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

38 | NSCA’s Essentials of Training Special Populations rate should be taken again. Use the following • Stopwatch information to determine appropriate work rates for stages 2 through 4: • Rating of perceived exertion chart Work Rates for the Recumbent Stepper Procedure Test Stage 2 Clients are required to maintain a constant pedal • Heart rate <80 beats/min: 125 watts (W) rate of 50 rpm (using a 6 m per revolution ywheel) • Heart rate 80-89 beats/min: 100 W for the entire test. The work rate for stage 1 is • Heart rate 90-100 beats/min: 75 W the same for all clients—150 kgm/min (a 0.5-kg • Heart rate >100 beats/min: 50 W workload)—and subsequent work rates are assigned based on the heart rate response from Stage 3 stage 1. Heart rate should be taken during the nal • Heart rate <80 beats/min: 150 W 30 seconds of minutes 2 and 3 of each stage to • Heart rate 80-89 beats/min: 125 W determine if steady-state heart rate (±5 beats per • Heart rate 90-100 beats/min: 100 W minute) has been attained. If steady-state heart • Heart rate >100 beats/min: 75 W rate has not been attained, then the current work rate should be maintained for an additional minute Stage 4 and heart rate should be taken again. Rating of • Heart rate <80 beats/min: 175 W perceived exertion should be measured during • Heart rate 80-89 beats/min: 150 W the nal minute of each work rate and recorded. • Heart rate 90-100 beats/min: 125 W The test should continue until volitional fatigue or • Heart rate >100 beats/min: 100 W achievement of 85% age-predicted maximal heart rate. Use the information in table 2.6 near the end of the chapter to determine appropriate work rates for stages 2 through 4. Adapted from Billinger et al., 2012. Scoring Rating of perceived exertion should be measured . during the nal minute of each work rate and To estimate VO2max from the YMCA cycle ergom- recorded. The test should continue until volitional eter test, the exercise professional must extrapolate fatigue or achievement of 85% age-predicted maximal heart rate. estimated maximal work rate from the heart rate and work rate data obtained from the submaximal test. Plot each heart rate obtained for every work Scoring rate from the test. Draw a diagonal line through VT.hOe2 following equation was developed to estimate the data points that extends to the age-predicted max from the work rate (wattsend )submax and maximal heart rate (220 − age). Extend a line heart rate in the nal stage (7): downward to the horizontal axis of the graph. The V. O2 peak (in ml · kg−1 · min−1) = 125.707 − estimated maximal work rate is the value obtained (0.476)(age in years) + (7.686)(sex [0= female; where this line bisects the horizontal axis. Figure 2.6 shows an example based on a 1= male]) − (0.451)(weight in kg) + (0.179) 38-year-old individual who had an exercise heart (wattsend )submax − (0.415)(HRend )submax rate at the end of stage 1 (150 kgm/min), stage 2 (450 kgm/min), and stage 3 (600 kgm/min) of 91, Assessment Protocol: YMCA 130, and 155 beats/min, respectively. Cycle Ergometer Test (17) Using the following formula, the exercise pro- fessional can.use the estimated maximal work rate to calculate VO2max: Equipment . VO2max = [(1.8 × estimated maximal work rate in • Cycle ergometer kgm/min) / body mass in kg] + 7

Health Appraisal and Fitness Assessments | 39 ST AGE HR I 150 (kgm/min) 91 II 450 (kgm/min) 130 220 - 38 years = 182 (beats/min) III 600 (kgm/min) 155 190 Heart rate (beats/min) 140 90 max work rate = 750 (kgm/min) 40 150 300 450 600 750 900 1050 1200 Power (kgm/min) Figure 2.6 Plotting heart rate and work rate to estimate maximal work rate. Reprinted, by permission, from V.H. HEe4y8w2a2r/dNaSnCdAA_.LS.pGeicbiasol_nP, 2o0p1u4la, Atiodvnasn/Fce0d2.0tn6e/s5s4a4s7se0s9sm/menht/kahn-dRe3xercise prescription, 7th ed. (Champaign, IL: Human Kinetics), 105. Assessment Protocol: Arm Scoring Ergometer Test (4) First, one converts watts to kgm/min by multiplying Equipment watts by 6.12; then, using the following formula, use the maxim. al work rate attained during the test • Upper body ergometer or a cycle ergometer to ca. lculate VO2max: with the pedals replaced by handgrips VO2max (in ml · kg−1 · min−1) = [(3 × work rate • Stopwatch in kgm/min) / body mass in kg] + 3.5 • Rating of perceived exertion chart Muscular Strength Assessments Procedure Muscle strength testing can reveal several impor- tant aspects of strength, including maximal force, The protocol for the arm ergometry tests requires the smoothness of contraction and relaxation that clients be seated in an upright position, with (lack of spasticity), balance of strength between the feet at on the ground, and the center of extensor and flexor muscle groups, symmetry the axis of rotation of the crank arms adjusted between left and right sides of the body, and to approximately shoulder height. The elbows resistance to fatigue (40). should remain slightly exed during the range of motion for every revolution of the crank arms. A Muscular strength is de ned as the force that crank arm speed of 75 to 80 rpm must be main- a muscle or muscle group can exert in a single tained for the duration of the test. Beginning maximal effort—a 1RM—while maintaining work rate is 10 watts, and this work rate should be proper form (28). Muscular strength is an impor- increased an additional 10 watts every 2 minutes tant component of tness, as a minimal level of until volitional fatigue or until 75 rpm cannot be maintained.

40 | NSCA’s Essentials of Training Special Populations muscular strength is necessary to conduct func- is that the movement is performed through a tions of daily living and participate in recreational standardized range of motion. To perform the activities (14). test, follow the same procedure as for the 1RM bench press test, though the loads that are lifted Assessment Protocol: 1RM Bench are usually heavier than for the 1RM bench press Press (28) test, so the load increases in each trial set will be greater (28). Equipment Scoring • Bench press bench • Barbell The 1RM must be divided by the client’s body • Weight plates weight in order to compare to normative values in • Barbell clips or locks table 2.8 near the end of the chapter. • Spotter Local Muscular Endurance Procedure Assessments The client should perform an exercise-speci c Local muscular endurance is the ability of mus- warm-up of 5 to 10 repetitions using a light to cles or groups of muscles to perform repeated moderate load rst. Then the client should perform submaximal contractions (28). Tests that evaluate at least two additional heavier warm-up sets of two local muscle endurance typically count the total to ve repetitions at approximately 60% to 80% number of repetitions per unit time. of the estimated 1RM. The resistances should be progressively increased in a conservative manner, Assessment Protocol: Partial and the client should attempt to perform one rep- Curl-Up Test (22) etition at each increment in resistance. Following each attempt, allow a recovery period of 2 to 4 Equipment minutes. Increase and decrease the load until the client can complete only one repetition with proper • Metronome technique and no assistance from the spotter. The • Ruler client’s 1RM should be attained within three to • Adhesive tape • Exercise mat ve total trials. Procedure Scoring The client lies supine on an exercise mat, arms The 1RM must be divided by the client’s body by the sides, elbows extended, palms at on weight in order to compare to normative values in the mat, and knees exed to 90°. Place a piece table 2.7 near the end of the chapter. of tape at the tip of the ngers of each hand and a second piece of tape parallel to the rst Assessment Protocol: 1RM Leg piece 10 cm (4 in.) away (see gure 2.7). Set the Press (22) metronome to 50 beats per minute and have the client curl forward and upward, lifting the Equipment shoulder blades off of the exercise mat by exing the trunk to 30° in time with the metronome • Leg press machine (25 curl-ups per minute). Clients should avoid Procedure exing the neck and perform as many curl-ups as possible in 1 minute without pausing until they Before testing begins, the exercise professional can no longer reach the distant piece of tape at should adjust the seat, foot platform, or both the end of the curl-up or until they complete a (depending on the design of the machine) so that maximum of 25 repetitions. when the client is in the bottom (or most forward) position of the leg press, his thighs are parallel to the foot platform. The result of this adjustment

Health Appraisal and Fitness Assessments | 41 Figure 2.7 Starting and ending positions for the performance also suggests the inclusion of the sit-and-reach test for health-related tness testing. partial curl-up test. Equipment Scoring • Sit-and-reach box or adhesive tape The score is the total number of curl-ups com- pleted; see table 2.9 near the end of the chapter • A measuring tape or stick for norms for this test. Procedure Flexibility Assessments Whether using a sit-and-reach box or a measuring Flexibility is defined as the range of motion (in tape or stick, the client should rst warm up with degrees) that can be performed by a joint of the exercises that engage the hamstrings and lower body (28). Maintaining flexibility of all joints back, such as walking or jogging for 3 to 5 minutes. facilitates optimal movement and function; in This should be followed by several repetitions of contrast, when an activity moves the structures alternating between exing forward and reaching of a joint beyond a joint’s range of motion, tissue toward the toes with the knees extended in a damage can occur. The degree of flexibility of a standing or sitting position, then reaching upward joint depends on the distensibility of the joint toward the ceiling in a smooth continuous motion capsule, appropriate warm-up, muscle viscosity, (without jerking). Make a note of the warm-up and compliance of connective tissues such as lig- routine used by the client so it can be replicated aments and tendons. Flexibility is joint specific, for future testing to assist in reliability of the test and as a result, no single test of flexibility exists results. that can be used to evaluate total body flexibility. When using a sit-and-reach box, the client Assessment Protocol: Sit-and- should be in a seated position facing the box with Reach Test (22) the shoes off. The knees should be fully extended with the feet placed on the base of the box and the The sit-and-reach test has been used commonly to medial edges of the feet 6 inches (15 cm) apart. The assess low back and hip joint exibility since low client should keep the knees fully extended during back pain affects a signi cant number of people in the duration of the test, arms fully extended, and their lifetime (40). The relative importance of ham- hands overlapped, with the palm of one touching string exibility to activities of daily living and sport the dorsal surface of the other. The client should then reach forward slowly, exing at the hips, and push the ngertips over the scale on the box in a controlled manner. When full extension is obtained, the client should hold this position for approxi- mately 2 seconds. To maximize the best stretch, ask the client to exhale when reaching forward. When using a measuring tape or stick, rst tape it to the oor; then place one piece of tape 24 inches (61 cm) long across and at a right angle to the measuring stick at the 15-inch (38 cm) mark. After warming up, the client should sit without shoes in a position with the measuring stick between the legs and its zero end toward the body. The feet should be approximately 12 inches (30 cm) apart, toes pointed upward, and heels touching the edge of the taped line at the 15-inch (38 cm) mark. Clients should keep the knees fully extended during the duration of the test, arms fully extended, and hands overlapped with the palm of one touching the dorsal surface of the other. The client should then be instructed to reach forward in a controlled manner with both hands as far as possible on the

42 | NSCA’s Essentials of Training Special Populations Figure 2.8 Starting and ending positions for the sit- possible. The elbow should be pointed up toward the ceiling. The client should then place the oppo- and-reach test using a measuring tape or stick. site arm around her back with the dorsal surface of the hand touching the back. With this hand, the client should reach up the back as far as possible in an attempt to touch or overlap the extended middle ngers of both hands. Practice attempts are allowed in order to determine the preferred position. Clients should not grip the ngers of opposite hands together and pull. Scoring Clients are allowed two practice trials in the pre- ferred position before administration of two test trials. Record both scores to the nearest 0.5 inch or 1 cm, measuring the distance of overlap or distance between the tips of the middle ngers, with the higher of the two values recorded as the overall score. Clients are awarded one of the following scores: • Minus (−) score if the middle ngers do not touch • Zero (0) score if the middle ngers just barely touch • Plus (+) score if the middle ngers overlap measuring stick. When full extension is obtained, Anthropometric and Body the client should hold this position for approxi- Composition Assessments mately 2 seconds with the ngertips remaining in contact with the measuring stick (see gure 2.8). To Measurements of limbs and body segments— maximize the best stretch, ask the client to exhale typically the largest circumference of those when reaching forward. The exercise professional areas—are commonly performed by an exercise may hold the client’s knees down, if necessary, to professional before a client begins an exercise keep them straight. program, especially if the goal is to lose body fat or gain muscle tissue. Those assessments do Scoring not determine the body composition of a client, however. Commonly, measurements of skinfold The client is allowed three trials, with the highest thicknesses at three to seven anatomical sites or taken as the score to the closest 0.25 inch (1 cm). a bioelectrical impedance analysis (BIA) test is See table 2.10 near the end of the chapter for performed to give better insight into the client’s norms for this test. fat weight and lean body mass. Assessment Protocol: Assessment Protocol: Back Scratch Test (38) Body Mass Index (BMI) Equipment Equipment • Yardstick (meterstick) • Scale or balance that can be calibrated for accuracy Procedure • Medical stadiometer or a wall with a tape meas- The client should stand and place her preferred ure af xed to it hand over the same-side shoulder with the palm down and ngers fully extended. The client should then reach down the middle of the back as far as

Health Appraisal and Fitness Assessments | 43 Procedure could be predicted. The thicknesses of the skinfolds at various sites (depending on the formula used Measure the client’s height and weight (refer to the based on the client’s demographic) are used to “Preassessment Measurements” section). estimate body density and calculate the client’s percentage of body fat. The body density equations Scoring for men and women typically use the sum of three or seven skinfolds. To be accurate and valid, the Determine the client’s BMI by using one of the exact skinfold techniques that were used to derive following formulas: the equations must be applied, and appropriate levels of training and experience of the exercise BMI (in kg/m2) = [body weight in pounds / professional should be observed. (height in inches × height in inches)] × 703 Equipment BMI (in kg/m2) = [body weight in kg / (height in meters) × (height in meters)] • Skinfold caliper that is valid and reliable and can be calibrated for accuracy Based on the client’s BMI, he is then placed into one of the following classi cations: • Gulick or other nonelastic measuring tape • Normal: between 18.5 and 24.9 kg/m2 • Overweight: between 25 and 29.9 kg/m2 • Marking pen • Obese: 30 kg/m2 or more Procedure Assessment Protocol: Waist-to-Hip Girth Ratio Skinfold measurements should be made on dry skin, before exercise, on the right side of the body. Equipment The skin should be rmly pinched with the thumb and index nger, and the caliper arms should be • Gulick or other nonelastic measuring tape placed 1 to 2 cm (0.4 to 0.8 in.) away from the thumb and nger, perpendicular to the skinfolds, Procedure and halfway between the crest and base of the fold. Wait 1 to 2 seconds (maximum) before reading Measure the circumference of the waist (the the caliper, and keep the skin pinched while reading narrowest portion of the abdomen) and the hip the caliper. Take duplicate measurements at each (maximum protrusion of the buttocks) in either site and retest if duplicate measurements are not inches or centimeters. Apply adequate tension to within 10%. Rotate through measurement sites or the measuring tape to promote an accurate meas- allow time for skin to regain normal texture and urement of circumference, but the tape should not thickness before taking the duplicate measurement be tight enough to indent the skin. Make certain and any additional retests. Average the two closest the measuring tape is horizontal and parallel to the measurements to the nearest 0.5 cm. oor before taking measurement readings. Based on the formula selected to estimate body density (see table 2.12 near the end of the chap- Scoring ter), choose the number and location of the sites for measuring the skinfolds using the following Determine the client’s waist-to-hip girth ratio by techniques (40): dividing the waist circumference by the hip circum- ference; see table 2.11 near the end of the chapter • Chest: A diagonal fold one-half of the distance for norms for this test. between the anterior axillary line and the nipple for men Assessment Protocol: Skinfold Measurements • Midaxillary: A vertical fold on the midaxillary line at the level of the xiphoid process of the sternum A caliper is used to measure the thickness of a (an alternate method is a horizontal fold taken double fold of skin at various anatomical sites. at the level of the xiphoid–sternal border in the The test relies on the observation that within any midaxillary line) population a certain fraction of the total body fat lies just under the skin (subcutaneous fat), and • Triceps: A vertical fold on the posterior mid- that if one could obtain a representative sample of line of the upper arm, halfway between the the fat, overall body fat (density and composition) acromion and olecranon processes, with the

44 | NSCA’s Essentials of Training Special Populations arm held relaxed to the side of the body in the anterior auxiliary line immediately superior to anatomical position the iliac crest • Subscapular: A diagonal fold (at a 45° angle) • Thigh: A vertical fold on the anterior midline of extending from the vertebral border to a point 1 the thigh, midway between the proximal border to 2 cm (0.4 to 0.8 in.) below the inferior angle of the patella and the inguinal crest (hip) of the scapula • Calf: A vertical fold at the maximum circum- • Abdomen: A vertical fold 2 cm (0.8 in.) to the ference of the calf on the midline of its medial right side of the umbilicus border • Suprailiac: A diagonal fold in line with the Photographs of the common sites are shown natural angle of the iliac crest taken in the in gure 2.9. abc de f gh Figure 2.9 Skinfold measurements: (a) chest skinfold, (b) midaxilla skinfold, (c) triceps skinfold, (d) subscapula skin- fold, (e) abdomen skinfold, (f) suprailium skinfold, (g) thigh skinfold, and (h) medial calf skinfold.

Health Appraisal and Fitness Assessments | 45 Scoring It is recommended that people with implanted de brillators avoid BIA assessment until the safety Use the appropriate formula from table 2.12 to of BIA with these clients has been determined estimate body density (Db) and then use the Siri (22). Also, any substance that alters the body’s equation (% body fat = 495 / Db − 450) where hydration state such as alcohol or diuretics, needed to calculate estimated percent body fat. including caffeine (for clients who do not ingest Percent body fat standards for adults, children, and it on a regular basis), should be avoided for at physically active adults are presented in table 2.13 least 48 hours before the test. (Note that diuretics near the end of the chapter. taken under a physician’s direction should not be stopped, however.) Exercise should be avoided for Assessment Protocol: 12 hours before the test, and clients should avoid Bioelectrical Impedance eating and should drink only enough to maintain hydration during the nal 4 hours before the test Bioelectrical impedance analysis is a simple, quick, (22). A client’s menstrual cycle phase should be noninvasive method that can be used to estimate noted for future testing because of its ability to percentage of body fat. This technique requires alter hydration level. that a small electrical current be sent through the body. This current is undetectable to the person Procedure being tested and is based on the assumption that tissues high in water content (e.g., skeletal muscle) Remove any oil and lotion from the skin with alco- will conduct electrical currents with less resistance hol before placing the electrodes on the skin, if than those with little water (e.g., adipose tissue) necessary. Place the electrodes precisely as directed (22). Because adipose tissue contains little water, by the manufacturer of the impedance device used. fat will impede the ow of electrical current. Incorrect electrode placement greatly reduces the accuracy of the test. There are several types of commercially avail- able BIA devices. Some place electrodes on the Scoring hand and foot; some are handheld devices; and others, which look much like bathroom scales, Percent body fat standards for adults, children, and have contact points at the bottom of the feet. physically active adults are presented in table 2.13. Whatever the design of the machine, as the intro- duced current passes through the body, voltage Neuromuscular Assessments decreases. This voltage drop (impedance) is used to calculate percentage of body fat. Typically, Neuromuscular tests assess balance, coordination, other information such as sex, height, and age and skill and are most useful for testing clients is used in conjunction with impedance to predict with a neuromuscular disability or deficits and percentage of body fat. those who are severely debilitated from chronic disease or are frail, therefore needing specific Bioelectrical impedance analysis has gained assessment and programming (30). wide use in the tness industry because it is easy to use, relatively inexpensive, and noninvasive. Assessment Protocol: Balance The accuracy of this technique depends on the Assessment (37) type of equipment and equations used; however, a standard error of approximately ±4% commonly The Balance Error Scoring System (BESS) is used to is reported (22). In other words, the percentage of evaluate a client’s static postural stability on hard body fat value from BIA is typically within 4% of and soft surfaces. that obtained using hydrostatic weighting, consid- ered the gold standard for body composition. One Equipment problem with the use of BIA is that the relationship between impedance and percentage of body fat • Hard oor surface varies among populations. This means that the best equation to predict percentage of body fat depends • Medium-density foam balance pad (45 cm2 × 13 on the person being tested and the corresponding cm [~18 in.2 × 5 in.] thick with a density of 60 equation used. kg/m3 and a load de ection of 80-90) • Stopwatch

46 | NSCA’s Essentials of Training Special Populations Procedure Functional Performance Assessments Static postural stability is evaluated while the client A wide array of tests and test batteries have been stands in three de ned positions on a hard oor developed to assess various aspects of functional surface and a foam balance pad for a total of six performance. These test batteries vary in their evaluation positions. The foot positions for the total number of tasks, but typically the tasks are BESS are as follows: timed or ranked using a simple scale. Many func- tional performance measures have components • Double-leg support with the feet together and that relate directly to the mobility and strength of parallel to each other an individual. These can be important assessment tools since, as an example, independent-living • Single-leg support while standing only on the individuals who barely surpass these functional nondominant foot with the knee of the domi- thresholds of mobility and strength are at risk for nant leg exed to approximately 90°. future disability (30). • Tandem with the dominant foot in the front and Assessment Protocol: the nondominant foot in the back, with the toes 8-Foot Up-and-Go Test (38) of the nondominant foot touching the heel of the dominant foot Equipment Scoring • Stopwatch While standing in each position, the client must • Folding chair with a 17-inch (43 cm) seat height close her eyes and place hands on hips while attempting to remain as steady as possible for • Tape measure 20 seconds. If the client loses her balance, the exercise professional should instruct her to attempt • Cone to regain the initial position as quickly as possible. Clients are assessed 1 point for each of the fol- Procedure lowing errors: The chair should be placed against a wall and be • Lifting hands off the hips facing the cone. The cone should be placed 8 feet (2.4 m) away from the front edge of the chair. • Opening the eyes The client should be instructed to sit upright in the middle of the chair with his feet at on the • Stepping, stumbling, or falling oor and with hands on knees. When the exercise • Moving the hip into more than 30° of exion professional says “go,” the client gets up from the or abduction chair and walks as quickly as possible around the cone and back to the chair and returns to a seated • Lifting the forefoot or heel position. The exercise professional should start the stopwatch on the “go” signal regardless of • Remaining out of the test position for more whether or not the client has begun moving. The than 5 seconds stopwatch should be stopped as soon as the client has returned to the seated position. The client is A trial is counted as incomplete if the client allowed practice trials before being scored. cannot maintain the position a minimum of 5 seconds, and for each incomplete position the Scoring client receives a maximum of 10 points. During each trial the exercise professional counts the The exercise professional should administer two total number of errors and awards 1 point for test trials and record both times to the nearest tenth each error up to a maximum of 10 errors per of a second. The faster of the two trials is recorded trial. The total number of errors from all six trials as the score. Standards for the test are presented is counted as the overall score. Normative data in table 2.15 near the end of the chapter. for the BESS test are provided in table 2.14 near the end of the chapter.

Health Appraisal and Fitness Assessments | 47 Assessments Speci c to Clients With a Scoring Limited Ability or Restrictions Record the score of each client as total yards (or Although most assessments can be performed by meters) walked in the 6-minute time period. Each clients who have a wide range of fitness levels, lap marker represents 50 yards (46 m), with the dis- some have limited physical ability to complete a tance of the nal partial lap added to the product test or have a medical condition that restricts them of the lap markers × 50 (or × 46 for total meters). from even beginning a test. In either case, there are For example, if a client has collected eight lap valid assessments an exercise professional can use markers (representing eight laps) and stopped next that apply reduced stress on a client when other to the 45-yard (41 m) marker, the score would be procedures are not appropriate or recommended. a total of 445 yards (407 m). Only one trial should be administered per day. Standards for the test are Assessment Protocol: shown in table 2.16 near the end of the chapter. 6-Minute Walk Test (38) Assessment Protocol: Equipment 2-Minute Step Test (38) • Long measuring tape Equipment • Two stopwatches • Four cones • Stopwatch • Masking or painter’s tape • Felt tip marker • Measuring tape or a piece of string or cord • 12 to 15 lap markers per person (ice pop sticks approximately 30 inches (76 cm) long or index cards and pencils to keep track of laps • Masking or painter’s tape walked) • Tally counter Procedure Procedure The area for the test is a rectangle 5 yards (4.6 m) by 20 yards (18 m). The long sides should be marked Determine the minimum step height for each client off in 5-yard (4.6 m) segments identi ed by strips of by nding the midway point between the patella tape, and a cone should be placed at each corner. (kneecap) and the front of the hip (iliac crest). The The cumulative distance of each segment should midway point can be found using a tape measure or be written on the piece of tape. A skilled exercise stretching a piece of string or cord from the middle professional can test up to 12 people at once, using of the patella to the iliac crest and then folding in partners to assist with scoring, but 6 at a time is half. This midway point on the thigh can be tem- more manageable. To keep the clients motivated, porarily marked with a piece of tape. To monitor two or more persons should be tested at a time. step height, have the client stand next to a wall, and transfer the marking tape from the thigh to the On the “go” signal, the exercise professional wall at the same height as it was on the thigh. On starts the two stopwatches and the clients begin the “go” signal the client begins stepping in place walking counterclockwise as fast as possible (not and continues for the 2-minute time period. Use running) around the course, covering as much the tally counter to count the number of times that distance as possible in the 6-minute time limit. the right knee reaches the height of the tape on To keep track of the distance walked, the exercise the wall. If the knee cannot be lifted to the height professional gives a lap marker to each client every of the tape, the client can be asked to slow down time a lap of the course is completed. Clients should (decrease step rate), or to stop to momentarily rest be made aware of the time remaining in the test so the client can resume lifting the knee to the right and be provided with verbal encouragement. At the height (but do not stop the stopwatch). end of the 6-minute test period, clients should stop, stand next to the closest 5-yard (4.6 m) segment Scoring tape marker on their right, and keep moving in place for a 1-minute cooldown. The score is the number of high enough steps completed with the right leg in 2 minutes. Only one trial should be administered per day. Standards for the test are shown in table 2.17 near the end of the chapter.

48 | NSCA’s Essentials of Training Special Populations Assessment Protocol: Assessment Protocol: 30-Second Chair Stand Test (38) 30-Second Arm Curl Test (38) Equipment Equipment • Stopwatch • Stopwatch • Chair with a seat height of approximately 17 • Straight-back or folding chair with no arms inches (43 cm) and preferably with legs that angle forward to prevent tipping • 5-pound (2.3 kg) dumbbell for women Procedure • 8-pound (3.6 kg) dumbbell for men Place the chair securely against a wall to avoid Procedure movement during testing. Instruct the client to sit in the middle of the chair with the back straight, The client should be seated upright on the chair feet at on the oor, and arms crossed at the with her feet at on the oor. The dominant side wrists and held against the chest. On the signal of the client’s body should be located close to the “go,” the client rises to a fully standing position edge of the seat to allow unimpeded movement without using the hands, and then returns to of the dumbbell. The dumbbell should be held a fully seated position. Encourage the client to at the side in the dominant hand using a neutral complete as many full stands as possible in the (handshake) grip with the elbow fully extended. 30 seconds. Before testing, demonstrate proper On the signal “go,” the client curls the dumbbell form, then at a faster pace, to show that the up to a supinated (palms facing up) position and object is to do as many repetitions as one can then lowers the dumbbell to the starting position. within safety limits; then have the client practice Encourage the client to complete as many arm one or two stands to learn and then reinforce curls as possible in the 30 seconds. Before testing, proper form. demonstrate proper form and have the client prac- tice one or two repetitions without the dumbbell Safety Tips to learn and then reinforce proper form. • Brace the chair against the wall or have someone Scoring hold it steady. The score is counted as the total number of repe- • Watch for balance problems. titions in 30 seconds. If the client’s elbow is more than halfway exed at the end of the 30 seconds, it • Stop the test immediately if the client complains counts as the nal repetition. Only one trial should of pain or dizziness. be administered per day. Standards for the test are shown in table 2.19 near the end of the chapter. If clients are unable to perform even one stand without using their hands, allow them to push off Assessment Protocol: their legs or the chair, or use a cane or walker, if Chair Sit-and-Reach Test (38) necessary. If an adaptation such as this is needed, be sure to describe it on the testing sheet. Although Equipment the recorded test score is zero for purposes of comparing to normative standards, indicate the • Chair with a seat height of approximately 17 adapted score so that performance changes can inches (43 cm) and preferably with legs that be evaluated from one test time to the next. angle forward to prevent tipping Scoring • 18-inch (46 cm) ruler or half of a yardstick or meterstick The score is the total number of stands completed in 30 seconds. If a client is more than halfway up Procedure at the end of 30 seconds, it counts as a full stand. Administer only one test trial per day. Standards Place the chair securely against a wall in order to for the test are shown in table 2.18 near the end avoid movement during testing. The assessment of the chapter. begins with the client sitting on the edge of the chair so that the buttocks are even with the front

Health Appraisal and Fitness Assessments | 49 edge of the chair. The knee of one leg should be enhancing a client’s adherence to the program exed with that foot at on the oor and the knee (27). of the other leg fully extended. The heel of the An exercise professional should assist a client extended leg should be placed on the oor with in setting short-, medium-, and long-term goals. the foot exed to approximately 90°. The client The goals of each client vary based on his desired should exhale while slowly exing forward at the training outcomes and individual limitations. waist toward the toes. While exing forward, The acronym SMART can be used to guide the the arms should be outstretched with the hands goal-setting process; it is commonly de ned in overlapping. If the extended knee starts to ex, this way (8): the client should be asked to move slowly back until the knee is fully extended again. The score is S: Speci c recorded as the maximum distance reached and held for 2 seconds. The client should stretch only M: Measurable to the point where slight discomfort from muscle tension is experienced and never to the point A: Action oriented (or achievable) of pain. This test should not be administered to individuals with osteoporosis or lower back pain R: Realistic (or relevant) caused by forward exion of the back. The client should attempt the test with both legs and deter- T: Time-bound (or timed) mine which is preferred, and only the preferred leg is used for test scoring purposes. Another way to characterize goal setting is to say that each goal set should demonstrate the Scoring seven practical principles of effective goal setting (20): The client is allowed two practice trials, and then two test trials are administered. The higher of the 1. Make goals speci c, measurable, and two trials is recorded as the score for the test. The observable. exercise professional measures the distance from the tips of the middle ngers to the top of the shoe 2. Clearly identify time constraints. (to the nearest half-inch or 1 cm). The midpoint at the top of the shoe represents the zero point. If 3. Set moderately dif cult goals. the reach is short of this point, record the distance as a negative (−) score. Standards for the test are 4. Record goals and monitor progress. shown in table 2.20 near the end of the chapter. 5. Diversify process, performance, and out- SMART GOAL SETTING comes. As an exercise professional starts to work with 6. Set short-range goals to achieve medium- a participant (typically after the exercise profes- and long-range goals. sional is hired and under contract), the participant becomes a client. One of the most important steps 7. Make sure goals are internalized (clients to take after the fitness assessment is completed should participate in setting them or should and the results are compared to norms or stand- set their own goals). ards is to set goals based on the deficiencies that are revealed from testing. Using a combination of these approaches and guidelines, the exercise professional should work Exercise professionals use goals in an effort to with each client to de ne goals for an exercise clearly de ne the purpose of an exercise program program. or a speci c exercise session. Goals can affect exercise program outcomes by providing direction MOTIVATIONAL AND and motivation for exercise and stimulating and COACHING TECHNIQUES Motivation is the drive that directs a client’s behavior (39). The exercise professional plays a key role in influencing and encouraging a client’s motivation. Addressing the three basic needs of clients—competence, autonomy, and related- ness—will result in an effective outcome (39):

50 | NSCA’s Essentials of Training Special Populations • Competence is typically met when a person clearance. Tests and assessments can be used to feels successful. evaluate current levels of functional fitness and areas in need of improvement, provide baseline • Autonomy is met when the person feels that measurements for developing an exercise pro- the decision to participate is made without gram, and establish a baseline for comparisons outside pressure or in uence. to future assessments. To evaluate assessment quality, exercise professionals must understand • Relatedness is achieved when the person feels validity, reliability, and accuracy. Test selection connected to and appreciated by others. should be based on the client’s level of functional capacity, chronic disease or disability status, and If the exercise professional can positively in u- fitness goals. Exercise professionals must always ence these three factors, the client is in the best remain keenly aware of potential risks during the position to succeed. assessment process, including risk of falls, and be attentive to signs and symptoms of possible health CONCLUSION problems that require medical referral. Consist- ent and effective test preparation is essential, The proper screening and assessment of clients and accordingly the assessment process should with chronic disease or disabilities is a critical be well structured and implemented using the starting point before testing or implementing an appropriate protocols. Following testing, it is exercise program because it enables the exer- important that the exercise professional present cise professional to educate, train, and motivate the results and explain how those results com- clients. Before developing an exercise program pare to established norms so that SMART short-, for an individual with a chronic disease or dis- medium-, and long-term goals can be set and ability, the exercise professional needs to gather reached through the effective use of motivational relevant information and documentation that and coaching techniques. will be used to assess current levels of health, potential medical risks, and need for medical Key Terms moderate-intensity exercise norm-referenced data angina orthopnea ataxia psppaehlalyokgrVm. Oo2manometer claudication supervised assessment and exercise program criterion-referenced standards syncope cyanosis vigorous-intensity exercise edema ischemia light-intensity exercise medically supervised assessment and exercise program Study Questions 1. An exercise professional is responsible for using which of the following forms for referring clients who may be of increased exercise-related risk of a serious cardiovascular event? a. PAR-Q+ b. informed consent c. medical history d. medical clearance

Health Appraisal and Fitness Assessments | 51 2. When performing assessments in a single session, what is the appropriate test order after nonfatiguing measurements have been performed? a. maximum muscle strength, agility, local muscle endurance, cardiovascular endurance b. cardiovascular endurance, local muscle endurance, agility, maximum muscle strength c. agility, maximum muscle strength, local muscle endurance, cardiovascular endurance d. local muscle endurance, maximum muscle strength, agility, cardiovascular endurance 3. Which of the following statements reflects proper procedure for the back scratch test? a. No practice trial is allowed. b. Both hands are palms up on the back. c. Score the test by measuring the distance or overlap between the hands. d. Both hands should go over the top of the shoulder and attempt to touch in the middle of the back. 4. For a client with extremely limited cardiovascular endurance, which of the following is the most appropriate test for cardiovascular endurance? a. YMCA step test b. 6-minute walk test c. Bruce treadmill test d. YMCA cycle ergometer test Table 2.1 Classification of Blood Pressure for Adults Blood Pressure Classification SBP (mmHg) DBP (mmHg) Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 Hypertension 140-159 or 90-99 Stage 2 Hypertension ≥160 or ≥100 SBP, systolic blood pressure; DBP, diastolic blood pressure Reprinted from National Institutes of Health/National Heart, Lung, and Blood Institute, 2004, The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure (Washington, DC: U.S. Department of Health and Human Services), 12.

Table 2.2 Cardiovascular Endurance Classifications for Adults (in ml · kg−1 · min−1) Age (years) Poor Fair Good Excellent Superior Women 20-29 ≤35 36-38 40-43 44-48 49+ 30-39 ≤33 34-36 37-41 42-46 47+ 40-49 ≤32 33-35 36-38 39-44 45+ 50-59 ≤28 29-31 32-35 36-40 41+ 60-69 ≤26 27-28 29-32 33-36 37+ 70-79 ≤25 26-27 28-29 30-36 37+ Men 20-29 ≤41 42-45 46-49 51-55 56+ 30-39 ≤40 41-43 44-47 48-53 54+ 40-49 ≤37 38-41 42-45 46-52 53+ 50-59 ≤34 35-38 39-42 43-48 49+ 60-69 ≤31 32-34 35-38 39-44 45+ 70-79 ≤28 29-31 32-35 36-42 43+ Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics), 81; Data from Cooper Institute for Aerobics Research 2005. Table 2.3 Time and Intensity Assignments for the Bruce Treadmill Test Stage Time (min) Speed (mph) Speed (km/h) METs Grade (%) 1 1-3 1.7 2.7 4.6 10 2 3-6 2.5 4.0 7.0 12 3 6-9 3.4 5.5 10.2 14 4 9-12 4.2 6.8 12.1 16 5 12-15 5.0 8.0 14.9 18 6 15-18 5.5 8.9 17.0 20 References: (9, 22) 52

Table 2.4 . Equations for Estimating VO2max from the Bruce and Balke-Ware Treadmill Tests Protocol Brucea Population Reference Equation Active and sedentary men Foster et al. (1984) V0..O425m1(atxim=e21)4−.706.−0112.(3ti7m9e(t3i)me) + Balke r = 0.98, SEE = 3.35 (ml · kg−1 · min−1) Active and sedentary women Pollock et al. (1982) Vr.O=2m0.a9x1,=SE4E.3=8(2ti.m7e(m) −l Cardiac patients and elderly McConnell and Clark (1987) 3.90 · min−1) personsb Pollock et al. (1976) · kg−1 Active and sedentary men Pollock et al. (1982) Vr.O=2m0.a8x2,=S2E.E28=24(t.i9m(em) l+· Active and sedentary womenc Vr. O=2m0.a9x2,=SE1.E4 8.545 kg−1 · min−1) 44(time) + 14.99 min−1) = 2.50 (ml · kg−1 · Vr. O=2m0.a9x4,=S1E.E38=(t2im.2e0) + 5.22 · min−1) (ml · kg−1 aFor use with the standard Bruce protocol; cannot be used with modified Bruce protocol. bThis equation is used only for treadmill walking while holding the handrails. cFor women, the Balke protocol was modified: speed 3.0 mph; initial workload 0% grade for 3 min, increasing 2.5% every 3 min thereafter. SEE = standard error of estimate. Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics), 92. Table 2.5 Norms for the YMCA Step Test (Recovery Heart Rate in beats/min) AGE (YEARS) Rating 18-25 26-35 36-45 46-55 56-65 66+ Male Excellent 70-78 73-79 72-81 78-84 72-82 72-86 Good 82-88 83-88 86-94 89-96 89-97 89-95 Above average 91-97 91-97 98-102 99-103 98-101 97-102 Average 101-104 101-106 105-111 109-115 105-111 104-113 Below average 107-114 109-116 113-118 118-121 113-118 114-119 Poor 118-126 119-126 120-128 124-130 122-128 122-128 Very poor 131-164 130-164 132-168 135-158 131-150 133-152 Female Excellent 72-83 72-86 74-87 76-93 74-92 73-86 Good 88-97 91-97 93-101 96-102 97-103 93-100 Above average 100-106 103-110 104-109 106-113 106-111 104-114 Average 110-116 112-118 111-117 117-120 113-117 117-121 Below average 118-124 121-127 120-127 121-126 119-127 123-127 Poor 128-137 129-135 130-138 127-133 129-136 129-134 Very poor 142-155 141-154 143-152 138-152 142-151 135-151 Reprinted, by permission, from J.R. Morrow et al., 2011, Measurement and evaluation in human performance, 4th ed. (Champaign, IL: Human Kinetics), 200. 53

Table 2.6 Work Rates for the YMCA Cycle Ergometer Test Stage Heart rate Heart rate Heart rate Heart rate Stage 2 <80 beats/min 80-89 beats/min 90-100 beats/min >100 beats/min Stage 3 750 kgm/min 600 kgm/min 450 kgm/min 300 kgm/min Stage 4 (2.5 kg) (2.0 kg) (1.5 kg) (1.0 kg) 900 kgm/min 750 kgm/min 600 kgm/min 450 kgm/min Reference: (17) (3.0 kg) (2.5 kg) (2.0 kg) (1.5 kg) 1,050 kgm/min 900 kgm/min 750 kgm/min 600 kgm/min (3.5 kg) (3.0 kg) (2.5 kg) (2.0 kg) Table 2.7 Body Weight-to-Strength Ratio Norms for the 1RM Bench Press Percentile rankings* AGE (YEARS) for men 90 20-29 30-39 40-49 50-59 60+ 80 1.48 1.24 0.89 70 1.32 1.12 1.10 0.97 0.82 60 1.22 1.04 0.77 50 1.14 0.98 1.00 0.90 0.72 40 1.06 0.93 0.68 30 0.99 0.88 0.93 0.84 0.66 20 0.93 0.83 0.63 10 0.88 0.78 0.88 0.79 0.57 0.80 0.71 0.53 Percentile rankings* 0.84 0.75 for women 20-29 30-39 60+ 90 0.54 0.49 0.80 0.71 0.41 80 0.49 0.45 0.38 70 0.42 0.42 0.76 0.68 0.36 60 0.41 0.41 0.32 50 0.40 0.38 0.72 0.63 0.30 40 0.37 0.37 0.29 30 0.35 0.34 0.65 0.57 0.28 20 0.33 0.32 0.26 10 0.30 0.27 AGE (YEARS) 0.25 40-49 50-59 70+ 0.44 0.46 0.40 0.39 0.33 0.40 0.37 0.31 0.27 0.38 0.35 0.25 0.24 0.37 0.33 0.21 0.20 0.34 0.31 0.32 0.28 0.30 0.26 0.27 0.23 0.23 0.19 *Descriptors for percentile rankings: 90 = well above average; 70 = above average; 30 = below average; 10 = well below average. Data for women provided by the Women’s Exercise Research Center, The George Washington University Medical Center, Washington, DC, 1998. Data for men provided by The Cooper Institute for Aerobics Research, The Physical Fitness Specialist Manual, Dallas: The Cooper Institute, 2005. Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics) 162. 54

Table 2.8 Body Weight-to-Strength Ratio Norms for the 1RM Leg Press Percentile rankings* AGE (YEARS) for men 90 20-29 30-39 40-49 50-59 60+ 80 2.27 2.07 1.73 70 2.13 1.93 1.92 1.80 1.62 60 2.05 1.85 1.56 50 1.97 1.77 1.82 1.71 1.49 40 1.91 1.71 1.43 30 1.83 1.65 1.74 1.64 1.38 20 1.74 1.59 1.30 10 1.63 1.52 1.68 1.58 1.25 1.51 1.43 1.16 Percentile rankings* 1.62 1.52 for women 20-29 30-39 60+ 90 2.05 1.73 1.57 1.46 1.40 80 1.66 1.50 1.25 70 1.42 1.47 1.51 1.39 1.18 60 1.36 1.32 1.15 50 1.32 1.26 1.44 1.32 1.08 40 1.25 1.21 1.04 30 1.23 1.16 1.35 1.22 0.98 20 1.13 1.09 0.94 10 1.02 0.94 AGE (YEARS) 0.84 40-49 50-59 70+ 1.27 1.63 1.51 1.12 1.10 1.46 1.30 0.95 0.89 1.35 1.24 0.83 0.82 1.26 1.18 0.79 0.75 1.19 1.09 1.12 1.03 1.03 0.95 0.94 0.86 0.76 0.75 *Descriptors for percentile rankings: 70 = above average; 50 = average; 30 = below average; 10 = well below average. Data for women provided by the Women’s Exercise Research Center, The George Washington University Medical Center, Washington, DC, 1998. Data for men provided by The Cooper Institute for Aerobics Research, The Physical Fitness Specialist Manual, Dallas: The Cooper Institute, 2005. Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics) 163. Table 2.9 Norms for the Partial Curl-Up Test AGE (YEARS) 15-19 20-29 30-39 40-49 50-59 60-69 Men 25 25 25 25 25 25 Excellent 23-24 21-24 18-24 18-24 17-24 16-24 Very good 21-22 16-20 15-17 13-17 11-16 11-15 Good 16-20 11-15 11-14 6-12 8-10 6-10 Fair ≤15 ≤10 ≤10 ≤5 ≤7 ≤5 Needs improvement Women 25 25 25 25 25 25 Excellent 22-24 18-24 19-24 19-24 19-24 17-24 Very good 17-21 14-17 10-18 11-18 10-18 8-16 Good 12-16 5-13 6-9 4-10 6-9 3-7 Fair ≤11 ≤4 ≤5 ≤3 ≤5 ≤2 Needs improvement Source: Canadian Physical Activity, Fitness & Lifestyle Approach: CSEP-Health & Fitness Program’s Appraisal and Counselling Strategy, 3rd edition, © 2003. Reprinted with permission from the Canadian Society for Exercise Physiology. 55

Table 2.10 Norms for the Sit-and-Reach Test* AGE (YEARS) 15-19 20-29 30-39 40-49 50-59 60-69 Men ≥39 ≥40 ≥38 ≥35 ≥35 ≥33 Excellent 34-38 34-39 33-37 29-34 28-34 25-32 Very good 29-33 30-33 28-32 24-28 24-27 20-24 Good 24-28 25-29 23-27 18-23 16-23 15-19 Fair ≤23 ≤24 ≤22 ≤17 ≤15 ≤14 Needs improvement Women ≥43 ≥41 ≥41 ≥38 ≥39 ≥35 Excellent 38-42 37-40 36-40 34-37 33-38 31-34 Very good 34-37 33-36 32-35 30-33 30-32 27-30 Good 29-33 28-32 27-31 25-29 25-29 23-26 Fair ≤28 ≤27 ≤26 ≤24 ≤24 ≤22 Needs improvement *Distance measured in centimeters using a sit-and-reach box with the zero point at 26 cm. If using a box with the zero point at 23 cm, subtract 3 cm from each value in this table. Source: Canadian Physical Activity, Fitness & Lifestyle Approach: CSEP-Health & Fitness Program’s Appraisal and Counselling Strategy, 3rd edition, © 2003. Reprinted with permission from the Canadian Society for Exercise Physiology. Table 2.11 Norms for Waist-to-Hip Girth Ratio Age Low Moderate RISK Very high High 20-29 <0.83 >0.94 Men 30-39 <0.84 0.83-0.88 0.89-0.94 >0.96 Women 40-49 <0.88 0.84-0.91 0.92-0.96 >1.00 50-59 <0.90 0.88-0.95 0.96-1.00 >1.02 60-69 <0.91 0.90-0.96 0.97-1.02 >1.03 0.91-0.98 0.99-1.03 20-29 <0.71 >0.82 30-39 <0.72 0.71-0.77 0.78-0.82 >0.84 40-49 <0.73 0.72-0.78 0.79-0.84 >0.87 50-59 <0.74 0.73-0.79 0.80-0.87 >0.88 60-69 <0.76 0.74-0.81 0.82-0.88 >0.90 0.76-0.83 0.84-0.90 Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Human Kinetics) 257; Data from G.A. Bray and D.S. Gray, 1988, \"Obesity - Part I - Pathogenesis,\" The Western Journal of Medicine 149:429-441. 56

Table 2.12 Body Composition Skinfold Prediction Equations SKF sites Population subgroups Equation Reference ∑7SKF (chest + abdomen + Black or Hispanic women, thigh + triceps + subscapular 18-55 years Db (g·cc−1)a = 1.0970 − Jackson et al. (1980) + suprailiac + midaxilla) Black men or male athletes, 0.00046971(∑7SKF) + 18-61 years 0.00000056(∑7SKF)2 − ∑4SKF (triceps + anterior Female athletes, 18-29 years 0.00012828(age) suprailiac + abdomen + thigh) ∑3SKF (triceps + suprailiac + White or anorexic women, Db (g·cc−1)a = 1.1120 − Jackson and Pollock (1978) thigh) 18-55 years 0.00043499(∑7SKF) + ∑3SKF (chest + abdomen + White men, 18-61 years 0.00000055(∑7SKF)2 − thigh) 0.00028826(age) ∑3SKF (abdomen + Black or white collegiate male thigh + triceps) and female athletes, 18-34 Db (g·cc−1)a = 1.096095 Jackson et al. (1980) ∑2SKF (triceps + calf) years − 0.0006952(∑4SKF) + Black or white boys, 6-17 years 0.0000011(∑4SKF)2 − Black or white girls, 6-17 years 0.0000714(age) Db (g·cc−1)a = 1.0994921 Jackson et al. (1980) − 0.0009929(∑3SKF) + 0.0000023(∑3SKF)2 − 0.0001392(age) Db (g·cc−1)a = 1.109380 Jackson and Pollock (1978) − 0.0008267(∑3SKF) + 0.0000016(∑3SKF)2 − 0.0002574(age) %BF = 8.997 + 0.2468(∑3SKF) Evans et al. (2005) − 6.343(genderb) − 1.998(racec) %BF = 0.735(∑2SKF) + 1.0 Slaughter et al. (1988) %BF = 0.610(∑2SKF) + 5.1 ∑SKF = sum of skinfolds (mm). aUse population-specific conversion formulas to calculate %BF (percent body fat) from Db (body density). bMale athletes = 1; female athletes = 0. cBlack athletes = 1; white athletes = 0. Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics), 237. 57

Table 2.13 Percent Body Fat Standards for Adults, Children, and Physically Active Adults RECOMMENDED %BF* LEVELS FOR ADULTS AND CHILDREN NR* Low Mid High Obesity Males <5 5-10 11-25 26-31 >31 6-17 years <8 18-34 years <10 8 13 22 >22 35-55 years <10 55+ years 10 18 25 >25 Females <12 6-17 years <20 10 16 23 >23 18-34 years <25 35-55 years <25 12-15 16-30 31-36 >36 55+ years 20 28 35 >35 Males 18-34 years 25 32 38 >38 35-55 years 55+ years 25 30 35 >35 Females 18-34 years RECOMMENDED %BF LEVELS FOR PHYSICALLY ACTIVE ADULTS 35-55 years 55+ years Low Mid Upper 5 10 15 7 11 18 9 12 18 16 23 28 20 27 33 20 27 33 *NR = not recommended; %BF = percent body fat. Data from Lohman, Houtkooper, and Going 1997. Reprinted, by permission, from V.H. Heyward and A.L. Gibson, 2014, Advanced tness assessment and exercise prescription, 7th ed. (Champaign, IL: Human Kinetics), 220. 58

Table 2.14 Norms for the Balance Error Scoring System (BESS) Test Classificationa Superior Above average Broadly normal Below average Poor Very poor Men 20-29 yearsb 0-4 5-6 7-14 15 16-21 22+ 30-39 years 0-4 5-6 7-15 16-18 19-26 27+ 40-49 years 0-5 6-7 8-16 17-20 21-27 28+ 50-54 years 0-6 7 8-17 18-23 24-28 29+ 55-59 years 0-7 8-10 11-20 21-28 29-34 35+ 60-64 years 0-8 9-11 12-21 22-27 28-35 36+ 65-69 years 0-12 13-14 15-23 24-33 34-39 40+ Women 20-29 yearsb 0-5 6-7 8-14 15-19 20-25 26+ 30-39 years 0-4 5-6 7-15 16-19 20-27 28+ 40-49 years 0-5 6-7 8-15 16-20 21-29 30+ 50-54 years 0-7 8-9 10-20 21-24 25-35 36+ 55-59 years 0-8 9-10 11-21 22-28 29-39 40+ 60-64 years 0-9 10-12 13-22 23-31 32-43 44+ 65-69 yearsb 0-13 14 15-24 25-27 28-38 39+ aThese classification ranges correspond to the following percentile ranks: superior: >90th percentile; above average: 76th to 90th percentile; broadly normal: 25th to 75th percentile; below average: 10th to 24th percentile; poor: 2nd to 9th percentile; very poor: <2nd percentile. bUnusually small sample sizes limit the usefulness of these normative reference values. Adapted from G.L. Iverson and M.S. Koehle, 2013, “Normative data for the balance error scoring system in adults,” Rehabilitation Research and Practice 1-5. Copyright © 2013 Grant L. Iverson and Michael S. Koehle. This is an open access article distributed under the Creative Commons Attribution License 3.0. 59

Table 2.15a Standards for the 8-Foot Up-and-Go Test for Women (in Seconds) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 3.2 3.6 3.8 4.5 5.0 85 3.7 4.1 4.0 4.0 4.0 4.7 5.3 80 4.0 4.4 4.3 5.3 6.1 75 4.2 4.6 4.7 4.3 4.4 5.8 6.7 70 4.4 4.8 4.9 6.2 7.3 65 4.6 5.0 5.2 4.6 4.9 6.6 7.7 60 4.7 5.1 5.4 6.9 8.2 55 4.9 5.3 5.6 5.0 5.4 7.3 8.6 50 5.0 5.4 5.8 7.6 9.0 45 5.2 5.6 6.0 5.2 5.7 7.9 9.4 40 5.4 5.8 6.2 8.2 9.8 35 5.5 5.9 6.4 5.5 6.1 8.5 10.2 30 5.7 6.1 6.6 8.9 10.6 25 5.8 6.2 6.8 5.7 6.3 9.2 11.1 20 6.0 6.4 7.1 9.6 11.5 15 6.2 6.6 7.3 5.9 6.7 10.0 12.1 10 6.4 6.8 7.7 10.5 12.7 5 6.7 7.1 8.0 6.1 6.9 11.1 13.5 7.2 7.6 8.6 12.0 14.6 6.3 7.2 6.5 7.5 6.7 7.8 6.9 8.1 7.1 8.3 7.4 8.7 7.6 9.0 8.0 9.5 8.3 10.0 8.9 10.8 Table 2.15b Standards for the 8-Foot Up-and-Go Test for Men (in Seconds) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 3.0 3.1 3.2 4.0 4.3 85 3.0 3.6 3.6 3.3 4.0 4.3 4.5 80 3.3 3.9 3.9 4.5 5.1 75 3.6 4.1 4.2 3.5 4.1 5.0 5.7 70 3.8 4.3 4.4 5.5 6.2 65 4.0 4.5 4.6 3.9 4.5 5.8 6.6 60 4.2 4.6 4.8 6.2 7.0 55 4.4 4.8 5.0 4.3 4.9 6.5 7.4 50 4.5 4.9 5.1 6.9 7.7 45 4.7 5.1 5.3 4.6 5.2 7.2 8.1 40 4.9 5.3 5.5 7.5 8.5 35 5.0 5.4 5.6 4.9 5.5 7.9 8.8 30 5.2 5.6 5.8 8.2 9.2 25 5.4 5.7 6.0 5.2 5.7 8.6 9.6 20 5.6 5.9 6.2 8.9 10.0 15 5.8 6.1 6.4 5.4 6.0 9.4 10.5 10 6.1 6.3 6.7 9.9 11.1 5 6.4 6.6 7.0 5.7 6.2 10.5 11.8 6.8 7.1 7.4 11.5 12.9 5.9 6.4 6.1 6.6 6.4 6.9 6.6 7.1 6.9 7.3 7.2 7.6 7.5 7.9 7.9 8.3 8.3 8.7 9.0 9.4 Reprinted, by permission, from R.E. Rikli and C. J. Jones, 2013, Senior tness test manual, 2nd ed. (Champaign, IL: Human Kinetics), 160. 60

Table 2.16a Standards for the 6-Minute Walk Test for Women (in Yards) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 741 734 709 638 564 85 711 697 673 696 654 591 518 80 690 673 650 560 488 75 674 653 630 655 612 534 463 70 659 636 614 512 441 65 647 621 599 628 584 493 423 60 636 607 586 476 406 55 624 593 572 605 560 458 388 50 614 581 561 443 373 45 603 568 548 585 540 426 357 40 592 555 535 409 341 35 582 543 524 568 523 394 326 30 570 529 510 376 308 25 559 515 497 553 508 359 291 20 547 500 482 340 273 15 532 483 466 538 491 318 251 10 516 463 446 292 226 5 495 439 423 524 477 261 196 465 402 387 214 150 509 462 494 447 480 433 465 416 450 401 433 384 413 364 390 340 363 312 322 270 Table 2.16b Standards for the 6-Minute Walk Test for Men (in Yards) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 825 800 779 710 646 85 792 763 743 762 721 659 592 80 770 738 718 625 557 75 751 718 698 716 678 596 527 70 736 700 680 572 502 65 722 685 665 686 649 551 480 60 710 671 652 532 461 55 697 657 638 661 625 512 440 50 686 644 625 495 422 45 674 631 612 639 604 477 403 40 662 618 599 459 384 35 651 605 586 621 586 442 366 30 638 591 572 422 345 25 626 577 559 604 571 403 326 20 612 562 544 382 304 15 597 544 526 586 554 358 279 10 578 524 506 329 249 5 556 499 481 571 540 295 214 523 462 445 244 160 555 524 539 508 524 494 506 477 489 462 471 444 449 423 424 399 394 370 348 327 Reprinted, by permission, from R.E. Rikli and C. J. Jones, 2013, Senior tness test manual, 2nd ed. (Champaign, IL: Human Kinetics), 156. 61

Table 2.17a Standards for the 2-Minute Step Test for Women (in Steps) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 130 133 125 106 92 85 122 123 116 123 113 98 85 80 116 117 110 93 80 75 111 112 105 115 104 88 76 70 107 107 101 85 72 65 103 104 97 109 99 81 69 60 100 100 94 79 66 55 97 96 90 104 94 76 63 50 94 93 87 73 61 45 91 90 84 100 90 70 58 40 88 87 81 67 55 35 85 84 78 96 87 64 53 30 82 80 74 61 50 25 79 76 71 93 84 59 47 20 75 73 67 55 44 15 71 68 63 90 81 52 40 10 66 63 58 47 36 5 60 57 52 87 78 42 31 52 47 43 39 24 84 75 81 72 78 69 75 66 72 63 68 60 64 56 59 51 53 46 45 37 Reprinted, by permission, from R.E. Rikli and C. J. Jones, 2013, Senior tness test manual, 2nd ed. (Champaign, IL: Human Kinetics), 157. Table 2.17b Standards for the 2-Minute Step Test for Men (in Steps) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 135 139 133 114 112 85 128 130 124 135 126 106 102 80 123 125 119 100 96 75 119 120 114 126 118 95 91 70 115 116 110 91 86 65 112 113 107 119 112 87 83 60 109 110 104 84 79 55 106 107 101 114 107 81 76 50 104 104 98 78 72 45 101 101 95 109 103 75 69 40 98 98 92 72 66 35 96 95 89 105 99 69 62 30 93 92 86 66 59 25 90 89 83 102 96 63 55 20 87 86 80 59 52 15 83 82 76 98 93 55 47 10 79 77 71 50 42 5 74 72 66 95 90 44 36 67 67 67 36 26 91 87 87 84 84 81 80 78 77 75 73 71 68 67 63 62 56 56 47 48 Reprinted, by permission, from R.E. Rikli and C. J. Jones, 2013, Senior tness test manual, 2nd ed. (Champaign, IL: Human Kinetics), 157. 62

Table 2.18a Standards for the 30-Second Chair Stand Test for Women (Number of Repetitions) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 21 19 19 17 16 85 20 18 18 19 18 15 15 80 19 17 17 14 13 75 18 16 16 17 17 14 12 17 16 15 13 11 70 16 16 65 17 15 15 12 11 60 16 15 14 16 15 12 10 55 16 14 14 11 9 50 15 14 13 15 14 11 9 45 15 14 13 10 8 40 14 13 12 14 13 10 7 35 14 13 12 9 7 30 13 12 11 14 13 9 6 25 12 12 11 8 5 20 12 11 10 13 12 8 4 15 11 11 10 7 4 10 10 10 9 13 12 6 3 5 9 9 8 5 1 8 8 7 12 11 4 0 12 11 12 10 11 10 11 9 10 9 98 97 86 64 Table 2.18b Standards for the 30-Second Chair Stand Test for Men (Number of Repetitions) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 23 23 21 19 16 85 22 21 20 21 19 17 15 80 21 20 19 16 14 75 20 19 18 20 17 15 13 70 19 18 17 14 12 65 19 18 17 18 16 13 12 60 18 17 16 13 11 55 17 16 16 18 16 12 11 50 17 16 15 12 10 45 16 15 14 17 15 11 10 40 16 15 14 11 9 35 15 14 13 16 14 10 9 30 15 13 13 9 8 25 14 13 12 16 14 9 8 20 14 12 12 8 7 15 13 11 11 15 13 7 7 10 12 11 10 6 6 5 11 9 9 15 13 5 5 9 8 8 4 3 14 12 13 12 13 11 12 11 12 10 11 10 10 9 10 8 87 76 Reprinted, by permission, from R.E. Rikli and C. J. Jones, 2013, Senior tness test manual, 2nd ed. (Champaign, IL: Human Kinetics), 154. 63

Table 2.19a Standards for the 30-Second Arm Curl Test for Women (Number of Repetitions) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 24 22 22 18 17 85 22 21 20 21 20 17 16 80 21 20 19 16 15 75 20 19 18 20 18 15 14 70 19 18 17 15 13 65 18 17 17 19 17 14 13 60 18 17 16 14 12 55 17 16 16 18 16 13 12 50 17 16 15 13 11 45 16 15 14 17 16 12 11 40 16 15 14 12 10 35 15 14 13 16 15 11 10 30 14 14 13 11 9 25 14 13 12 16 15 10 9 20 13 12 12 10 8 15 12 12 11 15 14 9 8 10 11 11 10 8 7 5 10 10 9 15 14 7 6 9 8 8 6 5 14 13 13 12 13 12 12 11 12 11 11 10 10 10 99 88 76 Table 2.19b Standards for the 30-Second Arm Curl Test for Men (Number of Repetitions) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 27 27 26 21 18 85 25 25 24 24 23 19 16 80 24 24 23 18 16 75 23 23 22 22 22 17 15 70 22 21 21 17 14 65 21 21 20 21 20 16 14 60 21 20 19 15 13 55 20 20 19 20 20 15 13 50 20 19 18 14 12 45 19 18 17 19 19 14 12 40 18 18 17 13 12 35 18 17 16 19 18 13 11 30 17 16 15 12 11 25 17 16 15 18 18 11 10 20 16 15 14 11 10 15 15 14 13 17 17 10 9 10 14 13 12 9 8 5 13 12 11 17 17 8 8 11 10 9 7 6 16 16 16 15 15 15 14 14 14 14 13 13 12 12 11 12 10 10 99 Reprinted, by permission, from R.E. Rikli and C. J. Jones, 2013, Senior tness test manual, 2nd ed. (Champaign, IL: Human Kinetics), 155. 64

Table 2.20a Standards for the Chair Sit-and-Reach Test for Women (in Inches) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 8.7 7.9 7.5 6.0 4.9 85 7.2 6.6 6.1 7.4 6.6 4.6 3.4 80 6.3 5.7 5.2 3.7 2.5 75 5.5 5.0 4.5 6.1 5.2 3.0 1.7 70 4.8 4.4 3.9 2.4 1.0 65 4.2 3.9 3.3 5.2 4.3 1.8 0.4 60 3.7 3.4 2.8 1.3 −0.1 55 3.1 2.9 2.3 4.4 3.6 0.8 −0.7 50 2.6 2.5 1.9 0.4 −1.2 45 2.1 2.0 1.4 3.7 3.0 −0.1 −1.7 40 1.6 1.5 0.9 −0.6 −2.2 35 1.1 1.1 0.5 3.2 2.4 −1.0 −2.7 30 0.5 0.6 0.0 −1.5 −3.3 25 0.0 0.1 −0.5 2.7 1.9 −2.0 −3.8 20 −0.6 −0.4 −1.1 −2.6 −4.4 15 −1.3 −1.0 −1.7 2.1 1.4 −3.2 −5.1 10 −2.1 −1.7 −2.4 −3.9 −5.9 5 −3.0 −2.6 −3.3 1.7 1.0 −4.8 −6.8 −4.0 −3.9 −4.7 −6.3 −7.9 1.2 0.5 0.7 0.0 0.2 −0.4 −0.3 −0.9 −0.8 −1.4 −1.3 −2.0 −2.0 −2.6 −2.8 −3.3 −3.7 −4.2 −5.0 −5.0 Table 2.20b Standards for the Chair Sit-and-Reach Test Men (in Inches) Percentile AGE (YEARS) rank 95 60-64 65-69 70-74 75-79 80-84 85-89 90-94 90 8.5 7.5 7.5 4.5 3.5 85 6.7 5.9 5.8 6.6 6.2 3.0 1.9 80 5.6 4.8 4.7 2.0 0.9 75 4.6 3.9 3.8 4.9 4.4 1.1 0.0 70 3.8 3.1 3.0 0.4 −0.7 65 3.1 2.4 2.4 3.8 3.2 −0.2 −1.4 60 2.5 1.8 1.8 −0.8 −1.9 55 1.8 1.1 1.1 2.8 2.2 −1.3 −2.5 50 1.2 0.6 0.6 −1.9 −3.0 45 0.6 0.0 0.0 2.0 1.4 −2.4 −3.6 40 0.0 −0.6 −0.6 −2.9 −4.2 35 −0.6 −1.1 −1.2 1.3 0.6 −3.5 −4.7 30 −1.3 −1.8 −1.8 −4.0 −5.3 25 −1.9 −2.4 −2.4 0.7 0.0 −4.6 −5.8 20 −2.6 −3.1 −3.1 −5.2 −6.5 15 −3.4 −3.9 −3.9 0.1 −0.8 −5.9 −7.2 10 −4.4 −4.8 −4.8 −6.8 −8.1 5 −5.5 −5.9 −5.9 −0.5 −1.4 −7.8 −9.1 −7.3 −7.5 −7.6 −9.3 −10.7 −1.1 −2.0 −1.7 −2.6 −2.3 −3.2 −2.9 −4.0 −3.5 −4.6 −4.2 −5.3 −5.0 −6.2 −6.0 −7.2 −7.1 −8.4 −8.8 −10.2 Reprinted, by permission, from R.E. Rikli and C. J. Jones, 2013, Senior tness test manual, 2nd ed. (Champaign, IL: Human Kinetics), 158. 65

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Musculoskeletal 3 Conditions and Disorders Carwyn Sharp, PhD, CSCS,*D After completing this chapter, you will be able to ◆ describe the pathophysiology of low back pain, posture conditions, osteoporosis and osteopenia, osteoarthritis, joint disorders, joint replacements, frailty, and sarcopenia; ◆ understand the major medication groups and their effects on individuals and the exercise response for those with these musculoskeletal conditions and disorders; ◆ explain the effects of different exercise modalities on individuals with low back pain, posture conditions, osteoporosis and osteopenia, osteoarthritis, joint disorders, joint replacements, frailty, and sarcopenia; and ◆ recognize appropriate exercise programming, precautions, and contraindications for individuals with low back pain, posture conditions, osteoporosis and osteopenia, osteoarthritis, joint disorders, joint replacements, frailty, and sarcopenia. 67

68 | NSCA’s Essentials of Training Special Populations This chapter describes a number of significant accepted clinical definition challenging. Thus low musculoskeletal limitations to healthy movement, back pain (LBP) is generally defined as “pain and physical activity, and exercise participation, discomfort, localized below the costal margin and which in turn affect overall health, morbidity, and above the inferior gluteal folds, with or without leg mortality. The underlying causes and risk factors pain” (157) (figure 3.1). Low back pain may be the of these conditions are outlined to provide the result of a known trauma or pathology, or more exercise professional with an understanding of the commonly, may have an idiopathic (i.e., unknown roles of exercise in the prevention, management, cause or origin) etiology, which is referred to as and treatment of symptoms. How the exercise nonspecific LBP. In conjunction, nonspecific LBP professional can develop and implement effective is characterized by the duration of persistent and safe training programs for these individuals symptoms: acute (<6 weeks); subacute (6 to 12 is then discussed. Included in this chapter are weeks); or chronic (12+ weeks) (157). low back pain, posture conditions, osteoporosis and osteopenia, osteoarthritis, joint disorders, The prevalence of LBP in developed countries joint replacements, frailty, and sarcopenia. As is pervasive, with an estimated lifetime preva- with other diseases and disabilities described in lence of 58% to 70% (111, 144, 161); prevalence this text, when developing a training program rates increase with advancing age (45, 66). The for individuals with one or more of these con- direct and indirect economic costs of LBP in the ditions, the exercise professional must not only United States have been estimated as $12.2 to understand the given disorder, but also be aware $90.6 billion and $7.4 to $28.17 billion per year, of and address other comorbidities that may be respectively (40). The wide variance in these esti- present and their accompanying treatment plans. mates has been attributed to the methodological differences employed by the various researchers, DISORDERS OF THE which may be further confounded by a lack of an SPINE AND ASSOCIATED accepted de nition (40). It is important to note, however, that the costs associated with LBP are MUSCULATURE substantial and include a combination of medical of ce visits, diagnostic tests, medications, surgery, Disorders of the spine and associated musculature travel costs to medical appointments, and lost are relatively common in Western countries such wages and productivity. Thus the high prevalence as the United States. However, they are complex of this condition and its costs to the individual and varied in onset, cause(s), and symptomatology and society are signi cant. between individuals and the disorders themselves, often leading to the disorders being defined based Pathophysiology of Low Back Pain on general features. The difficulties in determining the exact etiology and symptoms result in largely Low back pain and nonspecific LBP in particular individualized approaches to treatment, with exer- often have a complex, highly variable etiology, cise prescription recommendations that reflect an which has been associated with a number of integrated team strategy encompassing medical, factors including, but not limited to, age, sex, health, and exercise professionals. The conditions height, weight, low physical fitness, smoking, discussed next, low back pain and posture disor- and poor general health (140). In conjunction, ders, are examples of the more common afflictions studies have shown that various occupational described in the literature; thus the exercise pro- factors such as high physical demands, lifting fessional is more likely to see individuals suffering and forceful movements, and whole-body vibra- from these versus others over their career. tion may contribute 28% to 50% of reported low back issues (140). Differences in pathophysiology Low Back Pain or spinal abnormalities—affecting one or more spinous structures, various intervertebral joints or Low back pain has a complex and often individu- discs, musculature, or neural components leading alized etiology, making a specific and universally to inflammation, swelling, and pain in one or more of these areas—can also contribute to the

Musculoskeletal Conditions and Disorders | 69 Nipple line Inferior scapular tip Costal margin Posterior axillary line Anterior axillary line Inguinal ligament Iliac crest Inferior gluteal fold Figure 3.1 Low back pain is generally de ned as a localized pain or ache below the costal margin and above the inferior gluteal foldEs4. 822/NSCA Special Populations/Fig. 03.01/532510/HR/KH-R2 development of LBP and the high degree of vari- responses to physical activity (1, 140) but may ability in symptom severity and recurrence (141). impair the postexercise skeletal muscle protein synthetic response (153). Ingestion of NSAIDs Key Point can also result in gastrointestinal (GI) irritation or bleeding if they are taken for prolonged periods Low back pain is highly variable and complex or at higher than recommended doses; acetami- in etiology and is most commonly of unknown nophen may similarly cause GI discomfort such cause or origin. Symptom severity and recurrence as stomach pain and in rare cases may lead to GI are also highly variable, making an individualized bleeding or negatively affect hepatic and renal treatment plan essential. functioning (159). It should also be noted that in 2015 the U.S. Food and Drug Administration Common Medications Given to (FDA) updated and strengthened its warning Individuals With Low Back Pain that the use of NSAIDs increases the risk of heart attack and stroke and that these risks increase Various over-the-counter (OTC) and prescription with high doses and longer use (158). Topical cap- medications are prescribed for and used by indi- sicum plasters, another OTC medication, may also viduals with LBP (see medications table 3.1 near provide pain relief for individuals with LBP and the end of the chapter) (1, 157). Over-the-counter appear to have no impact on exercise capacity (1). nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (e.g., Advil and Motrin) and Individuals with LBP may also use anti- naproxen (e.g., Aleve) may reduce inflammation, spasmodic muscle relaxants such as Valium swelling, and mild pain. Over-the-counter non- in conjunction with or in isolation from other opioid analgesics such as acetaminophen (e.g., medications and may suffer from dizziness and Tylenol) are mild to moderate pain relievers that drowsiness as a result. This class of medication is are also often used by those with LBP. If used as typically prescribed to be taken before sleep and directed, both NSAIDs and nonopioid analgesics should have little effect on exercise capacity the have minimal side effects and impact on the acute following day, but communication with clients to verify is essential. Those individuals prescribed

70 | NSCA’s Essentials of Training Special Populations antidepressants, the most common class of which strength, trunk mobility, and aerobic conditioning is selective serotonin reuptake inhibitors (SSRIs) are common modalities for chronic nonspecific (e.g., Prozac, Zoloft, and Paxil), may experience LBP treatment, systematic reviews of the scientific numerous side effects such as nausea, dizziness, literature have failed to show strong correlations drowsiness, and headaches; however, these are or predictive capacity between these proposed less severe than with other classes and do not causes and the condition itself (140). These find- appear to affect the response to exercise (112). ings may be a product of the high variability in People who experience these side effects should the methodologies employed in the research of talk with their physician about timing, such as this area or the highly variable and individualized in the evening before sleep, so as to facilitate nature of symptoms. In any case, what is currently engagement in a physical activity program during evident is that exercise is more efficacious than the day. rest, so in the absence of specific guidelines, it is recommended that exercise professionals refer to Few research studies are available on whether the generally accepted guidelines adopted by the oral opiates to treat the symptoms of nonspeci c U.S. Department of Health and Human Services LBP have any negative effects on exercise capacity; (DHHS) in 2008 for developing exercise workouts however, some evidence suggests that opiates may and programs for adults with LBP (156). However, affect hand–eye coordination (2), and this should the exercise prescription must be individualized be taken into account. Long-term use of SSRIs in its implementation and progression to reflect and opiates is not recommended, as the list of the limitations, strengths, weaknesses, and goals side effects increases as does their physiological of the client for successful development of health, impact. fitness, and function. Exercise professionals should also be aware Exercise Recommendations for Clients that normal aging affects pharmacodynamics and With Low Back Pain that older adults with LBP are at a greater risk than others for side effects from medications taken for With this in mind, testing and assessment for this condition; this may be further complicated trunk strength, muscular endurance, and mobil- by other medications that are being taken con- ity, as well as general aerobic capacity, may be comitantly (30). considered before initiating a training program. In conjunction, a medical clearance should be Effects of Exercise in Individuals With required before testing to ensure there are no Low Back Pain structural limitations to exercise. Low back pain and nonspecific LBP often result Program design guidelines for clients with LBP in a reduction in levels of physical activity, which are summarized in table 3.1. The recommenda- may or may not be a result of physical impairment tions for a resistance training program to improve or disability (88). As such, a key aspect in the overall muscular strength and endurance, and treatment of this condition is education regarding in particular abdominal and lumbar extensor the efficacy of physical activity in both the treat- strength, are two to four sets (one set if the client ment and management of the condition, as well as is sedentary or low in conditioning) of 8 to 12 improving general health and physical function- repetitions per exercise at an initial light to mod- ing. The research examining the roles of exercise erate intensity, one or two times per week (156). for individuals with LBP has focused on either a Flexibility training should aim to increase trunk, biomedical impairment or a general conditioning hip exor, and extensor mobility via three repe- model (140). The biomedical impairment model titions of 10-second static hold for each exercise reflects the assumption that the condition is a (141). Recommendations for aerobic exercise (e.g., function of insufficient trunk strength, mobility, brisk walking) are to engage large muscle groups or both, whereas the general conditioning model at an initial light to moderate intensity for at least assumes that deconditioning is a significant 10 minutes three or more times per day on three underlying contributor. However, while trunk

Musculoskeletal Conditions and Disorders | 71 or more days per week, progressing to at least 300 if there is an increase in lower back pain, with minutes of moderate or 150 minutes of vigorous possible referral to a physician or other health (or an equivalent combination of both intensities) care professional depending on the severity and per week. Exercise should cease immediately duration of the increased pain. Table 3.1 Program Design Guidelines for Clients With Low Back Pain Type of exercise Frequency Intensity Volume Resistance training Begin with one or two sessions Begin with light to moderate Start with 1 set per exercise of Aerobic training per week intensity (40-80% one 8-12 reps Modes: walking, jogging, Increase to two or more repetition maximum [1RM]), Increase to 2-4 sets per running, swimming, other sessions per week as tolerated using multijoint exercises exercise as appropriate aquatic exercise to engage all major muscle groups Reference: (156) Progress to moderate to high intensity with 1-2 min rest between sets Begin with at least three Bionretgehniensaiwrttyirt(ah3t0lei%grhetstoetor<vme60oo%dr e5rV5.aO%te2 Begin with at least 10 min per sessions per week to <75% maximal heart rate session three or more times [MHR], or RPE of 9-13 on Borg per day Progress to four or more 6- to 20-point scale) 300 min per week sessions a week M<or6o60d5%e%raV.ttOeo2i<on7rte5hn%esaitrMyt Hr(4aRt0,e%orretsRoePrEve 150 min per week OR of 12-13 on Borg 6- to 20-point Three or more sessions a week osVcrigahloeer)aorutsraintteernessietyrv(e≥6o0r%≥7V5. O%2 MHR, or RPE of ≥14 on Borg 6- to 20-point scale) Case Study Low Back Pain Mr. Y, 41 years old, has had persistent dull pain his lower back. He was able to stand but with on the left aspects of his lower back for 14 weeks. considerable pain and stiffness. Mr. Y has taken He is an of ce administrator who sits at his acetaminophen intermittently for pain relief desk for almost 8 hours each day. The onset of ever since and uses a heating pad for relief also. pain occurred while he was play wrestling with Flexion of the spine, such as in picking up his his four children, when he felt a sharp pain in children, heightens the pain; and although the (continued)

72 | NSCA’s Essentials of Training Special Populations Low Back Pain (continued) tion exercise, for an initial four-week phase. The exercise professional also added trunk, hip pain has subsided it is still present, sometimes radiating down his left leg. Before his injury Mr. exor, and extensor mobility exercises before Y had been inconsistently running and doing each resistance and aerobic session, which Mr. Y resistance exercise a total of one or two times had not been doing previously. After this initial per week over the past year. phase, the exercise professional will reassess symptoms, trunk strength, muscular endurance, With this medical and tness history, and and mobility, as well as general aerobic capacity, following clearance from Mr. Y’s physician or to determine the ef cacy of these training pro- other health care professional, his exercise pro- gram modi cations. fessional altered the resistance training program to light to moderate intensity and added a second abdominal and lower back and gluteal activa- Recommended Readings Airaksinen, O, Brox, JI, Cedraschi, C, Hildebrandt, J, Klaber-Moffett, J, Kovacs, F, Mannion, AF, Reis, S, Staal, JB, Ursin, H, and Zanoli, G. Chapter 4. European guidelines for the management of chronic nonspe- ci c low back pain. Eur Spine J 15(suppl 2):S192-S300, 2006. van Tulder, M, Becker, A, Bekkering, T, Breen, A, Gil del Real, MT, Hutchinson, A, Koes, B, Laerum, E, and Malmivaara, A. Chapter 3. European guidelines for the management of acute nonspeci c low back pain in primary care. Eur Spine J 15(suppl 2):S169-S191, 2006. Posture Conditions kyphotic) thoracic curve, and the lordotic lumbar curve (figure 3.2). This curvature assists in main- The term posture generally refers to the position taining a balanced and efficient upright posture of a person’s head, neck, trunk, and limbs in space during standing and locomotion (22). However, or when standing, seated, or lying down. “Good certain medical and nonmedical conditions exist posture,” then, may be seen as alignment of the that can lead to hyperlordosis (i.e., excessive musculoskeletal system that allows maximum lordosis of the cervical or more commonly the efficiency of body movement and functions and lumbar spine), hyperkyphosis (i.e., excessive does not place pathological stress on the mus- kyphosis of the thoracic spine), and scoliosis (i.e., cular, skeletal, or nervous systems (22). In order mediolateral curvature of the spine), all of which to assess whether someone’s posture allows for negatively affect optimal posture. optimal health and functioning, testing should be undertaken under both static and dynamic The prevalence of these spinal conditions varies conditions to reflect daily conditions that are greatly depending on the population studied, static (e.g., sitting and standing) and those that environmental factors, methodology for spinal are dynamic (e.g., walking) (22, 79). The roles of measurement, and age (19, 22, 47, 71, 131, 135, the spine in posture are significant, and various 171). However, the National Scoliosis Foundation spinal conditions exist that lead to postural dys- estimates that 2% to 3% of the U.S. population, functions, pain, and discomfort, such as exces- or approximately 7 million people, have scolio- sive scoliosis. The spine has a natural shape and sis. The highest incidence of scoliosis is between curvature expressed as the forward convex (i.e., 10 to 15 years, with females being eight times lordotic) cervical curve, the forward concave (i.e., more likely than males to have a curvature that requires treatment (104). This prevalence, and the

Musculoskeletal Conditions and Disorders | 73 Normal Hyperlordotic Hyperkyphotic Scoliotic Figure 3.2 The normal, hyperlordotic, hyperkyphotic, and scoliotic spine. E4822/NSCA Special Populations/Fig. 03.02/532512/HR/R1 potential for long-term and chronic health issues if thritis, and in some cases pregnancy, as well as the opportunities for early intervention are missed, from shortened (i.e., “tight”) hip flexor muscles may result in adverse personal and societal health or weak abdominal, lower back, hamstring or impacts. gluteus maximus musculature (17, 22). Lumbar hyperlordosis can lead to LBP and increased Pathophysiology of Posture Conditions risk of lumbar injury. Hyperkyphosis (also called “humpback,” “hunchback,” or “dowager’s The spine undergoes a variety of changes hump”) may occur as the result of osteoarthritis, throughout the life span that alter the suscepti- osteoporosis, or trauma to the thoracic spine. bility to adverse spinal curvature and subsequent Severe hyperkyphosis can lead to impaired lung postural dysfunction (22). In general, the causes capacity and function, nerve impingement, and of lumbar hyperlordosis, hyperkyphosis, and pain (39). While the majority of scoliosis cases scoliosis are unknown (i.e., idiopathic); how- are largely idiopathic (104), they may still be ever, a number of risk factors have been identi- categorized as structural (e.g., a deformity in fied. Physical and psychological stress, trauma, the vertebrae) or functional scoliosis (which is sporting activities, occupational behaviors such reversible and the result of either disparity in as prolonged sitting, slouching, and wearing leg lengths, pain, or muscle spasm). Scoliosis high heels have been associated with increased can lead to compromised movement patterns, risks (22). Lumbar hyperlordosis has also been pain, reduced physical functioning, and impaired associated with conditions such as cerebral respiratory functions (166). palsy, muscular dystrophy, obesity, osteoar-

74 | NSCA’s Essentials of Training Special Populations Common Medications Given to tion to attenuate or reverse posture conditions. Individuals With Posture Conditions This appears largely due to variance in the meth- odologies, populations, and exercise prescription, Treatment for spinal deformities depends on the as well as the preponderance of idiopathic diag- severity, location, age of diagnosis, and concomitant noses. As such, guidelines and goals are general conditions. Severe curvature and resulting symp- and include increased strength of the weakened toms may require bracing or corrective surgery muscles and increased flexibility and range of such as disc replacement, kyphoplasty, or spinal motion of the tight and shortened muscles, which fusion. Mild lumbar hyperlordosis, hyperkyphosis, may have contributed to the condition. and scoliosis, on the other hand, may be treated with exercise or medications such as NSAIDs (e.g., • For those with mild lumbar hyperlordosis, ibuprofen), or both, and nonnarcotic analgesics inclusion of exercises that increase exibility (e.g., acetaminophen) for pain, inflammation, and of the hip exors, hamstrings, and erector swelling (see medications table 3.1 near the end of spinae, plus those that strengthen the abdom- the chapter). As mentioned previously, caution is inal, lower back, and gluteal muscles and advised with NSAIDs, as their use increases the risk hamstrings, are recommended. of heart attack and stroke, and these risks increase with high doses and longer use (158). • Mild hyperkyphosis exercise programming should include stretching the cervical and Effects of Exercise in Individuals With thoracic vertebral exors (e.g., isometric and Posture Conditions dynamic neck retraction) and strengthening the thoracic vertebral extensors. It should Exercise is commonly recommended as a means also be noted that hyperkyphosis can make it to treat or manage certain posture conditions and dif cult to complete overhead exercises such their symptoms (13, 57, 134). However, individ- as a military press. uals who have more than mild severity of any of these conditions should be referred to a physician • For clients with mild scoliosis, include or other health care professional for treatment, stretching for the concave side and strength- including corrective exercise programming. The ening exercises for the convex side. If verte- goals of an exercise program for clients with bral column rotation is also present, these posture conditions are typically to improve flex- clients should rst be referred to a physician ibility and range of motion and build muscular or other health care professional for further strength to support and maintain optimum pos- testing to ensure there is no risk of nerve ture. This is true also for those experiencing one impingement. or more of these conditions during pregnancy or postpartum. In conjunction, reducing body fat in Program design guidelines for clients with pos- individuals for whom this is a contributing factor ture conditions are summarized in table 3.2. The may also be a goal of an exercise program. recommended initial prescription for improving strength for beginner or deconditioned adults Exercise Recommendations for Clients with mild posture conditions is one to three With Posture Conditions sets of 6 to 12 repetitions at approximately 60% to 80% of estimated 1RM, two or three times Meta-analysis of the existing literature has not per week, with the goal of progressing (over 12 yielded a consensus on specific exercise prescrip- or more months of consistent training) to an advanced program of two to six sets of up to six Key Point repetitions at ≥85% of 1RM and 2 to 5 minutes rest between sets four or more times per week Individuals who have a posture condition of (105, 156). To increase exibility and range of more than mild severity should be referred to a motion, it is recommended that clients initially medical professional for treatment. complete static stretches three to seven times per week of all major muscle groups and hold each stretch for 15 to 30 seconds (105). An increased

Musculoskeletal Conditions and Disorders | 75 number of repetitions (typically two or three speci c to the posture condition of the client as initially) should be incorporated for those areas identi ed earlier in this section. Table 3.2 Program Design Guidelines for Clients With Mild Posture Conditions Type of exercise Frequency Intensity Volume Resistance training Modes: weight training Begin with 2-3 sessions per Initially moderate intensity Start with 1-3 sets per exercise machines, free weights, or week (60-80% 1RM), using of 6-12 reps and 2-5 min rest both, body weight, elastic multijoint exercises to engage between sets tubing all major muscle groups Progress to ≥4 sessions per Progress to high intensity Increase to 2-6 sets of ≤6 week (>80% 1RM) repetitions per exercise and 2-5 min rest between sets Flexibility training 3-7 times per week Stretches should be held at the Each stretch held for 15-30 s References: (105, 156) point of mild discomfort (i.e., not painful) Case Study Posture Conditions Mrs. P is a 79-year-old retiree who has been including two exercises to strengthen the diagnosed by her physician with mild thoracic thoracic vertebral extensors (e.g., supermans hyperkyphosis. Assessment by the exercise and back extension if tolerated), with one to professional has also highlighted that she three sets of six repetitions. Before and after has poor lower and upper body mobility and each training session (i.e., weight training and muscular weakness. The exercise professional aerobic sessions) Mrs. P will complete upper has developed a training program that ini- and lower body static stretching and mobility tially includes resistance training two days exercises for 5 to 10 minutes with particular per week, and because Mrs. P is a novice with emphasis on dynamic neck retraction to stretch risk of falling, has prescribed a total body the cervical exors, as well as stretches for the circuit weight training format on machines, thoracic spine exors. Recommended Readings Bansal, S, Katzman, WB, and Giangregorio, LM. Exercise for improving age-related hyperkyphotic posture: a systematic review. Arch Phys Med Rehabil 95(1):129-140, 2014. Britnell, SJ, Cole, JV, Isherwood, L, Stan, MM, Britnell, N, Burgi, S, Candido, G, and Watson, L. Postural health in women: the role of physiotherapy. J Obstet Gynaecol Can 27(5):493-510, 2005. Kritz, MF and Cronin, CJ. Static posture assessment screen of athletes: bene ts and considerations. Strength Cond J 30(5):18-27, 2008.

76 | NSCA’s Essentials of Training Special Populations DISORDERS OF THE tively affect them, exercise professionals should be SKELETAL SYSTEM knowledgeable of their pathophysiology, medical treatments, and optimal exercise interventions. The adult human skeleton consists of approxi- mately 206 bones as well as associated cartilage, Osteoporosis ligaments, and tendons; it functions to provide leverage, support, protection, blood cell produc- The World Health Organization (WHO) defines tion, endocrine functions, and energy metabolism osteoporosis as a bone mineral density (BMD) at and also acts as a reservoir for calcium and phos- the hip or spine greater than or equal to 2.5 stand- phorus. However, bone is not a static material. ard deviations (SD) below the “young normal” Rather, it is highly dynamic and responds to stim- adult score (clinically referred to as T-score ≤2.5 uli such as muscular contractions, which result SD), as measured by dual-energy x-ray absorpti- in movement around joints and locomotion, and ometry (DXA) (164). The National Institutes of the lack of stimuli, resulting in loss of bone mass Health further defines osteoporosis functionally and strength. Disorders of the skeletal system as a reduction in bone strength resulting in an such as osteoporosis and osteopenia, osteoarthri- increased risk of fracture (75). Bone is a dynamic tis, and joint disorders can have profound direct tissue with active and mature cells involved in and indirect impacts on an individuals’ health, bone deposition and resorption (figure 3.3), so well-being, and fitness. Due to these concerns and bone mass at any point in time is a function of the prevalence and incidence of these diseases and the net effects of bone formation and resorption disorders, as well as the ability of exercise to posi- mechanisms. Osteoporosis then is the result of cumulative net bone resorption. Spongy bone Compact bone Trabeculae Lamellae Lacuna Canaliculi Osteoclast Osteoblast Osteocyte Figure 3.3 Bone is a dynamic tissue that consists of active deposition (osteoblasts), resorption (osteo- clasts), and mature bone cells (osteocytes). E4822/NSCA Special Populations/Fig. 03.03/532513/HR/R1 Query: Labels needed for “Endosteum” or “Canaliculi openings on surface”?

Musculoskeletal Conditions and Disorders | 77 In 2014, osteoporosis was estimated to affect phase of loss (i.e., type 2 [senile] osteoporosis, 10.2 million adults 50 years and older in the which is evident after 70 years of age), resulting United States (169), contributing to approxi- in a further 20% to 25% loss of cortical and tra- mately 2 million bone fractures per year and becular bone in both men and women before the other physical and psychological effects (169). end of life. Type 2 osteoporosis is thought to be A further 43.4 million are estimated to have low caused by a combination of factors in both men bone density (i.e., osteopenia), which increases and women, including decreased renal vitamin D the risk for osteoporosis. Signi cant sex differ- production and subsequent calcium absorption, ences in osteoporosis have been observed, with decreased nutrient intake including calcium women eight times more likely to have type 1 and vitamin D, decreased physical activity, and and two times more likely to have type 2 osteo- decreased estrogen and testosterone activity (121, porosis (see next section for subtype clari cation) 155). In men, while testosterone positively affects (169). The estimated prevalence of osteoporosis bone formation, estrogen is a more potent stim- in the United States also differs among racial and ulator; and as testosterone levels decrease with ethnic groups, affecting an estimated 7.7 million aging, so too does the amount of testosterone non-Hispanic white, 0.5 million non-Hispanic available to be converted by the aromatase enzyme black, and 0.6 million Mexican American adults to estrogen (121, 122). In conjunction, aging men (169). The increase in mortality and morbidity experience an increase in sex hormone-binding associated with osteoporosis is highlighted by globulin, produced by the liver, which binds both the approximately 24% of individuals over the age testosterone and estrogen, thus further reducing of 50 with hip fractures who die within one year bioavailability and negatively affecting bone mass after the fracture (146). In addition, the nancial and strength (62). cost of osteoporosis and associated fractures in the United States in 2008 was estimated at $22 Secondary (type 3) osteoporosis is a con- billion (18), making it a signi cant health concern. sequence of another disease state (e.g., cystic Pathophysiology of Osteoporosis brosis, anorexia nervosa, Crohn’s disease) or medication use (e.g., glucocorticoid-induced Osteoporosis may be classified as either primary osteoporosis) (155). However, other risk factors or secondary. Primary osteoporosis, often called for osteoporosis have been identi ed, including age-related osteoporosis, is the most common and hypogonadism, inactive lifestyle, smoking, alco- represents the cumulative loss of bone associated hol abuse, and excessive protein, sodium, and with aging in both females and males (155). This caffeine intake (73). is in part a consequence of declining activity of osteoblasts (i.e., bone-forming cells) after the age Osteoporosis is a signi cant health concern of 35 years, resulting in a small but natural loss because it not only increases the risk of bone of bone mass each year thereafter (146). Primary fracture and health disorders such as progressive osteoporosis may be subclassified as type 1 or spinal deformity (e.g., thoracic kyphosis) in older type 2. Type 1 osteoporosis, also referred to as adults, but also increases morbidity and mortality postmenopausal osteoporosis, generally occurs rates (155). However, much can be done to prevent from 50 to 65 years of age, resulting in accelerated and treat this disease especially if it is diagnosed bone resorption and decreased bone formation and treated early. due to the loss of estrogen binding to its receptors on bone (155). This accelerated phase of bone loss Common Medications Given to appears to last from 4 to 10 years, resulting in Individuals With Osteoporosis an estimated loss of 5% to 10% and 20% to 30% of cortical and trabecular bone, respectively (35, Several medications have been shown to be effec- 121). This is followed by a continued but slower tive at improving BMD in osteoporotic individuals via antiresorptive and bone-forming mechanisms (see medications table 3.2 near the end of the chapter). Hormone therapy (previously known

78 | NSCA’s Essentials of Training Special Populations as hormone replacement therapy, HRT) using dons. In conjunction, improvements in muscular estrogen, progesterone, or both was formerly strength also assist in reducing the risk of falls the most prescribed antiresorption treatment for (100). Regular aerobic exercise has also been osteoporosis; however, evidence for a concom- shown to provide sufficient stimulus to improve itant decreased risk of heart disease with HRT markers of bone synthesis and breakdown (124). has recently been questioned, as several long- In conjunction, activities that improve balance term clinical trials have shown an increased risk and proprioception should also be included to for breast cancer, blood clots, stroke, and heart reduce the risk of falls and fractures (100). attacks (91). Thus it is recommended that cardi- ovascular risk factors be examined when HRT is Key Point being considered as a treatment for osteoporosis. (Note that progesterone is added to estrogen to Resistance training can reduce the risk of frac- reduce the risk of endometrial cancer.) tures not only by increasing bone strength and density, but the resultant increases in muscle Selective estrogen receptor modulators (SERMs) strength can reduce the risk of falls. are also classi ed as agents that reduce bone resorp- tion. These include raloxifene, which is approved for Exercise Recommendations for Clients use in postmenopausal women (146), and tamoxifen With Osteoporosis citrate, the rst commercially available SERM, which is also used to treat metastatic breast cancer. Oral As part of the preexercise screening process for amino bisphosphonates such as alendronate are those with osteoporosis, it is important to be commonly prescribed to reduce the resorption of aware of (1) any exercise limitations due to pre- bone; however, a common side effect of this class of vious fractures (e.g., reduced locomotion capacity drugs is GI irritation (146). A number of synthetic due to hip fracture), (2) muscle weaknesses or analogues of the thyroid hormone calcitonin exist imbalances, (3) balance or proprioceptive issues, and may be used to decrease bone resorption by (4) the presence of other chronic diseases (e.g., inhibiting the actions of the bone-resorbing osteo- cardiovascular disease, osteoarthritis), and (5) clasts and increasing osteoblast activity (32). From a associated medications. The severity and location nonpharmaceutical standpoint, the National Osteo- of osteoporosis are also important, as clients who porosis Foundation also recommends 1,200 mg per are severely osteoporotic should avoid high-impact day of calcium for adults more than 50 years of age weight-bearing activity, despite the evidence of its and not taking estrogen. efficacy, due to their increased risk of fracture. Effects of Exercise in Individuals With Exercise testing can be undertaken with those Osteoporosis who have osteoporosis to establish baseline values and determine exercise tolerance to assist in pre- The National Osteoporosis Foundation of the scription; however a physician or other health care United States recommends the implementation of professional’s clearance should be obtained before regular weight-bearing and muscle-strengthening testing, and fall mitigation procedures should exercise to both prevent and treat osteopo- be implemented and maintained at all times. rosis (38). While moderate- to high-intensity The validity of such tests may be compromised weight-bearing exercise with a cyclical movement in clients with a fear of falling, so appropriate pattern has been shown to be more beneficial education about the mitigation procedures may (100), light-intensity physical activity is a viable improve test results. option for those whose bones are too fragile or who have another condition that precludes high Program design guidelines for clients with intensity (146). Increasing muscular strength osteoporosis are summarized in table 3.3. Clients improves bone mass and strength through the with osteoporosis are likely to be deconditioned, transfer of mechanical stress to the bone via ten- and thus initial use of light-intensity training is recommended (146).

Musculoskeletal Conditions and Disorders | 79 • Aerobic exercise for those with mild to mod- conservative approach should be taken to erate osteoporosis (T-score <3) should include reduce or avoid high-impact, twisting, and weight-bearing, large muscle mass activities any activity resulting in bone or joint pain. such as running or walking at light to mod- erate intensity, 30 to 60 minutes per session, • Also recommended is exibility training to three to ve days per week (i.e., ≥150 minutes increase mobility and range of motion, par- per week) (146). ticularly at the hip, knee, and pectoral girdle, consisting of three stretches per muscle group, • Aerobic exercise in clients with severe osteo- holding each stretch for up to 30 seconds, at porosis, which may be represented as multiple a frequency of ve to seven days per week fractures in recent years or noticeable spinal (146). Avoid excessive twisting, exion, and changes (e.g., kyphosis), should follow the extension of the spine for anyone diagnosed same guidelines for duration and frequency as severely osteoporotic or with a history of but use light-intensity and low-impact exer- fractures. cises such as walking or swimming in the exercise program. • Functional training that speci cally aims to increase balance and proprioception is recom- • Resistance training of two or three sets of 8 mended two to ve days per week. to 10 repetitions at 60% to 80% 1RM, two or three days per week, is also recommended In order to achieve the frequency of prescription, (146). Using free weights with clients who it may be necessary to complete more than one are conditioned to do so safely will increase training modality in a single session, for example, proprioceptive and balance demands. Again, flexibility exercises before and after resistance for those with severe osteoporosis, a more training. Table 3.3 Program Design Guidelines for Clients With Osteoporosis Type of exercise Frequency Intensity Volume Resistance training Two or three sessions per Modes: weight training week Moderate intensity (60- 2-3 sets per exercise of 8-10 machines or free weights or 80% 1RM), using multijoint repetitions and 2-5 min rest both, body weight, elastic 3-5 days/week exercises to engage all major between sets tubing muscle groups Aerobic training Mild to moderate osteoporosis Light to moderate (40-70% 30-60 min per session (150 (T-score <3) HRpeak), weight-bearing, min per week) large muscle mass activities such as running or walking Severe osteoporosis 3-5 days/week Light to moderate (40-50% 30-60 min per session (150 HRpeak), low- or no-impact min per week) weight-bearing, large muscle mass activities such as walking or swimming Flexibility training 5-7 days/week Stretches should be held at the Three stretches per muscle point of mild discomfort (i.e., group; hold each stretch for not painful) 15-30 s

80 | NSCA’s Essentials of Training Special Populations Case Study Osteoporosis Ms. L is a 61-year-old woman who has recently exercises such as squats and avoid exercises been having pain in her hips and back when she that encourage or require excessive spinal ex- walks or stands for long periods of time. She ion or extension. To mitigate her osteoporosis, thought this might be arthritis, which “runs in the exercise professional prescribed resistance her family,” but she fell on the ice this past winter training of three sets of 8 to 10 repetitions at and the pain has worsened. X-rays showed a 75% 1RM two days per week using free weights, vertebral compression fracture, and follow-up as well as limited range of motion back exten- DXA showed that she had a T-score of −2.6 SD. sion and abdominal exion on machines. Ms. L already walked seven days per week for 60 Ms. L’s initial treatment for the vertebral minutes; however, she did not stretch before or compression fracture involved two weeks of after. So, her exercise professional added static rest and NSAIDs for pain management followed range of motion exercises for 5 to 10 minutes by two months of wearing a brace. After her before and for 5 minutes afterward (avoiding recovery phase, her physician provided clear- excessive vertebral exion, extension, and ance and encouragement for her to participate rotation) and intermittent periods of higher in a resistance exercise program; she received intensity during her walks. directions to avoid direct spinal loading from Recommended Readings Clarke, BL and Khosla, S. Physiology of bone loss. Radiol Clin North Am 48(3):483-495, 2010. Moreira, LD, Moreira, LDF, Oliveira, MLD, Lirani-Galvão, AP, Marin-Mio, RV, Santos, RND, and Lazaretti- Castro, M. Physical exercise and osteoporosis: effects of different types of exercises on bone and physical function of postmenopausal women. Arq Bras Endocrinol Metabol 58(5):514-522, 2014. Mosti, MP, Carlsen, T, Aas, E, Hoff, J, Stunes, AK, and Syversen, U. Maximal strength training improves bone mineral density and neuromuscular performance in young adult women. J Strength Cond Res 28(10):2935- 2945, 2014. Mosti, MP, Kaehler, N, Stunes, AK, Hoff, J, and Syversen, U. Maximal strength training in postmenopausal women with osteoporosis or osteopenia. J Strength Cond Res 27(10):2879-2886, 2013. Osteopenia however, the loss of bone mass and strength has not progressed to the same degree. It should be Osteopenia is defined by the WHO as a BMD of 1.0 noted that osteopenia is not a condition exclusive to 2.5 SD below that of a “young normal” adult (i.e., to postmenopausal women but rather is present T-score −1.0 to −2.5 SD) (164) and has been esti- in younger women as a result of various factors, mated to affect approximately 43.4 million individ- which may include hypothalamic amenorrhea, uals in the United States (169). These individuals anorexia nervosa, limited calcium intake, or are at a significantly increased risk of osteoporosis vitamin D insufficiency (61, 74). Individuals diag- and associated negative health concerns. nosed with osteopenia should ensure that they have an appropriate intake of readily bioavailable Pathophysiology of Osteopenia calcium and vitamin D and rule out malabsorp- tion from conditions such as celiac disease and The pathophysiology of osteopenia is generally the Crohn’s disease or the effect of medications such same as that already described for osteoporosis;

Musculoskeletal Conditions and Disorders | 81 as cholestyramine and neomycin, among others. the presence of osteopenia—may be prescribed In conjunction, assessment of current and previ- medications such as those for osteoporosis (see ous physical activity and exercise training pro- medications table 3.2 near the end of the chapter). grams can provide insight into whether afflicted individuals have been exposed to sufficient Effects of Exercise in Individuals With bone-forming stimuli throughout their lifetime. Osteopenia Diagnosis of osteopenia before osteoporosis allows for the implementation of interventions The positive effects of various resistance training that increase the likelihood of reversing or slow- and aerobic exercise protocols to treat and manage ing the rate of this disease. osteopenia have been demonstrated (20, 101, 102) and reflect those for osteoporosis. These protocols Key Point typically place high cyclical strain on bone, which appears to be most effective at increasing BMD Osteopenia is not just a condition of postmen- and strength. opausal women, but can be present in younger women as a result of a variety of factors includ- Exercise Recommendations for Clients ing certain medical conditions, insufficient nutri- With Osteopenia ent intake, or the side effect of a medication. Due to the shared pathophysiology and progres- Common Medications Given to sive nature of osteopenia in relation to osteoporo- Individuals With Osteopenia sis, the exercise recommendations for osteopenia are the same as those for osteoporosis (see exercise All medications have risks for side effects, and recommendations for osteoporosis earlier in the because the absolute risk of fracture for someone chapter), with the exception that in most cases of with osteopenia is relatively low, medications are osteopenia, the absolute risk of fracture is lower generally not recommended until lifestyle (i.e., than that of osteoporosis, so the high-impact or diet and exercise) and underlying conditions have high-intensity exercise may be included. Note been investigated as potential contributors. Those that consultation with the client’s physician to who are deemed to have a high risk for fractures— determine fracture risk should be undertaken that is, they have other risk factors including as part of the assessment phase of developing an exercise program. Case Study Osteopenia Mrs. A is a 34-year-old executive who has a her swimming and cycling until her stress sedentary job but is an active triathlete. She is fractures healed (six to eight weeks) and then conscious of her diet and has been gluten and gradually reintroduce running. In addition it dairy free for 10 years. She has been having was recommended that she incorporate and pain in her shins when she runs and has found maintain high-intensity resistance training to that she has multiple stress fractures in both improve muscle strength and bone stress to tibia. Further testing showed that she has celiac further increase her bone density. disease, resulting in calcium and vitamin D malabsorption. Subsequent DXA illustrated that Because Mrs. A had no experience in resist- she has a BMD T-score of −1.4 SD. ance training and knew she would struggle to slowly reintroduce running into her program, To improve Mrs. A’s BMD and strength, her she hired an exercise professional to assist physician recommended that she start calcium her. She began her resistance training with and vitamin D supplementation. She was also two sessions per week at 75% of her predicted asked to refrain from running but to maintain 1RM, with three sets per exercise of 8 to 10 (continued)

82 | NSCA’s Essentials of Training Special Populations Osteopenia (continued) all training sessions, with three repetitions of each stretch, and 30 seconds of holding each repetitions and 2 minutes rest between sets. postexercise static stretch. Given that special- Her exercise professional included core multi- ized nutrition guidance and prescription and joint exercises such as the squat and deadlift clinical psychology were outside her exercise to engage all major muscle groups and to professional’s scope of practice, it was recom- maximize the bone deposition stimulus. Mrs. A mended that Mrs. A meet and work with a also started a walking program of 30 minutes sport dietician in conjunction with her sport psychologist to optimize her short- and long- ve days per week and progressed to three days term success. of running at 70% of her peak heart rate and two days of walking. Her exercise professional prescribed exibility training before and after Recommended Readings Bolton, KL, Egerton, T, Wark, J, Wee, E, Matthews, B, Kelly, A, Craven, R, Kantor, S, and Bennell, KL. Effects of exercise on bone density and falls risk factors in post-menopausal women with osteopenia: a randomised controlled trial. J Sci Med Sport 15(2):102-109, 2012. Kim, YI, Park, JH, Lee, JS, Kim, JW, Yang, SO, Jeon, DJ, Kim, MC, Jeong, TH, Lee, YG, and Rhee, BD. Preva- lence and risk factors of the osteoporosis of perimenopausal women in the community population. Korean J Med 62(1):11-24, 2002. Mosti, MP, Kaehler, N, Stunes, AK, Hoff, J, and Syversen, U. Maximal strength training in postmenopausal women with osteoporosis or osteopenia. J Strength Cond Res 27(10):2879-2886, 2013. Roghani, T, Torkaman, G, Movasseghe, S, Hedayati, M, Goosheh, B, and Bayat, N. Effects of short-term aerobic exercise with and without external loading on bone metabolism and balance in postmenopausal women with osteoporosis. Rheumatol Int 33(2):291-298, 2013. DISORDERS OF JOINT However, physical activity can also provide a pos- STRUCTURES itive stimulus for joint health and, as previously discussed, is important to overall health. Joints are a key component of the musculoskeletal system and not only play a central role in move- This section examines a number of the more ment of the human body and body segments (e.g., common conditions associated with joints (i.e., appendages), but also must support the weight osteoarthritis, joint sprains and dislocations, and of the various limbs and the entire body (e.g., joint replacements) that the exercise professional vertebral joints). Thus the health and viability of is most likely to encounter in clients. Exercise pro- joints are integral to movement and subsequently fessionals should be knowledgeable regarding the to health. The structural components of the body’s pathophysiology, medical treatments, and consid- joints undergo various normal and sometimes erations and the roles of exercise interventions degenerative changes due to aging and are also that can support individuals’ physical activity and susceptible to injury, infection, disease, and other health even with these joint structure disorders. conditions that can have negative impacts on the ability of joints to function optimally. This in Osteoarthritis turn can often lead to decreases in movement and physical activity and thereby a plethora of well- Osteoarthritis (OA) is a degenerative joint disease known associated negative health consequences. affecting the cartilage, joint lining, ligaments, and bone, leading to pain, swelling, and stiffness of the affected joint(s) (figure 3.4). Osteoarthritis most

Musculoskeletal Conditions and Disorders | 83 Bone Muscle Tendon Synovial membrane Articular cavity filled with synovial fluid Cartilage Fat Eroded Bursa cartilage Bone ends rub together Normal knee joint Osteoarthritis Figure 3.4 Osteoarthritis is a degenerative joint disease affecting the cartilage, joint lining, ligaments, and E4822/NSCA Special Populations/Fig. 03.04/532515/HR/R1 bone of the affected joint. from E4754/Sharkey/Fig. 09.06/361429/JG/R3 commonly affects the knees, hips, hands, and in severity and range with aging (85). spine and is associated with decreased physical The speci c cause(s) of OA are currently activity and increased morbidity and mortality (108, 130). Osteoarthritis is the most common unknown, and while a genetic association has form of arthritis and joint disorder in the United been proposed, other risk factors for the devel- States (106, 172), affecting approximately 13.9% opment of OA have been identi ed (72, 118, or 26 million adults over the age of 25 years (82). 147); these include sex, age, race, excess body Females are at higher risk than males, especially mass, prior joint trauma, physically demanding after the age of 50 years (25), and there is an occupation, structural misalignment, muscle increased incidence with aging for both sexes weakness, and estrogen de ciency. Progression of that plateaus at approximately 80 years (25). As the disease can be in uenced by improper loading such, with an expanding older population, the patterns that place repetitive stress on areas of prevalence of OA is expected to concomitantly the joint cartilage and associated structures that increase. In terms of financial impact, the direct are suboptimally suited to accommodating such and indirect costs of OA were estimated in excess loads (159). With these risk factors in mind, OA is of $40 billion in 2009 (103). classi ed by its etiology and is generally regarded as idiopathic localized, idiopathic general, or Pathophysiology of Osteoarthritis secondary osteoarthritis (i.e., associated with known trauma, neuropathic, or other identi able The American Academy of Orthopedic Surgeons medical condition). defines OA as quantifiable joint deterioration (cartilage, bone, and joint space) by x-ray or DXA, Key Point symptoms of deterioration (i.e., pain, swelling, inflammation, and stiffness of the joint), or a com- The progression of osteoarthritis can be influ- bination of the two (5). The progressive degener- enced by improper loading patterns that place ation of cartilage and underlying bone changes repetitive stress on areas of the joint cartilage; with OA can be substantial and may result in bone therefore, it is essential that proper exercise tech- articulating directly with bone. The symptoms of nique and movement patterns be taught and OA typically begin at 40 years of age and increase demonstrated before increasing training load or volume.

84 | NSCA’s Essentials of Training Special Populations Common Medications Given to pain (3, 27, 148), and further research to elucidate Individuals With Osteoarthritis their effectiveness is needed. Currently there is no cure for OA, and thus Nonsteroidal anti-in ammatory drugs includ- the goal of treatment options is to reduce pain, ing ibuprofen (e.g., Advil) and aspirin, which inflammation, and other symptoms as well as can help reduce in ammation, swelling, and progression of the disease, thereby increasing associated pain, are common nonprescription function. This may be achieved, depending on medications taken by those with OA. If taken as the risk factors present with each individual, by directed in low doses for short periods of time, a combination of education, weight reduction, OTC NSAIDs have relatively few and minor side gait modification, exercise, medication, or sur- effects. However, they can result in GI irritation gery (e.g., arthroscopy, osteotomy, joint fusion, or bleeding, and their use can increase the risk of and joint replacement) (see medications table heart attack and stroke; these risks increase if they 3.3 near the end of the chapter). The American are taken for prolonged periods or at higher than College of Rheumatology (ACR) recommends a recommended doses (158). Nonopioid analgesics combination of pharmacological and nonpharma- such as acetaminophen (e.g., Tylenol) are mild to cological measures to improve the effectiveness moderate pain relievers that are also commonly of the treatments (65). taken by those with OA. They have relatively few side effects when taken as directed. The known A number of OTC and prescription medications side effects include GI discomfort such as stomach are used by individuals in the management and pain, headache, and in rare cases GI bleeding, or treatment of symptoms of OA (see medications negative effects on hepatic and renal functioning. table 3.3 near the end of the chapter) (9). Over- the-counter NSAIDs such as ibuprofen (e.g., Advil If the pain or swelling from OA is moderate to and Motrin) and naproxen (e.g., Aleve) may reduce severe, the physician may prescribe one or more in ammation, swelling, and mild pain. Over-the- medications such as cyclooxygenase-2 (COX-2) counter nonopioid analgesics such as acetami- enzyme inhibitors. These drugs are a subclass of nophen (e.g., Tylenol) are mild to moderate pain NSAIDs but act selectively on COX-2 enzymes to relievers that are also often used by those with reduce in ammation, with reduced risk of stomach LBP. Over-the-counter dietary supplements such irritation. However, as with other cyclooxygenase as glucosamine (hydrochloride and sulfate) and inhibitors, there is an increased risk of heart attack chondroitin sulfate individually and in combina- and stroke with longer duration of use. tion have been extensively researched as nutraceu- ticals to assist in relieving pain and in ammation Corticosteroids, powerful anti-in ammatory and stimulating net cartilage production (48). agents that are injected directly into the joint Current reviews of the literature are equivocal in (e.g., betamethasone, cortisone acetate, and humans; however, a limitation in some studies is prednisone), may also be used in isolation or the use of nonpharmaceutical-grade ingredients conjunction with other medications depending that may affect potency; more research is needed on the individual’s symptoms. Despite the name, to determine their ef cacy (48, 64, 113). (Note corticosteroids are not in fact steroids but rather that the U.S. FDA does not test or analyze dietary are synthetic drugs that structurally resem- supplements, as they are not regulated in the same ble cortisol. Corticosteroids are prescribed for manner as pharmaceuticals. People should always moderate to severe joint pain or in ammation consult their physician or other health care pro- after NSAIDs have been found to be ineffective. fessional before consuming dietary supplements.) In general, corticosteroids are considered safe; Various topical pain relievers with ingredients however, potential side effects associated with such as capsaicin, menthol, comfrey, and salicy- large doses taken over prolonged periods (i.e., lates (e.g., Aspercreme, Bengay, Capzasin-P, and months or years) include heart attack, stroke, and Icy Hot) are also available OTC; however, they stomach bleeding. Another known potential side appear to have equivocal bene cial effects on OA effect of use of corticosteroids is osteoporosis, as they can both reduce osteoblast activity and increase bone resorption. Viscosupplements are

Musculoskeletal Conditions and Disorders | 85 agents injected into the joint cavity of patients bearing joints. Exercise may also increase joint with OA to increase joint lubrication and cush- stability, muscle strength, coordination, balance, ioning. Hyaluronic acid (e.g., Eu exxa, Hyalgan) proprioception, and joint mobility (11). is one such agent that is naturally found in joint Exercise Recommendations for Clients uid (149) and has been shown to be safe and With Osteoarthritis ef cacious as a treatment and may be given as a weekly injection (149). Program design guidelines for individuals with OA are summarized in table 3.4. The American For severe joint pain, powerful prescription College of Rheumatology recommends that clients analgesics (i.e., narcotic pain relievers) may be with OA engage in range of motion, resistance, used for short-term treatment (e.g., Darvocet, and aerobic exercise. morphine, Oxycontin, Percocet, and Vicodin). Unlike NSAIDs, which act as anti-in ammatory • Aerobic exercise that uses large muscle mass agents and have a mild analgesic effect, narcotic such as swimming, cycling, or walking should pain relievers have no anti-in ammatory effects. be undertaken three to ve days per week at The most common side effects are constipation, a light to moderate intensity (i.e., 55 to <75% drowsiness, dry mouth, and sometimes dif culty maximal heart rate [MHR] or an RPE of 9 to urinating. Caution should be taken with their 13) for 20 to 30 minutes (10). use, as there is a risk of developing a tolerance, dependency, or addiction. • Resistance training, two or three times per week at a moderate intensity for six to eight Effects of Exercise in Individuals With repetitions and two or three sets per exercise, Osteoarthritis in a progressive overload manner is also rec- ommended (10). While activities that cause or exacerbate pain in individuals with OA should be avoided, the • Exercise to increase exibility and mobility benefits of exercise are well documented and may should be initiated three to seven days per reduce joint pain for many (81, 123). Those with week, with three sets of one to ve repeti- OA who are overweight or obese can also bene- tions per muscle group, and held for 5 to 30 fit from physical activity and exercise-induced seconds, according to initial exibility and fat loss as this reduces the pressure on weight- comfort levels. Table 3.4 Program Design Guidelines for Clients With Osteoarthritis Type of exercise Frequency Intensity Volume Resistance training Two or three sessions per Modes: weight training week Moderate intensity (60- 2-3 sets per exercise of 6-8 machines, free weights or 80% 1RM), using multijoint repetitions and 2-3 min rest both, body weight, elastic 3-5 days/week exercises to engage all major between sets tubing muscle groups Aerobic training Light to moderate (55-75% 20-30 min per session (goal of MHR), RPE 9-13) weight- at least 150 min per week) bearing, large muscle mass activities such as swimming, cycling, or walking Flexibility training 3-7 days/week Stretches should be held at the 3 sets of one to five stretches point of mild discomfort (i.e., per muscle group; hold each not painful) stretch for 5-30 s

Case Study Osteoarthritis Mrs. J is 58 years old, physically active, 5 feet, Due to the continuing decline in her exer- 6 inches tall (1.68 m), and 135 pounds (61 kg). cise abilities in the past year and the long-term She is a manager for a temporary staf ng agency medical and health implications, Mrs. J hired and has had progressively increasing pain and an exercise professional with certi cation and swelling in both knees for the past 12 months. experience working with OA clients. With her Initially in the morning her knees are stiff until reduced ability to run, her exercise professional she has been moving for 10 to 15 minutes. She prescribed aerobic sessions on a bicycle three has had to reduce her running to walking, and to ve days per week at a moderate intensity recently even walking more than 20 minutes (RPE of 12-13) for a duration as long as she has become painful. She has been taking ibu- was pain-free or her pain was tolerable. On profen daily for nine months to reduce swelling days when her symptoms are low, Mrs. J was and pain, and while her self-selected dosage encouraged to walk, as this is what she pre- has steadily increased, it is no longer effective fers and enjoys. Her exercise professional also at managing her pain. X-rays of her lower initiated a resistance training program twice a back, hips, and knees reveal that Mrs. J has week again at a moderate intensity, given her narrowing of the joint spaces, an indication of athletic background, engaging in two sets of six cartilage loss, and mild increased density of the to eight repetitions of predominantly multijoint subchondral bone consistent with OA. Due to exercises while remaining in a pain-free range the ineffectiveness of ibuprofen, her physician of motion. However, to accommodate the car- has prescribed celecoxib (Celebrex), a COX-2 tilage loss in her lower back, hips, and knees, inhibitor, even in light of the FDA’s recent Mrs. J’s exercise professional implemented low warning that COX-2 inhibitors may increase step-ups, leg press, and lying hamstring curls the risk of heart attack and stroke. This was in instead of squats and deadlifts, and asked her conjunction with recommending a modi ed to limit her range of motion by her symptoms. aerobic training program, adding resistance Her exercise professional also started her training and mobility to improve overall joint on a progressive exibility program of static health and function, as well as addressing any stretches three days per week, repeating each potential issues of bone and muscular strength, stretch three times and holding for up to 30 which are both important at Mrs. J’s age. seconds. Recommended Readings Buckwalter, JA, Saltzman, C, and Brown, T. The impact of osteoarthritis: implications for research. Clin Orthop Relat Res Oct(427 suppl):S6-S15, 2004. Roddy, E, Zhang, W, Doherty, M, Arden, NK, Barlow, J, Birrell, F, Carr, A, Chakravarty, K, Dickson, J, Hay, E, and Hosie, G. Evidence-based recommendations for the role of exercise in the management of osteoar- thritis of the hip or knee—the MOVE consensus. Rheumatology (Oxford) 44(1):67-73, 2005. Vincent, KR, Conrad, BP, Fregly, BJ, and Vincent, HK. The pathophysiology of osteoarthritis: a mechanical perspective on the knee joint. PM R 4(5 suppl):S3-S9, 2012. 86

Musculoskeletal Conditions and Disorders | 87 Joint Disorders Joint dislocation (i.e., luxation), on the other hand, is an abnormal separation of the joint The joints of the human body are made up of surfaces. Common acute symptoms of a disloca- primary and supporting structures including tion include pain at the joint especially during cartilage, ligaments, bone, bursa, joint cavity, movement, limited range of motion, numbness synovial fluid, muscle, tendons, blood vessels, or tingling, swelling, and bruising. The joint may and nerves. Joints, and the various structures that be visibly misshapen, particularly in the case of make up a joint, are susceptible to disorders of complete dislocation; however this is not always varying etiology, for example, genetics, disease, the case, as with partial dislocations. The shoulder trauma, and aging. Two of the most common joint is the most commonly reported joint dislocation, disorders are sprains (figure 3.5) and dislocations with 71.8% of cases occurring in males and with a (figure 3.6). peak incidence for those aged 20 to 29 years (170). The American Academy of Orthopaedic Sur- The risks of joint sprains or dislocation with geons (AAOS) de nes a joint sprain as a stretch participation in exercise and physical activity are or tear (or both) of a ligament (8). Typical acute evident, with almost half of the reported injuries symptoms of a sprain include tenderness or pain occurring during sport activity or recreation (170). at the joint, bruising, in ammation, swelling, and Thus, since all children and adults are encouraged joint laxity or stiffness. The joints most suscep- to engage in daily physical activity to improve and tible to sprains are the ankles, knees, and wrists. maintain health, exercise professionals should be From 2002 to 2006 there were an estimated knowledgeable about these conditions. 3,140,132 ankle sprains in the United States (162), with the incidence higher in females compared Pathophysiology of Joint Disorders with males, children compared with adolescents, and adolescents compared with adults (46). Lat- Sprains are caused by direct or indirect trauma such eral ankle sprains were the most common ankle as a fall (e.g., landing on outstretched arms and sprain cited (46), with nearly half of all ankle hands while falling, causing wrist sprain), excessive sprains reported during athletic activity. Basket- joint movement (e.g., “rolling an ankle” on a rock ball, football, and soccer were associated with while walking), or a blow to the body or joint (e.g., the highest percentages of ankle sprains at 41.1%, tackling an opponent at the knee, causing sprain 9.3%, and 7.9%, respectively (162). of the medial collateral ligament of the knee). The Intact posterior Intact anterior tibiofibular ligament tibiofibular ligament Torn anterior talofibular ligament Torn calcaneofibular ligament Figure 3.5 Joint sprain is one of the most common joint disorders and involves a stretch or tear of a ligament. E4822/NSCA Special Populations/Fig. 03.05/532517/HR/R1 from E4799/Hillman/Fig 10.11/403460/TimB/R1