those who are clinically obese, the training facility should provide access to car- should be provided with comfortable seating in diovascular training with arms via such devices the exercise equipment (e.g., tractor-style seats), as arm cranking systems. as they may not be able to comfortably position themselves in the seats of general equipment. The use of specialized adaptive equipment and reasonable accommodations greatly enhances the It is vital when training special populations to participation of persons with special needs. Rea- provide exercise equipment that allows training sonable accommodations should be provided in at the exercise intensity appropriate for the client. order to facilitate participation and may include For example, numerous people with chronic con- rule modifications or additional staffing to ditions exhibit reduced walking pace, which is a increase participation, as long as the accommoda- limitation in the performance of many important tion does not provide an unfair competitive advan- daily activities. Treadmill walking may be an tage. Similarly, adaptive equipment may provide appropriate training activity for many clients, a means to participate in exercise activities that but it is imperative that the treadmill allow quite would otherwise not be possible. For example, reduced speeds of walking for safety. Some special an adaptive apparatus to assist hand grasp may population clients may display reduced exercise allow some persons to participate in a number of capacity or aerobic endurance (or both). In such recreation and exercise activities requiring a rm, cases, it may be appropriate to provide seating steady grasp of an implement or device. (other than the exercise equipment) in the train- ing area for recovery periods between exercise In some cases, adaptations serve to make the intervals. use of generalized exercise equipment safer for someone with special needs. For example, a The exercise training environment for special wheelchair user with limited leg and torso con- populations should provide a safe and effective trol will have sitting limitations in most exercise setting for the performance of the client’s train- equipment due to lack of stability. The use of ing program. In some cases, this may involve the addition or modi cation of existing equipment

Rationale and Considerations for Training Special Populations | 13 and facilities for the general population. Other Some groups of individuals can be considered situations may call for reduction or elimination special populations as they exhibit particular of some aspects within the generalized exercise characteristics that require specific recom- training setting. For example, when working with mendations, precautions, and contraindications individuals who have cognitive issues (e.g., Down for exercise that may differ from those for the syndrome, autism), it may be appropriate to train general, apparently healthy population. Exercise these individuals with reduced noise and visual professionals working with special populations distractions. should possess the appropriate education and experience in order to provide safe and effective CONCLUSION exercise training for these individuals. The Certi- The benefits of leading an active lifestyle, includ- ed Special Population Specialist (CSPS) certi - ing regular exercise training, are apparent across cation is awarded to exercise professionals who populations irrespective of age, sex, and current demonstrate the appropriate expertise necessary health condition. Unfortunately, many groups of to safely and effectively train special population persons that could benefit the most from super- clients in exercise programming. vised exercise training are unlikely to partici- pate due to perceived and actual barriers. Many Exercise training of special populations should barriers to exercise can be effectively addressed be carried out in the most inclusive manner pos- by exercise professionals with the appropriate sible. That is, whenever possible, persons with background and training. special needs should be able to exercise in the same environment as family, friends, and others in the community. Key Terms accessibility Americans with Disabilities Act inclusive fitness metabolic syndrome special populations Study Questions 1. When treating chronic disease or disability, what would moving from curative efforts to palliative efforts represent? a. more emphasis on quality of life b. increased requirement for the number of medical professionals c. greater importance on disease survival d. more interest in increasing life span 2. Which of these barriers to exercise training currently represents a unique accessibility issue for those with physical disabilities or chronic diseases? a. lack of personal management skills or social support b. inadequate time to exercise c. inadequate financial resources d. lack of properly trained exercise professionals

14 | NSCA’s Essentials of Training Special Populations 3. Which of the following is a benefit of an exercise professional establishing a good relationship with medical professionals? a. provides an opportunity for the medical professional to suggest specific exercises b. allows the exercise professional to receive accurate advice in treating medical issues in clients c. makes direct referrals of clients to a qualified exercise professional more likely d. gives the exercise professional access to clients’ medical records 4. All of the following describe the scope of practice of an exercise professional except a. assessing current health status b. assessing a client’s physical goals c. designing an exercise program to meet a client’s goals d. designing a stretching program to reduce joint pain and swelling

Health Appraisal and 2 Fitness Assessments John F. Graham, MS, CSCS,*D, RSCC*E, FNSCA Malcolm T. Whitehead, PhD, CSCS After completing this chapter, you will be able to ◆ describe the medical and health appraisal process; ◆ determine the need for medical clearance and medical supervision during exercise testing and training; ◆ administer specific tests that evaluate individual fitness parameters; ◆ evaluate the results of fitness tests; ◆ create SMART short-, medium-, and long-term goals; and ◆ understand the effective use of motivational and coaching techniques. 15

16 | NSCA’s Essentials of Training Special Populations Before designing an exercise program for an large portion of mortality due to heart disease individual who has a special need or condition, and cancer (11). As a result of the prevalence of it is essential to review and evaluate the medical chronic diseases, the screening process needs to and health history. This analysis is an essential be effective and efficient in order to determine step before performing a safe and appropriate limitations, reduce barriers to exercise, and fitness assessment and developing an effective reduce the risk to clients when initiating the exercise program. This chapter identifies and exercise program (14, 29). outlines the medical and health history review process, explains the medical clearance process, Preparticipation screening tools are a means by clarifies the purposes and guidelines of safe and which valuable information can be collected and effective fitness assessments, provides detailed evaluated before a tness assessment and exercise directions for common testing protocols and the program implementation. These tools include interpretation of test results, and explains how the Physical Activity Readiness Questionnaire an exercise professional can motivate a client to for Everyone (PAR-Q+) and the medical history maximize success. questionnaire. These screening tools provide important information needed for determination MEDICAL AND HEALTH of the appropriateness for medical clearance. It is HISTORY APPRAISAL important to point out that that everyone who will be exposed to clients’ medical data needs to hold It is the responsibility of the exercise professional that information con dential in compliance with to provide each client with an evidence-based the Health Insurance Portability and Accounta- approach to assess, inform, and formulate short-, bility Act (HIPAA). medium, and long-term plans regarding exercise needs and goals. A review of each client’s medical Key Point and health history yields the information and data necessary to develop an effective and safe exer- The exercise professional should use prepartic- cise program. It is also important to determine if ipation screening as a tool to identify risks and the client needs to be referred to an appropriate limitations of each client before engaging in health care professional for further evaluation and exercise testing or programming. clearance before completing a fitness assessment and starting an exercise program. Therefore, this Physical Activity Readiness section focuses on assessing certain medical risks Questionnaire for Everyone and determining health status as a precursor to performing a fitness assessment. The Physical Activity Readiness Questionnaire for Everyone, commonly abbreviated as PAR-Q+, is Preparticipation Screening a questionnaire (figure 2.1) developed in Canada that asks an individual to self-report signs and The purpose of the preparticipation screening symptoms that may indicate the need for further process is to identify and classify any concerns medical-based screening before completing a fit- related to participation in an exercise program, ness assessment or starting an exercise program such as known or unknown chronic diseases or (25, 42). The benefits of using the PAR-Q+ include conditions that might limit exercise. This infor- cost-effectiveness and ease of administration. mation may be obtained through the completion Further screening may be required to determine and review of a form that asks questions about the appropriateness of submaximal or maximal medical and health history. A common component exercise testing and whether the program can that nearly all questionnaires address relates to include moderate- or high-intensity exercise. While chronic disease. In the United States, chronic a client exercise readiness questionnaire such as the disease (or a related condition) afflicts as many PAR-Q+ is an excellent initial screening tool, it does as 117 million people (43) and contributes to a not identify all of an individual’s medical and health concerns, so a further assessment may be needed.

Health Appraisal and Fitness Assessments | 17 Medical History Questionnaire administrators, legal counsel, or an institutional review board before use (22). The medical history questionnaire (figure 2.2) is a tool complementary to the PAR-Q+ that more Medical Clearance Form thoroughly recognizes existing diagnosed pathol- ogies, orthopedic conditions, recent surgical The exercise professional is responsible for screen- procedures, self-reported medical history, and ing clients to identify individuals who may be of current medications. Sometimes one question- increased exercise-related risk of serious cardi- naire covers both medical- and health-related ovascular events, such as myocardial infarction issues, and other times there are two separate or sudden cardiac death. Professional guidelines questionnaires; the specific form or forms depend have been established for referral of these indi- on the preference of the exercise professional, type viduals to a health care professional for clearance of facility where he works, common conditions before initiating a fitness assessment or starting of the clients he works with, or a combination an exercise program (36). The medical clearance of these factors. The information gathered from recommendation in no way relieves the exercise the PAR-Q+ and medical history questionnaire professional of the obligation to properly screen provides the exercise professional with the details the client; rather it offers an opportunity for the necessary to identify specific health needs and health care professional and exercise professional risk factors and to determine the appropriateness to collectively ensure that the assessment and of a fitness assessment and exercise program. exercise program are implemented with the cli- ent’s health and safety as a priority. After all preparticipation screening forms are completed and all documentation has been The medical clearance form allows the health thoroughly reviewed, it is necessary to evaluate care professional to identify speci c medical con- the content of the information to identify any cerns and, when appropriate, clearance (approval) potential risks associated with the individual’s for the individual to participate in exercise testing present health status. This evaluation enables the and programming. Additional information pro- exercise professional to refer people with existing vided in the medical clearance form may include disease or symptoms of disease to a health care additional medical concerns or restrictions to professional for medical clearance. exercise programming and the need for a client to have a diagnostic test before exercise. Informed Consent Form After the client has been referred to a health care Before the administration of any exercise test or professional for medical clearance, the exercise pro- the initiation of a prescribed exercise program, it fessional must be sure that the medical clearance is the responsibility of the exercise professional form is completed and returned to the exercise to make certain that all procedures and exercises, professional. There are many examples of this form; benefits of participation, and risks and discomforts a comprehensive version is shown in gure 2.4. of each test, exercise, or program are explained to and understood by the client. Many professionals Preparticipation Screening use an informed consent form (figure 2.3) to be Review sure that this task is adequately accomplished. The informed consent form contains details The preparticipation screening tools (i.e., the regarding the testing procedures and exercise PAR-Q+ form and the medical history ques- programming and typically requires a signature tionnaire) allow the client to self-report known from the client to indicate that she understands medical and health concerns. These tools address the procedures and exercises, acknowledges that the client’s medical history, current medications, participation in all activities is voluntary, and surgical history, and orthopedic conditions, as is aware that a test or exercise session can be well as diagnosed disease and signs of disease. The stopped at any time without penalty. Any and all exercise professional should use the information informed consent forms should be approved by derived from the screening tools to develop the client’s fitness assessment and exercise program.

Figure 2.1 PAR-Q+ The Physical Activity Readiness Questionnaire for Everyone The health bene ts of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a quali ed exercise professional before becoming more physically active. GENERAL HEALTH QUESTIONS Please read the 7 questions below carefully and answer each one honestly: check YES or NO. YES NO 1) Has your doctor ever said that you have a heart condition OR high blood pressure ? 2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? 3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). 4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? PLEASE LIST CONDITION(S) HERE: 5) Are you currently taking prescribed medications for a chronic medical condition? PLEASE LIST CONDITION(S) AND MEDICATIONS HERE: 6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE: 7) Has your doctor ever said that you should only do medically supervised physical activity? If you answered NO to all of the questions above, you are cleared for physical activity. Go to Page 4 to sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3. Start becoming much more physically active – start slowly and build up gradually. Follow International Physical Activity Guidelines for your age (www.who.int/dietphysicalactivity/en/). You may take part in a health and tness appraisal. cIfoynosuulatrae qouvealritheedaegxeerocfis4e5pyrroafensdsiNonOaTl bacecfoursetoemngeadgtiongreignutlhairsvinigtoernosuitsytoofmexaexricmisael.e ort exercise, If you have any further questions, contact a quali ed exercise professional. If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3. Delay becoming more active if: You have a temporary illness such as a cold or fever; it is best to wait until you feel better. You are pregnant - talk to your health care practitioner, your physician, a quali ed exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active. Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a quali ed exercise professional before continuing with any physical activity program. 01-01-2016 From NSCA, 2018, NSCA’s essentials of tEra4i8n2in2g/NspSeCciAal_pSoppuelcaitailo_nPs,oPp.uJalactoiobnss(e/Fd0.),2(.C01h/a5m30p8ai7g1n/,mILh:-HRu1man Kinetics). Reprinted, by permission, from the PAR-Q+ Collaboration and the authors of the PAR-Q+ (Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin). 18

PAR-Q+ FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S) 1. Do you have Arthritis, Osteoporosis, or Back Problems? If NO go to question 2 If the above condition(s) is/are present, answer questions 1a-1c 1a. Do you have di culty controlling your condition with medications or other physician-prescribed therapies? YES NO (Answer NO if you are not currently taking medications or other treatments) 1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, YES NO displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)? 1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months? YES NO 2. Do you have Cancer of any kind? If NO go to question 3 If the above condition(s) is/are present, answer questions 2a-2b 2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of YES NO plasma cells), head, and neck? 2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)? YES NO 3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm If the above condition(s) is/are present, answer questions 3a-3d If NO go to question 4 3a. Do you have di culty controlling your condition with medications or other physician-prescribed therapies? YES NO (Answer NO if you are not currently taking medications or other treatments) 3b. Do you have an irregular heart beat that requires medical management? YES NO (e.g., atrial brillation, premature ventricular contraction) 3c. Do you have chronic heart failure? YES NO 3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical YES NO activity in the last 2 months? 4. Do you have High Blood Pressure? If NO go to question 5 If the above condition(s) is/are present, answer questions 4a-4b 4a. Do you have di culty controlling your condition with medications or other physician-prescribed therapies? YES NO (Answer NO if you are not currently taking medications or other treatments) 4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? YES NO (Answer YES if you do not know your resting blood pressure) 5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes If the above condition(s) is/are present, answer questions 5a-5e If NO go to question 6 5a. Do you often have di culty controlling your blood sugar levels with foods, medications, or other physician- YES NO prescribed therapies? 5b. Do you often su er from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, YES NO abnormal sweating, dizziness or light-headedness, mental confusion, di culty speaking, weakness, or sleepiness. 5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or YES NO complications a ecting your eyes, kidneys, OR the sensation in your toes and feet? 5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or YES NO liver problems)? 5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future? YES NO 01-01-2016 (continued) E4822/NSCA_Special_Populations/F02.01/573502/mh-R1 From NSCA, 2018, NSCA’s essentials of training special populations, P. Jacobs (ed.), (Champaign, IL: Human Kinetics). Reprinted, by permission, from the PAR-Q+ Collaboration and the authors of the PAR-Q+ (Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin). 19

PAR-Q+ 6. Do you have any Mental Health Problems or Learning Di culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome If the above condition(s) is/are present, answer questions 6a-6b If NO go to question 7 6a. Do you have di culty controlling your condition with medications or other physician-prescribed therapies? YES NO (Answer NO if you are not currently taking medications or other treatments) YES NO 6b. Do you have Down Syndrome and back problems a ecting nerves or muscles? 7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure If the above condition(s) is/are present, answer questions 7a-7d If NO go to question 8 7a. Do you have di culty controlling your condition with medications or other physician-prescribed therapies? YES NO (Answer NO if you are not currently taking medications or other treatments) 7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require YES NO supplemental oxygen therapy? 7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough YES NO (more than 2 days/week), or have you used your rescue medication more than twice in the last week? 7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs? YES NO 8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia If the above condition(s) is/are present, answer questions 8a-8c If NO go to question 9 8a. Do you have di culty controlling your condition with medications or other physician-prescribed therapies? YES NO (Answer NO if you are not currently taking medications or other treatments) 8b. Do you commonly exhibit low resting blood pressure signi cant enough to cause dizziness, light-headedness, YES NO and/or fainting? 8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic YES NO Dysre exia)? 9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event If the above condition(s) is/are present, answer questions 9a-9c If NO go to question 10 9a. Do you have di culty controlling your condition with medications or other physician-prescribed therapies? YES NO (Answer NO if you are not currently taking medications or other treatments) 9b. Do you have any impairment in walking or mobility? YES NO 9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months? YES NO 10. Do you have any other medical condition not listed above or do you have two or more medical conditions? If you have other medical conditions, answer questions 10a-10c If NO read the Page 4 recommendations 10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 YES NO months OR have you had a diagnosed concussion within the last 12 months? 10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)? YES NO 10c. Do you currently live with two or more medical conditions? YES NO PLEASE LIST YOUR MEDICAL CONDITION(S) AND ANY RELATED MEDICATIONS HERE: GO to Page 4 for recommendations about your current medical condition(s) and sign the PARTICIPANT DECLARATION. 01-01-2016 E4822/NSCA_Special_Populations/F02.01/573503/mh-R2 From NSCA, 2018, NSCA’s essentials of training special populations, P. Jacobs (ed.), (Champaign, IL: Human Kinetics). Reprinted, by permission, from the PAR-Q+ Collaboration and the authors of the PAR-Q+ (Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin). 20

PAR-Q+ If you answered NO to all of the follow-up questions about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below: It is advised that you consult a quali ed exercise professional to help you develop a safe and e ective physical activity plan to meet your health needs. Y3o-5udaareysepnecrowureaegkeidnctolusdtianrgt saleorwolbyicanadndbumiludsuclpegstrraednugatlhlye-n2in0gtoex6e0rcmisiensu. tes of low to moderate intensity exercise, As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week. If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal e ort exercise, consult a quali ed exercise professional before engaging in this intensity of exercise. If you answered YES to one or more of the follow-up questions about your medical condition: You should seek further information before becoming more physically active or engaging in a tness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a quali ed exercise professional to work through the ePARmed-X+ and for further information. Delay becoming more active if: You have a temporary illness such as a cold or fever; it is best to wait until you feel better. You are pregnant - talk to your health care practitioner, your physician, a quali ed exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active. Your health changes - talk to your doctor or quali ed exercise professional before continuing with any physical activity program. You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted. The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity. PARTICIPANT DECLARATION All persons who have completed the PAR-Q+ please read and sign the declaration below. If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form. I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that a Trustee (such as my employer, community/ tness centre, health care provider, or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere to local, national, and international guidelines regarding the storage of personal health information ensuring that the Trustee maintains the privacy of the information and does not misuse or wrongfully disclose such information. NAME ____________________________________________________ DATE _________________________________________ SIGNATURE ________________________________________________ WITNESS ______________________________________ SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________________ For more information, please contact www.eparmedx.com The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+ Email: [email protected] Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Donald C. McKenzie (2). Production of this document has been made possible Citation for PAR-Q+ through nancial contributions from the Public Health Agency of Canada and the BC Ministry Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+ Collaboration. of Health Services. The views expressed herein do not necessarily represent the views of the The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011. Key References Public Health Agency of Canada or the BC Ministry of Health Services. 1. Jamnik VK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the e ectiveness of clearance for physical activity participation; background and overall process. APNM 36(S1):S3-S13, 2011. 2. Warburton DER, Gledhill N, Jamnik VK, Bredin SSD, McKenzie DC, Stone J, Charlesworth S, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM 36(S1):S266-s298, 2011. This document has been adapted (with permission) for inclusion in can tpro documents. 01-01-2016 E4822/NSCA_Special_Populations/F02.01/573504/mh-R1 From NSCA, 2018, NSCA’s essentials of training special populations, P. Jacobs (ed.), (Champaign, IL: Human Kinetics). Reprinted, by permission, from the PAR-Q+ Collaboration and the authors of the PAR-Q+ (Dr. Darren Warburton, Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Shannon Bredin). 21

Figure 2.2 Medical History Questionnaire Demographic Information Last name First name Middle initial Date of birth Sex Home phone Address City, State Zip code Work phone Family physician Section A 1. When was the last time you had a physical examination? 2. If you are allergic to any medications, foods, or other substances, please name them. 3. If you have been told that you have any chronic or serious illnesses, please list them. 4. Give the following information pertaining to the last 3 times you have been hospitalized. Note: Women, do not list normal pregnancies. Reason for hospitalization Hospitalization 1 Hospitalization 2 Hospitalization 3 Month and year of hospitalization Hospital ___________________ ___________________ ___________________ City and state ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Section B During the past 12 months 1. Has a physician prescribed any form of medication for you? ❐ Yes ❐ No 2. Has your weight uctuated more than a few pounds? ❐ Yes ❐ No 3. Did you attempt to bring about this weight change through diet or exercise? ❐ Yes ❐ No 4. Have you experienced any faintness, light-headedness, or blackouts? ❐ Yes ❐ No 5. Have you occasionally had trouble sleeping? ❐ Yes ❐ No 6. Have you experienced any blurred vision? ❐ Yes ❐ No 7. Have you had any severe headaches? ❐ Yes ❐ No 8. Have you experienced chronic morning cough? ❐ Yes ❐ No 9. Have you experienced any temporary change in your speech pattern, ❐ Yes ❐ No such as slurring or loss of speech? 10. Have you felt unusually nervous or anxious for no apparent reason? ❐ Yes ❐ No 11. Have you experienced unusual heartbeats such as skipped beats or palpitations? ❐ Yes ❐ No 12. Have you experienced periods in which your heart felt as though it were racing for no apparent reason? ❐ Yes ❐ No 22

At present 1. Do you experience shortness or loss of breath while walking with others ❐ Yes ❐ No your own age? 2. Do you experience sudden tingling, numbness, or loss of feeling in your arms, hands, legs, feet, or face? ❐ Yes ❐ No 3. Have you ever noticed that your hands or feet sometimes feel cooler than other parts of your body? ❐ Yes ❐ No 4. Do you experience swelling of your feet and ankles? ❐ Yes ❐ No 5. Do you get pains or cramps in your legs? ❐ Yes ❐ No 6. Do you experience any pain or discomfort in your chest? ❐ Yes ❐ No 7. Do you experience any pressure or heaviness in your chest? ❐ Yes ❐ No 8. Have you ever been told that your blood pressure was abnormal? ❐ Yes ❐ No 9. Have you ever been told that your serum cholesterol or triglyceride level ❐ Yes ❐ No was high? 10. Do you have diabetes? ❐ Yes ❐ No If yes, how is it controlled? ❐ Dietary means ❐ Insulin injection ❐ Oral medication ❐ Uncontrolled 11. How often would you characterize your stress level as being high? ❐ Occasionally ❐ Frequently ❐ Constantly 12. Have you ever been told that you have any of the following illnesses? ❐ Yes ❐ No ❐ Myocardial infarction ❐ Arteriosclerosis ❐ Heart disease ❐ Thyroid disease ❐ Coronary thrombosis ❐ Rheumatic heart ❐ Heart attack ❐ Heart valve disease ❐ Coronary occlusion ❐ Heart failure ❐ Heart murmur ❐ Heart block ❐ Aneurysm ❐ Angina 13. Have you ever had any of the following medical procedures? ❐ Yes ❐ No ❐ Heart surgery ❐ Pacemaker implant ❐ Cardiac catheterization ❐ De brillator ❐ Coronary angioplasty ❐ Heart transplantation Section C Has any member of your immediate family been treated for or suspected to have had any of these conditions? Please identify their relationship to you (father, mother, sister, brother, etc.). a. Diabetes b. Heart disease c. Stroke d. High blood pressure From NSCA, 2018, NSCA’s essentials of training special populations, P. Jacobs (ed.), (Champaign, IL: Human Kinetics). Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics), 366, 367. 23

Figure 2.3 Informed Consent In order to assess cardiovascular function, body composition, and other physical tness com- ponents, the undersigned hereby voluntarily consents to engage in one or more of the following tests (check the appropriate boxes): ❏ Graded exercise stress test ❏ Body composition tests ❏ Muscle tness tests ❏ Flexibility tests ❏ Balance tests Explanation of the Tests The graded exercise test is performed on a cycle ergometer or motor-driven treadmill. The workload is increased every few minutes until exhaustion or until other symptoms dictate that we terminate the test. You may stop the test at any time because of fatigue or discomfort. The underwater weighing procedure involves being completely submerged in a tank or tub after fully exhaling the air from your lungs. You will be submerged for 3 to 5 seconds while we measure your underwater weight. This test provides an accurate assessment of your body composition. For muscle tness testing, you lift weights for a number of repetitions using barbells or exer- cise machines. These tests assess the muscular strength and endurance of the major muscle groups in the body. For evaluation of exibility, you perform a number of tests. During these tests, we measure the range of motion in your joints. For balance tests, we will be measuring the amount of time you can maintain certain stances or the distance you are able to reach without losing balance. Risks and Discomforts During the graded exercise test, certain changes may occur. These changes include abnormal blood pressure responses, fainting, irregularities in heartbeat, and heart attack. Every effort is made to minimize these occurrences. Emergency equipment and trained personnel are available to deal with these situations if they occur. You may experience some discomfort during the underwater weighing, especially after you expire all the air from your lungs. However, this discomfort is momentary, lasting only 3 to 5 seconds. If this test causes you too much discomfort, an alternative procedure (e.g., skinfold or bioelectrical impedance test) can be used to estimate your body composition. There is a slight possibility of pulling a muscle or spraining a ligament during the muscle tness and exibility testing. In addition, you may experience muscle soreness 24 or 48 hours after testing. These risks can be minimized by performing warm-up exercises before taking the tests. If muscle soreness occurs, appropriate stretching exercises to relieve this soreness will be demonstrated. 24

Expected Benefits From Testing These tests allow us to assess your physical working capacity and to appraise your physical tness status. The results are used to prescribe a safe, sound exercise program for you. Records are kept strictly con dential unless you consent to release this information. Inquiries Questions about the procedures used in the physical tness tests are encouraged. If you have any questions or need additional information, please ask us to explain further. Freedom of Consent Your permission to perform these physical tness tests is strictly voluntary. You are free to stop the tests at any point, if you so desire. I have read this form carefully and I fully understand the test procedures that I will perform and the risks and discomforts. Knowing these risks and having had the opportunity to ask questions that have been answered to my satisfaction, I consent to participate in these tests. Date ___________________________ Signature of patient _________________________________ Date ___________________________ Signature of witness ________________________________ Date ___________________________ Signature of supervisor _____________________________ From NSCA, 2018, NSCA’s essentials of training special populations, P. Jacobs (ed.), (Champaign, IL: Human Kinetics). Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics), 381-382. 25

Figure 2.4 Medical Clearance Form Pertaining to a Fitness Assessment and Exercise Program Dear Health Care Professional: Your patient, ______________________________, has contacted us regarding the tness evaluation conducted by _________________________________. The program is designed to evaluate the individual’s tness status before embarking on an exercise program. From this evaluation, an exercise prescription is formulated. In addition, other parameters related to a health improvement program are discussed with the participant. It is important to understand that this program is preventive and is not intended to be rehabilitative in nature. The tness testing includes: ________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ A comprehensive consultation will be provided to the participant that serves to review the test results and explain recommendations for an individualized tness program. A summary of test results and our recommendations will be kept on le and may be made available to you upon request. In the interest of your patient and for our information, please complete the following: a. Has this patient undergone a physical examination within the last year to assess functional capacity to perform exercise? Yes ___ No ___ b. I consider this patient (please check one): ____ Class I: presumably healthy without apparent heart disease eligible to participate in an unsupervised program ____ Class II: presumably healthy with one or more risk factors for heart disease eligible to participate in a supervised program ____ Class III: patient not eligible for this program, and a medically supervised program is recommended c. Does this patient have any preexisting medical/orthopedic condition(s) requiring continued or long-term medical treatment or follow-up? Yes ___ No ___ Please explain: __________________________________________________________________ ________________________________________________________________________________ d. Are you aware of any medical condition(s) that this patient may have or may have had that could be worsened by exercise? Yes ___ No ___ e. Please list any currently prescribed medication(s): ____________________________________ _____________________________________________________________________________ _____________________________________________________________________________ f. Please provide speci c recommendations and/or list any restrictions concerning this patient’s present health status as it relates to active participation in a tness program. ________________________________________________________________________________ _______________________________________________________________________________ Comments: _____________________________________________________________________ _______________________________________________________________________________ 26

Health Care Professional’s signature: _________________________________Date: ______________ Client’s name: ______________________________________________________________________ Phone (H): ______________________________ Phone (W): _______________________________ Address: __________________________________________________________________________ ____________________________________________________________________________________ AUTHORIZATION TO RELEASE MEDICAL INFORMATION I consent to and authorize ______________________________ to release any medical information concerning my ability to participate in an exercise program or tness assessment. My authori- zation is not valid beyond one year of signature. Patient’s name (print) ________________________________________ Date __________________ Patient’s signature ___________________________________________________________________ Please return this form to: Name ______________________________________________________________________________ Street address ______________________________________________________________________ City, State, Zip _____________________________________________________________________ From NSCA, 2018, NSCA’s essentials of training special populations, P. Jacobs (ed.), (Champaign, IL: Human Kinetics). Reprinted, by permission, from NSCA, 2013, NSCA’s essentials of personal training, 2nd ed., J. Coburn and M. Malek (eds.), (Champaign, IL: Human Kinetics), 178. 27

28 | NSCA’s Essentials of Training Special Populations Recognizing the risk factors for disease is vital (13). The relative risks of exercise-related cardio- for the accountability of the exercise professional vascular events are known to be markedly greater and the reduction of health and safety risks from intense exercise than at rest; however, the incurred by clients. Additionally, it is the exercise absolute risk of a cardiac event during exercise professional’s responsibility to identify signs and is low (1). Finally, warning signs or symptoms of symptoms of cardiovascular, pulmonary, meta- disease, particularly cardiovascular disease, are bolic, immunologic, hematologic, orthopedic, neu- commonly exhibited before a serious cardiovas- romuscular, cognitive, psychological, and sensory cular event (41). Thus, the recommendations for disorders that require restrictions or modi cations medical referral are based on the known risks of with exercise due to a potential exacerbation of an exercise and include the client’s current exercise existing condition. Clients who have been diag- training status, the presence of disease, signs or nosed with or exhibit symptoms of disease may symptoms of disease, and the intensity of recom- require modi ed assessment and programming mended exercise testing and training. guidelines, which are outlined for various condi- tions in subsequent chapters in this text. Recommendations for referral of clients for medical clearance is based to a great degree on the The preparticipation screening affords data known presence of disease recognized to increase critical in the consideration for medical referral. the risk of a serious exercise-related cardiovascu- Exercise professionals should apply established lar event. Diseases that should be considered in guidelines to determine the appropriateness of this regard include the following: medical clearance before initiating an exercise program (36). The preparticipation tools include • Cardiovascular disease a self-report of the presence of disease, signs of disease, and training status, all of which deter- • Cardiac mine the recommendations for medical clearance. • Peripheral vascular disease Medical Clearance Process • Cerebrovascular disease A fitness assessment should not be performed and an exercise program should not begin until • Metabolic disease the exercise professional has determined that the client does not exhibit or possess characteristics • Type I and Type II diabetes that potentially place the client at increased risk of a serious cardiovascular event. There are • Renal disease guidelines specifying the conditions that war- rant referral of clients to a medical professional The exercise professional should use the results for clearance before the initiation of exercise of the PAR-Q+ and the medical history question- testing or training (36). These recommendations naire to reveal any signs or symptoms that are are based on factors (e.g., current activity level, suggestive of disease known to increase the risk of signs of potential disease, and known existence of a cardiovascular event during exercise. Signs and disease) that increase the risk of a cardiovascular symptoms of cardiovascular, renal, or metabolic event during exercise and affect the parameters disease include the following (2, 14, 18): (e.g., intensity) of prescribed exercise. • Pain or discomfort in the arms, neck, chest, It is known that persons who are physically jaw, or other areas that could be indicative of inactive present a signi cantly greater risk of angina or ischemia (impaired coronary artery serious cardiovascular events as compared with blood ow) physically active individuals (16). Regular phys- ical activity has also been shown to be inversely • Shortness of breath during mild exertion or related to the risk of a serious cardiovascular event while resting during or immediately following intense exercise • Dizziness or syncope (fainting) • Orthopnea (shortness of breath while lying supine) or paroxysmal dyspnea (shortness of breath that occurs while sleeping) • Ankle edema (swelling or water retention)

Health Appraisal and Fitness Assessments | 29 • Heart palpations or tachycardia (elevated receive medical clearance for moderate-intensity resting heart rate) exercise if they have received clearance in the pre- vious 12-month period. Physically inactive clients • Intermittent claudication (cramps in the lower who have a known disease but are asymptomatic leg) should be referred to a medical professional for clearance prior to any exercise testing or training. • Heart murmur Following medical clearance, these clients should begin with light- to moderate-intensity exercise • Unusual fatigue occurring with usual activi- with intensity gradually increased as tolerated. ties or shortness of breath with usual activities Guidelines for the referral of clients for medical Clients who develop new signs or symptoms of disease should be referred for medical clearance clearance are related to the prescribed intensity regardless of training status or the presence of of the exercise program. Parameters for light- disease. If the client is presently engaged in an exer- intensity exercise, moderate-intensity exercise, cise program, it must be discontinued and medical and vigorous-intensity exercise are the following clearance should be obtained before recommencing (36): any exercise program. Following medical clear- ance, inactive clients displaying symptoms of dis- • L•ig3h0t-%intteon<s4it0y%exV.eOrc2ioser:heart rate reserve ease should initiate exercise at a light to moderate • 2 to <3 METs intensity level and progress as tolerated. • 9-11 RPE (on 6- to 20-point Borg scale) Program Supervision Recommendations • Intensity producing a slight increase in heart rate and respiration rate Medical clearance provides the exercise pro- fessional with approval and recommendations • Moderate-intensity exercise: regarding specific concerns or restrictions to • 40% to <60% V.O2 or heart rate reserve exercise testing and programming. Based on the • 3 to <6 METs medical evaluation and diagnosis, the physician or other health care professional will generally • 12-13 RPE (on 6- to 20-point Borg scale) recommend either a supervised or medically supervised assessment and exercise program. A • Intensity producing a noticeable increase supervised assessment and exercise program is in heart rate and respiration rate recommended for clients who have a medically identified condition or limitation but are still • Vigorous-intensity exercise: allowed to participate in a fitness assessment • ≥60% to 90% V.O2 or heart rate reserve or exercise program (14). The assessment and • ≥6 METs programming need to be overseen by a certified fitness professional who can assess, monitor, • ≥14 RPE (on 6- to 20-point Borg scale) and modify the testing or exercise session when necessary. • Intensity producing a substantial increase in heart rate and respiration rate A medically supervised assessment and exer- cise program is recommended for high-risk cli- Physically active clients who do not exhibit ents who have medically identi ed participation known disease or signs or symptoms of disease restrictions related to assessment tests, exercise are not recommended to seek medical clearance programming, or both (14). The assessments and and may continue with moderate- to vigorous- programming are directed and monitored by a intensity training and may increase intensity as health care professional in a controlled clinical tolerated. Physically inactive clients without dis- setting that offers immediate emergency care (14). ease or signs of disease may start exercise training with light to moderate intensity without medical clearance, progressing intensity as tolerated. Clients who are physically active and have history of cardiovascular, metabolic, or renal disease but are asymptomatic are not required to

30 | NSCA’s Essentials of Training Special Populations Key Point • Establishment of appropriate exercise selec- tion, frequency of exercise, intensity of exer- Medical clearance provides the exercise profes- cise, and volume of exercise sional with approval from a health care profes- sional for the participation in either a supervised • Development of short-, medium-, and long- program or a medically supervised program. term tness goals Exercise professionals should oversee the testing and training in supervised programs, while medi- • Identi cation of a client’s needs and limita- cally supervised programs should be managed by tions before exercise program initiation, as a health care professional. directed by a health care professional, and information received from client interaction FITNESS ASSESSMENT • A method of recording decisions regarding After the medical and health history appraisal pro- appropriate scope of practice in case the client cess, the exercise professional needs to assess the experiences an injury or an exacerbation of a client’s current level of functional fitness capaci- current medical or health condition after the ties before developing an exercise program. The program begins (21) decision regarding the battery of tests to perform requires consideration of the client’s medical and Assessment Goals health history and fitness-related goals, as well as the exercise professional’s experience in conduct- The exercise professional can use the results of ing assessments on clients who have the specific an assessment in combination with information needs or conditions presented by the client. Test gathered from the medical and health history selection is also influenced by the availability questionnaire and medical clearance form to and necessity of the appropriate environment, design a proper exercise program. Understand- facilities, and equipment. ing the client’s current physical fitness, medical and health concerns, and well-being enables the After determining the tests, the exercise profes- exercise professional to create a program that is sional is responsible for administering the tests, reasonable in frequency, intensity, time, and type recording and managing the data, and interpret- of exercise to promote long-term participation. ing the results. These steps need to be completed In conjunction, establishing program goals and before short-, medium-, and long-term goals can objectives with the client as part of the assessment be established. process is critical to adherence. Rationale for and Bene ts of Assessment Standardization Testing One of the responsibilities of the exercise profes- Assessment (often simply called testing) is a crit- sional working with a client is to enhance physical ical component in the development of a safe and fitness without causing harm to the client (21). effective exercise program especially for clients Assessment test batteries should be standardized as who have a medical- or health-related condition. much as possible, but some variation in test selection In all cases, the selected tests should be specific may be necessary to accommodate individual needs. to each client and based on his needs. All fitness assessment tests should be of high valid- ity, reliability, and accuracy. Test administration The rationale for performing an assessment on should be standardized as much as possible, and the a client includes the following (35): professional performing the assessments should be qualified and trained to administer each test. • A baseline for future comparisons of improve- ment or rate of progress Assessment Standards • Identi cation of current levels of tness that The results obtained from fitness assessment will contribute to the exercise program tests can be compared to standards derived from norm-referenced data, from criterion-referenced

Health Appraisal and Fitness Assessments | 31 standards, longitudinally to the results of the Client Factors client, or from a combination of these approaches. Standards for fitness assessments based on In selecting a test, it is essential to evaluate factors norm-referenced data are used to compare the that may positively and negatively influence a fitness level of like individuals (sex, age, and so client’s performance and subsequently affect the on) on the same test. These results are usually validity, reliability, and accuracy of the assess- reported as a percentile rank. In this type of ment results. It is incumbent on the exercise system, results are often indicated as follows: professional to recognize any condition that may result in the alteration of the standard assessment • 0% to 20% = well below average or poor test battery and make adjustments according to the client’s individual needs. For example, a • 21% to 40% = below average client who has trouble walking should use an arm ergometer and not a treadmill as a testing • 41% to 60% = average mode during an assessment. Additionally, fatigue, whether a function of recent activities, insufficient • 61% to 80% = above average nutrition or fluid intake, or the demands of the tests being administered, can affect assessment • 81% to 100% = well above average or excellent outcomes and as such should be accounted for when one is determining the timing and duration Criterion-referenced physical tness tests have of test administration. predetermined levels of acceptable minimal out- comes for performance. If the results of a criterion- A client’s maturity level and chronological age referenced test exceed the minimal standard, then may also affect her test performance. For exam- the client has successfully completed the test. A ple, a treadmill test using the Bruce protocol may good example of a criterion-referenced tness be considered an appropriate test for younger assessment is FitnessGram, which is a battery of clients, but this protocol may need to be reduced tests that includes assessment of aerobic endur- in intensity for those with known disease or for ance, strength, exibility, and body composition older adult clients who have higher levels of risk. (44). The periodic and systematic collection of a client’s longitudinal data allows for the observation Sex-speci c physiological factors can affect of improvement in each tness category over time. assessment scores or the protocol of some assess- What is most critical for clients to observe with ments. Women generally have larger quantities of repeated assessments is a positive improvement in body fat and less muscle mass than men, as well assessment scores from the baseline level, which as a smaller shoulder, hip, and knee structure that highlights improvement and continuous move- supports less muscle mass; as a result they have ment toward the client’s goals. less of a mechanical advantage than their male counterparts (15). For example, the 30-second Currently, there are no general physical tness arm curl test requires different xed loads for men standards based on normative or criterion-referenced (8 pounds [3.6 kg]) than for women (5 pounds data for diseased or disabled populations; there- [2.3 kg]), demonstrating the sex-speci c differ- fore it is essential that the exercise professional ences related to client factors that an exercise establish realistic short-, medium-, and long-term professional needs to consider when selecting goals for clients whose baseline scores place them appropriate tests (38). below average or well below average for healthy individuals. The ability to set reasonable goals for Key Point improvements and progress levels for all clients who may not reach an average score based on The exercise professional needs to be aware that norm-referenced standards is critical to exercise a client’s maturity level and chronological age adherence for the client. Setting reasonable goals can both affect exercise test performance and that can be attained provides a client with positive the evaluation of the results. feedback upon attaining goals. Goal setting can be a valuable tool for enhancing participation in exercise programming (20). See the discussion of SMART goal setting later in this chapter.

32 | NSCA’s Essentials of Training Special Populations Test Order before more active fitness assessments when the person is resting and not subject to the rigors of an Assessment tests should generally be sequenced exercise test. These measurements help establish a such that one test does not affect a subsequent baseline to measure progress and play a role in the test. For example, assessment of resting heart design of the subsequent exercise program (e.g., rate should precede assessments of cardiovascular resting heart rate needs to be known to calculate endurance, as the cardiovascular endurance test exercise heart rate using the Karvonen formula). will result in a heart rate that is elevated above resting levels. It is also important to always Assessment Protocol: Resting perform assessments in the same order so that Heart Rate comparisons can be made between assessments. The following list places assessment tests in an Equipment acceptable order (28): • Watch with a second hand 1. Nonfatiguing tests such as height, weight, • Chair resting heart rate, resting blood pressure, exibility, body composition, anthropo- Procedure metric measurements, and neuromuscular assessments Have the client sit comfortably for 3 to 5 minutes. Palpate the radial pulse using the tips of the index 2. Tests of agility such as the T-test and hex- and middle nger; do not use the thumb. Count agon test the number of beats starting at 0 and count for 60 seconds. 3. Maximum muscular strength tests such as a one-repetition maximum (1RM) bench press Note: The exercise professional should not use the thumb to measure heart rate because the thumb 4. Local muscular endurance such as the par- has a pulse, which can cause inaccurate counting. tial curl-up test Assessment Protocol: Resting 5. Cardiovascular endurance such as the Bruce Blood Pressure protocol or the arm ergometer test Blood pressure has two values: Systolic pressure FITNESS ASSESSMENT is generated during left ventricular contraction, PROTOCOLS and diastolic pressure is generated when the left ventricle heart is relaxing and re lling during the Evaluating a client’s fitness level requires prepara- cardiac cycle. tion and organization to ensure valid, accurate, and reliable results and maintenance of client safety. Equipment Proper and signi cant assessment outcomes • Mercury or aneroid sphygmomanometer (a are greatly affected by the ability of the exercise blood pressure measuring device) with cuffs professional to prepare clients by educating them sized for children and adults as to the measurement and assessment description, preparation guidelines, purpose and explanation of • Stethoscope procedures, risks, bene ts, and assessment expecta- • Watch with a second hand tions. Preparation to evaluate a client’s tness level • Chair requires preassessment measurements and selection of appropriate tness assessments, which involves Procedure reviewing safety guidelines, calibrating equipment, and following documentation procedures. To obtain valid and reliable blood pressure meas- urements, the exercise professional should practice Preassessment Measurements and become competent with this assessment before testing. Systolic and diastolic blood pres- A client’s resting heart rate, resting blood pres- sure can be measured according to the following sure, weight, and height are commonly measured protocol (see gure 2.5):

Health Appraisal and Fitness Assessments | 33 Figure 2.5 Body and equipment positions for meas- Assessment Protocol: Body Weight uring resting blood pressure. Equipment • Position the client in an upright seated posture with the back supported and legs uncrossed. • Scale or balance that can be calibrated for accuracy • Select an appropriately sized cuff based on the circumference of the upper arm. Procedure • Locate the brachial artery of the client. Have the client empty his pockets and remove • Securely place the cuff of the sphygmomanom- shoes and any other heavy articles of clothing (belts, jackets, heavy sweaters, shoes, and so on). eter on the upper arm in a manner that covers Have the client stand on the measuring device until the brachial artery and with the bottom of the a stable measurement can be made, and report cuff approximately 1 inch (2.5 cm) above the the weight (pounds or kilograms) to the precision antecubital space. allowed by the measuring device. • The cuff of the sphygmomanometer should be placed such that the dial or display is readily Assessment Protocol: viewable by the exercise professional. Height • When taking measurements, the bell of the steth- oscope should be rmly placed directly over the Equipment antecubital space, and the client’s arm should be level with the heart and in a horizontal position. • Medical stadiometer or a wall with a tape meas- • In ate the cuff rapidly to 160 mmHg or 20 mmHg ure af xed to it above known resting systolic blood pressure (40). • Begin to release the pressure from the cuff slowly Procedure (2-3 mmHg per second). • Systolic blood pressure is recorded as the rst Have the client remove her shoes and stand erect audible Korotkoff sound. with the feet together in front of the stadiometer • Diastolic pressure is recorded as the disappear- or facing away from the wall with the back of the ance of all Korotkoff sounds. heels touching the wall. Measure height as the • Record systolic and diastolic blood pressure in vertical distance (inches or centimeters) from the even numbers and to the nearest 2 mmHg (40). • Consult table 2.1 near the end of the chapter oor to the crown on the top of the head to the for the blood pressure classi cations for adults. precision allowed by the measuring device. If using a tape measure af xed to a wall, place a ruler (or Note: The exercise professional should always similar object) on top of the client’s head and, select an appropriately sized blood pressure cuff while keeping it level, extend it straight back to for each client. the tape measure. Assessment Protocol: Lung Function The forced expiratory volume (FEV1) test is used to determine the volume of air exhaled in the rst second following a maximal inhalation (3). This test can be used to determine a limitation in pulmonary ow rate. Equipment • Spirometer • Nose clip

34 | NSCA’s Essentials of Training Special Populations Procedure measurements, skinfold thicknesses, and bioelectrical impedance analysis (BIA). The instructions for the speci c spirometer being used for the test should be followed to obtain 6. Neuromuscular assessments measure the correct measurement of FEV1. The exercise profes- ability to do activities that require balance, sional should use the nose clip to make certain that coordination, skill, or a combination of no air will come out of the nostrils during the test. these. The client is asked to perform a forced expiratory maneuver, which requires a maximal inhalation 7. Functional performance assessments followed by a maximal exhalation while breathing measure the ability to do speci c physical into the spirometer. activities of daily living. An example of a functional performance test is the 8-foot Common Fitness Tests up-and-go test. There are eight types or categories of fitness 8. Assessments speci c to clients who have a assessments that are tied to the general compo- medical condition can be used in circum- nents of overall fitness (30); commonly, at least stances when other testing protocols may one test from each of the following categories is be inappropriate due to tness or movement performed: restrictions. These assessments include the 6-minute walk test, 2-minute step test, 1. Cardiovascular endurance assessments 30-second chair stand test, 30-second arm poxroyvgiedneceosntismumatpiotniosno(fV.tOhe2mclaiexn).tC’s amrdaixoivmaas-l curl test, and the chair sit-and-reach test. cular endurance tests employ a variety of testing modalities including the treadmill, Cardiovascular Endurance stair stepper, recumbent stepper (6), cycle Assessments ergometer, and arm ergometer. The ability to perform cardiovascular endurance 2. Muscular strength assessments determine the maximum force that a muscle or muscle exercise is important for completing activities of group can exert in a single effort while maintaining proper technique. Muscular daily living and is commonly directly assessed in a strength is typically assessed by the use of a one-repetition maximum (1RM) protocol. laboratory setting through the use of a graded exer- 3. Local muscular endurance assessments cise test or a comparable field test. However, some measure the ability of a muscle or muscle group to perform repeated submaximal con- clients with chronic aditsreuaesVe. Oo2rmdaixsa(b3i0li)t.iResatmheary, tractions. Local muscle endurance assess- not be able to achieve ments typically count the total number of repetitions per unit time, such as for the they prematurely reach a point at which they partial curl-up test. slciuamnchinteopdteoecoxpnlhetaihunasuvteieoaann,vdreerafyerrleorsewadipdtoetaaoksrVp.eOeaac2;khuVs.syOuma2.lplMytolaemnsys- 4. Flexibility assessments measure the ability than 25 ml · kg−1 · min−1 and often less than 20 to move joints through a prescribed range of motion (ROM). Flexibility assessments ml · kg−1 · min−1 (30). Daily living activities, often include the sit-and-reach and back scratch tests. taken for granted by those who are healthy and 5. Anthropometric assessments measure size, without disability, require oxygen consumption shape, and composition of the human body or body segments. Anthropometric assess- in the range of 12 to 30 ml · kg−1 · min−1. Thus, ments include body mass index (BMI), girth some clients V.wOit2mh achxroornipcedaikseV.aOse2boerlodwisawbhilaittieiss may have a required for activities of daily living, employment, and maintenance of client independence, resulting in a reduced quality of life. In general, reduced-intensity graded exercise test protocols (e.g., a RAMP protocol) are preferred for these populations over standard protocols (e.g., Bruce protocol). Many standard protocols increase work rate in relatively large, often non-

Health Appraisal and Fitness Assessments | 35 linear gradients and are effective only in screening or any other sign indicative of poor blood for ischemic heart disease. In the management perfusion. of chronic disease or disabilities, however, it is valuable to discern the exercise response in the 8. Failure of heart rate to increase with submaximal range to best establish a proper increasing work rate. exercise intensity for the client’s exercise pro- gram. Ramp protocols can be superior in this 9. Change in heart rhythm. regard because they indicate exercise responses at smaller increments, enabling the exercise profes- 10. Client requests to stop the test. sional to best determine the client’s submaximal exercise capacity. 11. Physical or verbal indication of severe fatigue. Another disadvantage of using a standard pro- tocol is that the test cannot be individualized so 12. Malfunction of the testing equipment. that each client can complete the 8 to 10 minutes of exercise time recommended for an accurate Exercise Test Modalities The treadmill and cycle assessment (26, 32, 33, 40). In other words, per- sons with chronic disease or disabilities may have ergometer are the most commonly used devices low cardiovascular endurance exercise capacity and be unable to complete the test. Therefore, it for clinical exercise testing. Treadmill testing is important for the exercise professional to know the client’s approximate ability, estimate his peak provides a more familiar form of physiological exercise capacity, and design a test to yield three or four changes in work rates during an 8- to stress (because the client is walking or running), 10-minute test period (10). with clients more likely to attain a slightly higher Test Termination The exercise professional must understand that a client can stop the exercise test oxygen consumption and peak heart rate than at any time and for any reason. There are also test termination indicators that can be determined during cycle ergometer testing due to increased from observations of the client during a test; every exercise professional should be aware of these. muscle mass utilization (3, 19, 34). The treadmill An exercise test should be stopped immediately if any of the following occurs (22): should have readily accessible handrails for cli- 1. Client reports symptoms of angina. ents to steady themselves; however, consistently 2. Systolic blood pressure drops >10 mmHg holding the handrails can reduce the accuracy of from baseline with increasing work rate. exercise capacity and the quality of the heart rate 3. Extreme increase in blood pressure. recording and so should be discouraged. However, 4. Systolic blood pressure >250 mmHg. it may be necessary for some clients to hold the 5. Diastolic blood pressure >115 mmHg. handrails lightly for balance. An emergency stop 6. Client experiences shortness of breath, wheezing, leg cramps, or other symptoms button should also be readily available to the client of claudication due to inadequate blood ow to the leg muscles. and supervising exercise professional. 7. Client experiences ataxia (loss of voluntary Arm ergometry is an alternative method of coordination of muscle movements), dizzi- ness, pallor (pale skin color), cyanosis (blue exercise testing for clients who cannot perform or purple skin color due to a lack of oxygen in the blood), cold or clammy skin, nausea, leg exercise (e.g., due to a spinal cord injury) or for clients who primarily perform dynamic upper body work during occupational or nleoisV.uOre2m-tiamx–e activities (4, 23). At the current time, peak normative data exist for comparing values derived from arm ergometry to the general popu- lation. Of additional concern is the impact of the rsemsaulllteinr gmiunscrleepmoratsssoufsVe.Od2dmuarixn–gpaeramk ergometry, values that are approximately 20% to 30% lower than the vTahleuerseaolbbtaeinneedtsdoufritnegsttinregadV.mO2imll atexs–tpinegak(4u, s2in3)g. arm ergometry are to evaluate a client’s progress and measure the effectiveness of a training pro- gram over time. Testing Protocols Many resources provide testing protocols for measuring cardiovascular endurance.

36 | NSCA’s Essentials of Training Special Populations General guidelines for all cardiovascular 5 minutes after the test. In the event of an endurance tests include the following recommen- abnormal response to the test, an extended dations (22): postexercise test observation period may be warranted. • Heart rate and blood pressure should be taken After estimating or calculating V. O2max from immediately before the exercise test with the the various tests, consult table 2.2 near the end client in the same posture as will be used of the chapter for the cardiovascular endurance during the exercise test. classi cations for adults. • Clients should be familiarized with the mode Key Point of exercise that will be used for the test. The exercise professional should always remind • An adequate warm-up of approximately 2 the client that she can stop the exercise test at to 3 minutes should be completed before an any time and for any reason. exercise test. Assessment Protocol: • Every protocol used should consist of approx- Treadmill Test imately 3-minute exercise stages accompanied by appropriate increments in work rate. Equipment • Heart rate should be measured a minimum of • Treadmill with an emergency stop button two times during each stage (near the end of • Stopwatch the second and third minutes of each stage). • Rating of perceived exertion chart • Blood pressure should be measured during Procedure the last minute of each stage so the exercise professional is aware of an abnormal blood The Bruce treadmill test remains the most com- pressure response to increasing work rate. monly used protocol; however, it employs rela- tively large intensity increments (i.e., 1-3 METs • Ratings of perceived exertion (RPE) should be [metabolic equivalents] per stage) every 3 minutes. taken near the end of the last minute of each Consequently, changes in physiological responses stage using an appropriate scale. may be less uniform and exercise capacity may be markedly overestimated when it is predicted from • The exercise professional should monitor the exercise time or work rate. Protocols with larger client for signs or symptoms to terminate the intensity increments are better suited for screening test, such as these: younger or physically active clients, whereas proto- cols with smaller increments, such as Balke-Ware • Attainment of 70% HRR or 85% of age- (i.e., 1 MET per stage or less), are preferable for predicted maximal heart rate clients with chronic disease or disabilities. Advan- tages of smaller incremental increases include the • If the client fails to conform to the exercise following (2): test protocol • Avoidance of large and unequal increments in • If the client requests to stop the test for work rate any reason • Uniform increases in hemodynamic and physi- • If the client experiences an emergency ological responses situation • More accurate estimates of exercise capacity • An adequate cooldown at an intensity less and ventilatory threshold than or equal to the work rate of the rst stage should be completed after the test (if the test • Individualization of the test protocol (individu- has not been terminated for an emergency). A alized incremental changes) passive cooldown should be implemented if the client has experienced signs of discomfort • Targeted test duration or if an emergency situation has occurred. • Measurement of heart rate, blood pressure, and RPE should continue for a minimum of

Health Appraisal and Fitness Assessments | 37 Whichever exercise protocol is selected, it Procedure should be individualized so the treadmill speed and increments in grade are based on the client’s Set the metronome to 96 beats (24 steps) per capability. For example, increases in grade of 1% minute and the stopwatch to 3 minutes. Instruct to 3% per stage, with constant belt speeds of 1.5 the client to keep pace with the metronome by to 2.5 miles per hour (2.4-4 km/h), can be used for stepping up on the box or bench with the right treadmill tests for clients with a chronic disease or foot, then the left foot, and then stepping down other limitation. with the right foot, then the left foot. The client should practice stepping in time to the metronome Due to the fatiguing effect of cardiovascular before doing the test. endurance assessments, they should be adminis- tered after all other tests have been completed. Clients can measure their heart rate in one During each stage of a treadmill test the exercise of two ways: either by locating their radial pulse professional can obtain RPE and heart rate data that (marking it with a felt tip pen) and taking it manu- can be used to compare the level of fatigue to future ally, or by wearing a heart rate monitor. Time starts tests on the same client. Protocols for the Bruce when the client begins stepping. and Balke-Ware treadmill tests are presented next. Scoring Bruce Treadmill Protocol The Bruce treadmill test begins with a very slow After time expires, have the client immediately sit speed but at a relatively steep incline, and every down and take the pulse for 1 minute. The score for 3 minutes, both the speed and the percent grade the test is the heart rate during this minute. Results are increased until volitional fatigue is attained by from this test can be compared to the normative the client (9). See table 2.3 near the end of the data found in table 2.5 near the end of the chapter. chapter for the time and intensity assignments for each stage of the test. Clients should stop the test if they can no longer keep up with the metronome or if they become Balke-Ware Treadmill Protocol too fatigued to continue. If this occurs, record The Balke-Ware treadmill test begins at a speed the ending pulse rate and the amount of time of 3.4 miles per hour (5.5 km/h) and 0% grade. completed. On the next test, the goal will be to The speed of the treadmill does not change again complete the full 3 minutes, or at least a greater during the test. At the beginning of the second percentage of it than the last time. minute, the grade is set to 2% and increases by 1% every minute until volitional fatigue is reached (5). Assessment Protocol: Recumbent Stepper (7) Scoring Equipment To estimate V. O2max for the Bruce and Balke-Ware treadmill tests, the exercise duration spent during • Recumbent stepper the test should be used in one of the equations from table 2.4 near the end of the chapter. Exercise • Stopwatch duration should be expressed as time in minutes and in decimal format; for example, 9 minutes and • Rating of perceived exertion chart 15 seconds would equal 9.25 minutes. Procedure Assessment Protocol: YMCA Step Test (40) Individuals are required to maintain a constant step rate of 100 steps per minute for the entire Equipment test. The work rate for stage 1 is the same for all clients (30 watts), and subsequent work rates are • Box or bench 12 inches (30 cm) in height assigned based on the heart rate response from stage 1. Heart rate should be taken during the • Metronome nal 10 seconds of minutes 2 and 3 of each stage • Stopwatch to determine if steady-state heart rate (a change of no more than ±5 beats per minute) has been attained. If steady-state heart rate has not been attained, then the current work rate should be maintained for an additional minute and heart