ACSM CPT Chapter 20: Special Populations

ACSM CPT Chapter 20: Special Populations

Chapter Objectives:

  • Know the value of physical activity for kids and make exercise programs that are age appropriate.
  • Know the physiological changes that happen due to age and make programs that are optimal for older adults.
  • Discuss exercise programming for people that have CV, diabetes, and hypertension.
  • Discuss programming for exercise while pregnant or postpartum.
  • Discuss programming exercise for people that are obese.
  • Know how you can create programs for people that have comorbidities. 

Programming for Children 

  • Children and adolescents count as people that are 6 to 17 years old. It is recommended that children do a minimum of 60 minutes of activity every day, consisting of moderate and vigorous intensities and also to include some form of resistance and bone loading type exercise for 3 days a week.
  • Regular endurance, resistance, and bone loading exercise will confer some favorable training adaptations for children which results in benefits for the metabolic, cardiovascular, and skeletal health.
  • Physical Activity for Children
    • Personal trainers play a role in identifying a variety of activities that are age appropriate for children for safe and effective development of aerobic, muscular, and bone strength.
    • When children have not been doing the 60 minutes of recommended time, it is important to slowly work up to that level. 
    • The two main goals that trainer should have in mind when making programs for children are:
      • The program needs to meet the recommended time for physical activity that is needed for achieving the health benefits that come with regular activity.
      • Children should be encouraged to do many activities that they enjoy and are appropriate for their age. So things should be fun and safe when working with children.
  • Other Considerations for Children
    • Children need to be properly supervised and the activities in resistance training need to be safe. They should be watched carefully and supervised the whole time.
    • The general principles that we applied to adults in the previous chapter on resistance training can also be applied for children. There is however even more importance placed on the proper instruction of lifting technique as this is a time for kids where they are developing. 
    • One thing that children have is a thermoregulatory system that is underdeveloped and thus more prone to getting heat related injuries than adults. Proper hydration is very important.

Programming for Older Adults

  • Aging happens for everyone and the life expectancy in the US has gone up by about 30 years from 1900. It is currently 81.2 for women and 76.4 for men. We actually define older adults as anyone that is older than 64.
  • The range of changes and the magnitude of those changes are dependent upon genetics, someone’s own health, the presence of any diseases or injuries, and history of exercise. People that are close in age can have very different functional capacities, which affects their own responses to exercising. 
  • Physiological Changes with Aging
    • The resting heart rate remains the same virtually, but the maximum heart rate will have a steady decline when aging. Our max stroke volume and our max cardiac output will also decline with age. The stroke volume goes down by 10% and max cardiac output by 20% from the ages of 30 – 60. For people that are sedentary, there is about a 9% decrease in VO2 max per decade. 
    • We have declines in our anaerobic capacity with increases in age and less ability for doing high intensity exercise. 
    • Between the ages of 45 and 85 there is a much decreased flow of blood to the brain and a decrease of about 20% of weight of the brain. A lot of these same decreases in weight happen in the muscles along with increases in fat stored in the muscles and the body as a whole. 
  • Exercise Testing Can Make A Difference
    • There are about 50% of these decreases that can be stopped by staying active and exercising. So, this also means the other 50% of decreases that happen are just due to the actual aging process and are essentially unavoidable. 
  • Successful Aging
    • Exercise is proven to increase our quality of life and our length of life. 
    • Regularly being involved with aerobic, anaerobic, resistance, flexibility, and functional training are key for aging successfully. 
  • Exercise Testing in Older Adults
    • It is likely that older adults have some big chronic disease issues, thus the trainers need to make sure that they do a thorough assessment prior to starting a program with the population.
    • Trainers need to make programs for older adults that have these three main goals:
      • Prevent and/or delay chronic disease progression.
      • Keep or even potentially enhance your cardiorespiratory levels.
      • Stop and do not allow functional limitations and disabilities.
  • Design Considerations for Developing Cardiorespiratory Fitness in Older Adults
    • The most important goal for older adults should be working on cardiorespiratory fitness, as having it low would contribute to early disease. 
    • Regularly being active in life will significantly lower the normal age related changes and restore the functional capacity in sedentary adults.
    • There should be about 150 – 300 minutes of moderate intensity activity or 75 – 100 for vigorous intensities.
  • Design Considerations for Developing Muscular Strength in Older Adults
    • There is a large reduction in muscle mass as we age, which will also lead to less strength and functional capacity. The general principles we used for adults can be applied here, too. Even things like explosive power training are fine for older adults to do. 
    • Range of motion should be highly focused on so that the clients can develop properly. This is always the focus in training of all ages, but for older adults it can be more challenging.
  • Design Considerations for Developing Flexibility in Older Adults
    • This is an essential fitness component and it goes down as we age and are not physically active. Out connective tissues become stiffer and his makes the bending of joints harder.
    • The same flexibility program recommendations apply to older adults.
  • Design Considerations for Developing Balance in Older Adults
    • The rates of falling goes up as we age and an important feature of the programs that trainers should make are for the inclusion of balance based exercises. 
    • This can be put into many different phases of exercise sessions and the balance training should be done on 3 days every week and for 10 – 15 minutes.

Programming for Clients with CVD

  • People who reach 50 years old and have no risks of CVD also have markedly higher rates of survival than anyone with any combination of risk factors.
  • Programing goals for CVD
    • The modification of risk factors in a positive way is the main goal associated with anaerobic exercise programs. 
    • Programs should follow FITT-VP parameters.
  • Design Considerations for Cardiorespiratory Training for Clients with CVD
    • Exercising is pretty much safe for most clients that have CVD if there is a proper assessment and screening done prior to the start of the program. Baseline assessments, preparticipation screening, education of patients, and adherence for clients will markedly reduce the chance of an adverse event occurring. 
    • For many people that were sedentary previously, the intensity threshold for improving cardiorespiratory fitness is about 40 – 80% of the person’s VO2R or HRR.
  • Designing Resistance Training Programs for Clients with CVD
    • The main goals for the design of resistance training programs for clients with CVD are: 
      • To keep and even improve the levels of muscular fitness when doing ADLs.
      • Reduce the demands that are relating to cardiovascular that tend to be associated with these tasks. 
    • There should be a request that the client get permission from their physician when seeking out a resistance program.

Programming during Pregnancy and Postpartum

  • Like many other populations, physical activities for people that are pregnant and also postpartum will have many benefits and these people should be highly encouraged to participate in them.
  • Preparticipation Screening Exercise during Pregnancy and Postpartum
    • Before participating in exercise programs, these clients should be evaluated by their obstetric provider in order to make sure there are no contraindications. There are specific forms for women that are pregnant to have filled out for prescreening.
  • General Exercise Considerations during Pregnancy and Postpartum
    • The fatigue, vomiting, and nausea that come with pregnancy may limit their exercise in the first trimester and trainers need to know about the increase in their nutritional needs. 
    • Reduced thermoregulatory control during the pregnancy is important to note.
    • The physiological changes from pregnancy will go on for about 4 – 6 weeks after pregnancy, but typically we see women return to exercise right after.
  • Aerobic Exercise Prescription during Pregnancy
    • The general principles form chapter 15 will also apply to pregnant and postpartum women. There are however some adaptations that trainers will be making due to the anatomical and physiological changes.
  • Resistance Training and Flexibility Prescription during Pregnancy
    • The principles found throughout chapters 14 and 16 apply to pregnant women but it might be slightly changed for the accounting of the morphological and physiological changes occurring.

Programming for Clients with Diabetes

  • Diabetes is a metabolic disorder that comes from abnormal pancreatic production of insulin and possibly a diminished peripheral action of insulin. There is also a lot with the development of diseases and disorders of the heart, the vascular system, the kidneys, the eyes, and the nervous system.
  • There are two types of diabetes: one and two.
    • Type one is usually what someone is born with and where the body’s own immune system will mistakenly destroy the pancreas’ insulin producing cells. This is only 5 – 10% of cases.
    • Type two is what is usually developed from a sedentary life and even bad diet.
  • Pathophysiology of Diabetes
    • Type one diabetes sees the pancreatic beta cells that make insulin being destroyed by an autoimmune disorder, thus creating a deficiency in insulin.
    • Type two sees insulin being less effective for the control of blood glucose due to insulin resistance occurring in the tissues of the body.
  • Programming Goals for Those with Diabetes
    • The main goals are:
      • Improving the sensitivity to insulin and the control of blood glucose while decreasing the insulin requirements.
      • Improving cardiorespiratory fitness.
      • Improving the blood lipid profiles.
      • Reducing the blood pressure.
      • Improving the muscular strength and endurance through the enhancements in skeletal muscle mass.
      • Improving flexibility and the range of motion of joints.
      • Reducing the body weight.
      • Assisting with the decrease in risk for diabetic complications.
  • Aerobic Training for Clients with Diabetes
    • Frequency
      • 3 – 7 days per week with no more than 2 days consecutively between sessions of aerobic activity. Trainers should have the goal be 5 days per week or even daily while mixing up the intensity and duration.
    • Intensity
      • There is a recommendation of 40 – 59% of the VO2R or the HRR for people with diabetes. The RPE range of 11 – 13 is what we look for with this scale.
    • Time
      • The recommendation is for 20 – 60 minutes of either continuous or accumulated bouts of a minimum of 10 minutes in total and it should add up to 150 minutes every week.
    • Type
      • The guidelines for choosing an exercise mode is about the same as it is for healthy adults. It should generally be something that the client actually enjoys.
    • Progression
      • It is important for us to put a priority on expending the most calorie as possible and increase the duration of activity linearly as time goes one.
  • Resistance Training for Clients with Diabetes
    • Resistance programs are essential for managing their disease and the associated complications. It also adds to the improvement of strength and endurance.
    • Other Considerations for Clients with Diabetes 
      • Hypoglycemia ad hyperglycemia are major things to consider and these are the strategies for minimizing them:
        • Know the signs that lead to hyperglycemia and hypoglycemia.
        • Avoid exercising in times when the hypoglycemic medication is at its peak of working.
        • The clients need to eat 1 – 2 hours prior to exercising.
        • Check your blood pressure prior to exercising and if it is lower than 100, then they should have a snack.
        • Clients need to exercise with partners for added safety.
        • There should be fruit juice or candy close when exercising for times when blood glucose is low.

Programming for Obese Clients

  • Obesity is defined as a BMI being more than 30. 
  • Trainers should be ready to interact with many different professionals and design the right effective programming strategies.

Programming Goals

  • The main goals are to:
    • Maximize the caloric expenditure
    • Keep or even increase the lean body mass for keeping the resting metabolic rate
    • Improve the metabolic profile
    • Decrease the risk for comorbidities
    • Lower the risk of mortality
    • Promote the control of appetite
    • Improve the state of mood
  • Aerobic Training for Obese Clients
    • Frequency
      • 5 or more days per week of training will maximize the energy expenditure.
    • Intensity
      • Moderate to vigorous activity is encouraged and the intensity is based upon the fitness level of the clients.
    • Time
      • A minimum of 30 minutes per day and a gradual increase to the optimal level of 60 minutes per day.
    • Type
      • Any exercise that the person will do is recommended.
  • Resistance Training for Obese Clients
    • Resistance training might also improve the maintenance of lean body mass for clients after a calorically restricted diet.
  • Weight Loss Expectations
    • A lot of people have set unrealistic expectations when they start exercising and this can lead to a lot of  disappointment, so it is important to make sure they know what is realistic to expect.
  • Other Consideration for Working with Obese Clients
    • Trainers need to be prepared to modify the program they made for other conditions that may arise or just be associated with obesity.

Programming for Hypertension

  • Hypertension is known as the silent killer due to the lack of noticeable symptoms of hypertension occurring until there are serious problems.
  • Programming Goals 
    • The general goals are to:
      • Lower the systolic and the diastolic blood pressure at rest and while exercising.
      • Lower the risk of mortality from CVD.
      • Lower risk of other comorbidities.
      • Incorporate client opportunities for pursuing lifestyle changes.
  • Aerobic Training for Clients with Hypertension
    • Frequency
      •  Clients with hypertension are recommended to get exercise on as many as they can, or if not all, days. 
    • Intensity
      • Moderate intensity is ideal and that is 40 – 59% of their VO2R or HRR. Also a RPE value of 12 – 13.
    • Time
      • 30 – 60 minutes of accumulated exercise per session. 2 thousand calories per week is the ideal for treating hypertension.
    • Type
      • They should engage in aerobic activities that use their large muscle groups and are rhythmic.
    • Progression
      • Progressions basic information applies to people that have hypertension also.
  • Resistance Training for Clients with Hypertension
    • This is going to be used simply as a supplement to the aerobic exercise that is programmed and will not be the main form of exercise.
    • The intensity of this exercise needs to be kept at 60 – 80% of 1RM.
  • Other Considerations for Clients with Hypertension
    • Hypertension is oftentimes put together with many conditions that also might need attention and specific precautions for exercising. It is important to have a grasp on these associated conditions and also fine tune the programs for these. 

Programming for Clients with Comorbidities

  • About 80% of people that are 65 or older are living with one chronic health problem, and then 50% have at least two.
  • Programming Goals
    • The programming goals are:
      • To lower the risks for mortality by finding the condition that has the highest mortality risk and then prioritizing it in the exercise program.
      • Find the comorbidity presence that serves as the competing demand on the self-management resource and reduces time and energy for the person that devotes these to the conditions.
      • To have their expectations be realistic for the improvement of all comorbidities.
  • Training for Clients with Comorbidities
    • Exercise is safe for the vast majority of people that have comorbidities once the trainer has done the right prescreening and assessment. 
    • The general framework will follow the current FITT-VP guidelines for the various exercise forms. It is important to consider the previously mentioned diseases and their potential presence.
  • Other Considerations for Clients with Comorbidities
    • Though trainers are able to work with clients that have stable chronic diseases and are also able to exercise on their own, it is also important to know that some situations will require medical consultation and the trainer may be unable to take on this client.
ACSM CPT Chapter 20: Special Populations 1
ACSM CPT Chapter 20: Special Populations 2
ACSM CPT Chapter 20: Special Populations 3

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