Programme Modification

By this stage, you should be familiar with common conditions including obesity, arthritis, diabetes, pregnancy, or age specific individuals, and training recommendations. You’ve also learnt how to fitness test, programme design, and coach for general population in Exercise Prescription Part B. Now we take a look at how those processes change for special populations.

In this topic, we'll cover:

• Acute and chronic responses to training
• Pre-screening for special populations
• Fitness testing for special populations
• Programme modification examples

During exercise, the body undergoes various changes to adapt to the new demands placed upon it. These changes can be classified as either acute or chronic, with acute changes further categorised as desirable or undesirable.

Acute changes occur during the exercise session and are typically immediate responses from one or more systems in the body, such as an increased heart rate during warm-up, elevated blood pressure during resistance training, or a faster breathing rate during high-intensity exercise. Acute changes can be positive or negative, with negative changes considered undesirable.

When working with special populations, it is crucial to be aware of any signs or symptoms that may indicate adverse effects of training. This requires monitoring clients during and after each session to ensure they are both safe and enjoying themselves.

Chronic changes, on the other hand, are longer-lasting and typically reflect the benefits an individual receives from long-term exercise if they maintain a consistent exercise regime. However, certain changes, such as increased stroke volume, tidal volume, and cardiac output, can be seen as both acute and chronic responses, depending on the context.

Both acute and chronic training responses can be further categorised as physiological or psychological and can be either positive or negative. Before exploring acute responses in more depth, it is important to briefly consider physiological and psychological chronic responses.

Chronic responses to training

Physiological	Psychological
Decreased blood pressure (diastolic)	Decreased symptoms associated with depression
Decreased body fat percentage	Increased energy levels
Increased muscular strength	Increased self-esteem
Increased neuromuscular activation	Increased confidence in abilities
Improved flexibility	Improved memory/retention of information
Improved balance and coordination, decreased risk of falls	Increased ability to cope with stressful situations or events
Increased bone density	Increased ‘can-do’ attitude
Improved muscular endurance	Improved sleep pattern
Increase in VO2max	Improved social life

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

Acute training responses

Acute training responses can be a valuable tool for both trainers and clients to identify whether the F.I.T.T. variables, including type of exercise, frequency, intensity, and duration of the session, are appropriately balanced. Additionally, environmental factors can also impact the physiological and psychological responses that everyone will experience before, during, and after a training session. Therefore, it is essential to understand and identify these responses to improve the training experience.

Physiological responses

When the body engages in exercise or physical activity, it responds by attempting to meet the demands of the activity. All eleven systems of the body work together to support the body, which requires greater fuel demands (carbohydrates, protein, and fats) with the level of response dictated by the duration, type, and intensity of the exercise.

Positive responses:

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

Negative responses:

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

Psychological responses

When it comes to exercise, the emphasis is often placed on the physical benefits. However, it's important not to overlook the psychological benefits, as they can be just as important for some individuals. In this article, we'll discuss the positive and negative psychological responses to exercise, and how to respond to them during a training session.

Exercise can have significant positive impacts on mental health in areas such as anxiety, depression, and ADHD. It's important to recognize that not every client begins training simply to look better or fit into smaller pants. Many have goals related to the following positive psychological aspects of training:

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

It's also important to be aware of the negative psychological responses to exercise, such as:

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

How to respond to acute training responses

As a trainer, it's important to identify any signs of negative physiological or psychological outcomes as a result of training. If you feel that your client is displaying any signs of negative effects, you can take steps to support them. Some examples include:

• Providing water
• Asking the client how exercises are feeling - RPE (rate of perceived exertion)?
• Allowing for a longer rest period
• Regressing exercises to decrease intensity
• Suggesting the removal of layers of clothing
• Checking if the client is hungover or tired from a long night of work
• Checking if there has been a change in medication
• Reassuring the client with two-way communication and letting them know their feedback is welcome
• Lowering the intensity of the workout
• Providing education on session preparation
• Changing the location of the workout
• Fanning or cooling down the client
• Altering the session based on the client's state
• Stopping the session if necessary
• Placing the client in a recovery position
• Administering first aid if necessary
• Improving the screening process for new clients
• Referring the client to a doctor, physiotherapist, or other relevant allied health professional if necessary

WHAT COULD THIS LOOK LIKE IN PRACTICE?

During a session with your client, you notice they are unable to hold a conversation through their rest periods. This is an example of an acute response to exercise, indicating breathlessness due to working at a higher intensity. To manage this, you could provide your client with a longer rest period so they are fully recovered before continuing with the workout. You could also consider decreasing the intensity

Why do we test clients? Fitness testing offers immense motivational value. Actions speak louder than words! Fitness testing before, during, and after training programmes provides visual proof of results. It also helps identify strengths and weaknesses, monitor performance, and participation screening.

Timing

Testing usually happens during the initial session. This provides baseline data, essential for planning goals and a great starting point. Testing can be intimidating for everyone, but particularly special population groups. Be sensitive, make it motivational and relevant. Reassessments are usually carried out every 6-8 weeks, allowing for adaptation.

Baseline testing is essentially pointless unless it is followed up by reassessment. Reassessment allows you to determine the efficacy of the programme (how well it worked). Make sure you use identical testing protocols to those used in initial testing. The results can be used to adjust training intensity, duration, and frequency.

Explain the tests

It’s important your client is fully informed of what the tests are and why you are doing them. Explain:

• How you going to do the test (equipment, resources, time)
• Why you doing the test (how they relate to the client’s goals)
• What the results mean (consider if are there any issues with accuracy)

Think about the characteristics of special population groups and consider how you may need to adapt your communication style to suit the client. The special population group and pre-screening form will also influence which tests you carry out with the client.

Here’s a simple testing protocol to follow, particularly helpful for functional movement testing/screening where you need to explain technique and demonstrate.

Name and purpose of the test – why are you doing it?

1. Guidelines – discuss the technique without giving away things you’re looking for, and mention what disqualification/failure is
2. Test scoring and what they mean
3. Ask if your client has any questions, and permission to go forward
4. Demonstrate the test
5. Time for client to practice and ask questions
6. Recommendations for maximising performance to client

Remember, always communicate with your client during the test, see how they’re feeling. If they’re in pain – STOP the test!

Sequence

At a minimum, all clients must have their resting heart rate (RHR) and blood pressure (BP) measured. These are standardised tests which should be performed on all clients. You should complete these tests first. Any additional tests you decide to conduct should be tailored towards client goals.

The recommended order of tests is:

1. Resting tests (RHR and BP)
2. Non-fatiguing tests (BMI, BF%)
3. Muscular strength tests
4. Muscular endurance tests
5. Sub maximal aerobic capacity tests

The following table suggests tests which are suitable for specific client goals.

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

Submaximal testing

Submaximal testing is a type of fitness assessment that measures an individual's physical fitness without requiring them to perform at their maximum effort or exhaustion. The purpose of submaximal testing is to estimate an individual's maximal oxygen uptake (VO2 max), which is a measure of their cardiorespiratory fitness. Submaximal testing is particularly useful for special population groups.

• Children and adolescents: Submaximal testing is often used to assess the fitness level of children and adolescents, who may not be able to perform maximal exercise tests due to safety concerns.
• Elderly: As people age, their cardiorespiratory fitness tends to decline. Submaximal testing can be used to assess the fitness level of elderly individuals without requiring them to exercise at a high intensity.
• Pregnancy: Pregnant women may be at a higher risk of injury or complications during exercise, so submaximal testing can be used to assess their fitness level and determine appropriate exercise programmes. Submaximal testing can also be used to monitor the effects of pregnancy on fitness levels and adjust exercise programmes accordingly.
• Obesity: People with obesity may be at a higher risk of injury or cardiovascular events during maximal exercise testing. Submaximal testing can be used to assess their fitness level safely.
• Cardiovascular disease: Individuals with cardiovascular disease may have a higher risk of complications during maximal exercise testing. Submaximal testing can be used to assess their fitness level safely.
• Arthritis: Individuals with arthritis may experience joint pain and inflammation, which can make it difficult or unsafe to perform maximal exercise testing. Submaximal testing can be used to assess their fitness level without causing excessive pain or inflammation.
• Asthma: Maximal exercise testing can trigger asthma symptoms, so submaximal testing is often used to assess the fitness level of individuals with asthma.

There are several submaximal tests that personal trainers can carry out with their special population clients. Here are a few examples:

• 6-minute walk test: This test involves having the client walk as far as they can in 6 minutes.
• Cycle ergometer test: This test involves having the client pedal a stationary bike at a submaximal intensity for a set period of time.
• Step test: This test involves having the client step up and down on a step bench for a set period of time.
• Treadmill test: This test involves having the client walk or run on a treadmill at a submaximal intensity for a set period of time.
• Rockport Fitness Walking Test: This test involves having the client walk 1 mile at a brisk pace, while wearing a heart rate monitor.
• Astrand-Rhyming Cycle Ergometer Test: This test involves having the client pedal a stationary bike at a set workload for 6 minutes.

Functional Movement Screening (FMS)

Functional Movement Screening (FMS) is a screening tool that is used to assess movement patterns and identify potential limitations or imbalances in a client’s functional movement. The screening involves a series of tests that assess primal movement patterns. These movements are assessed through a combination of simple tasks that require a range of body movements.

During screening, the client is asked to perform each of the movement patterns, while you as the personal trainer assess the movement quality and identify any asymmetries or limitations. Each movement pattern is scored on a scale of 0-3, with 3 indicating a perfect score and 0 indicating the inability to perform the movement.

Identifying limitations or asymmetries in a client’s movement patterns, allows you to consider which movements may increase the client's risk of injury or reduce their physical performance. It also helps you design a personalised exercise programme that addresses the individual's specific needs and improves their movement quality.

Let’s look at some FMS tests you can use with special population clients.

Overhead squat

Purpose: To assess flexibility at the ankle, knee, hip and shoulder, as well as balance.

Set up	Scoring
Feet hip-width apart, facing forward Wooden dowel directly over crown of head (elbows at 90 degrees to set up, then extend) Squat as deep as possible whilst keeping dowel above crown Observe 3 reps from the front, back and side – looking for any movement in the feet, ankles and the bar position	3 = Perfect overhead squat 2 = Perfect OH squat with heels raised 1 = Not perfect with heels raised   0 = Client experiences pain

Shoulder mobility

Purpose: To test shoulder mobility. Poor flexibility at glenohumeral joint a common cause of acute and chronic injury. Increasing flexibility is an effective pre-emptive approach to reduce injury likelihood.

Set up	Scoring
Client stands with one arm extended overhead, holding wooden dowel in line with spine Place second hand on dowel as closely as possible below the first Measure the distance between hands with the width (4 fingers) Repeat with the other side	3 = Less than 1 hand width between hands 2 = Less than 1.5 hand widths between hands    1 = More than 1.5 hand widths between hands    0 = Pain during test

Trunk stability push up

Purpose: Core strength is essential for everyday movements and spinal health. Poor core strength is attributed to issues like lower back pain. Sedentary postures decrease firing frequency.

Set up	Score (male)	Score (female)
Clearance: ‘Cobra Prone Hold’. Progress if no pain experienced (graded as pass or fail) Adopt prone position with chest & hips on ground, feet together and hands at chin (males) or shoulders (females) Lift whole body off ground as ‘a unit’ and hold end position for 3 seconds	3 = Hands at temple 2 = Hands at chin 1 = Failed at chin	3 = Hands at chin 2 = Hands at shoulders 1 = Failed shoulders

Static lunge

Purpose: Unilateral – tests balance, medial knee and ankle strength, tightness of hip flexors.

Set up	Scoring
Dowel placed down spine and comfortably held in place. Feet directly in-line with one another Perform lunge movement until back knee touches the ground Repeat for 3 reps, and then the other side	3 = Knee to ground, balance maintained, spine straight 2 = Knee not to ground, spine not straight 1 = Balance cannot be maintained

Lying leg raise

Purpose: Test of hamstring flexibility. It can also be used to assess hip flexor/abdominal activation if not done as a passive movement.

Set up	Scoring
Client lying on back, legs flat on floor and relaxed Passively flex hip with knee kept straight to full range of motion Repeat on the other side Note: There should be little to no movement for the opposite hip and bottom leg	3 = less than 90° hip flexion achieved 2 = between 120-90° hip flexion achieved 1 = greater than 120° hip flexion achieved

Harvard step test

Purpose: To measure the aerobic capacity of your client in a submaximal fitness testing method.

Equipment:

• Step/box 50cm for males or 40cm for females or 30cm modified for all age groups
• 60 bpm metronome
• Calculator
• Stopwatch

Set up: Have your client start with both feet on the floor and facing the step. Practice the stepping cycle as follows:

1. Up-right foot up
2. Up-left foot up
3. Down-right foot down
4. Down-left foot down

Once your client has started, they must keep in time with the beep. Their step rate should be 30 completed steps per minute.

They must maintain the stepping cycle for 5 minutes or until exhaustion.

After the 5 minutes is complete, measure the heart rate for 30 seconds at:

• First minute = 1:00-1:30 after finishing
• Second minute = 2:00-2:30 after finishing
• Third minute = 3:00-3:30 after finishing

Then enter their results into the equation:

• (100 x test duration in seconds) divided by (2 x sum of heart beats in the recovery periods)

For example, 300 seconds and their number of heart beats between the first 1-1½ minutes was 90, between 2-2½ it was 80 and between 3-3½ it was 70 their score would be:

• (100 x 300) / (240 x 2) = 62.5

Note: you are using the total number of heart beats in the 30 second period, not the clients heart rate (beats per minute) during that time.

300 seconds = 5-minute duration of the test

Throughout the test we should regularly monitor how our client is feeling. If they feel any discomfort the test should be stopped.

If we need to stop the test measure:

• The duration of the test, in seconds; and
• Their heart rate (as the same as step 3)

Data for Harvard Step Test

Gender	Excellent	Above Average	Average	Below Average	Poor
Male	>90	80-90	65-79	55-64	<55
Female	>86	76-86	61-75	50-60	<50

Rockport 1 Mile Walk Test

Purpose: To assess an individual's cardiovascular fitness level.

Equipment:

• Treadmill
• Stopwatch
• Phone for website
• Scales

Set Up:

1. Record weight
2. Set treadmill to 1% incline
3. Allow your client to have a 1 minute warm up of easy walking
4. Start the stopwatch after the minute and as soon as the client is as the appropriate speed
5. Walk one mile (1609 metres/1.609 km) as fast as possible
6. Record the time to complete the one-mile walk
7. Immediately on finishing the walk record your heart rate (beats per minute)
8. Now use the Rockport calculator to estimate VO2 max http://www.brianmac.co.uk/rockport.htm

Females: VO2 = 139.168 - (0.388 x age) - (0.077 x weight in lb.) - (3.265 x walk time in minutes) - (0.156 x heart rate).

Males: add 6.318 to the equation for females above.

Considerations:

• There are no set number of reps. The client should repeat until you are confident with your scoring.
• The client should perform initial set without any feedback, using their natural movement.
• The personal trainer should view from all angles – may be best to start side, then back, then front.

Testing for components of fitness

Testing for components of fitness involves assessing an individual's physical capabilities in specific areas such as cardiovascular endurance, muscular strength, muscular endurance, flexibility, and body composition. These tests are covered in Exercise Prescription Part B. If you wish to review some of the tests, expand the accordions below.

Further fitness testing for balance, muscular endurance, and mobility are provided below:

test name	Description
8 Foot Up & Go	The client circles the cone in the shortest possible time at a distance of 2.44 m from the sitting starting position and returns to the starting position.
30-Second Chair Stand	The client repeats full stands from the sitting position. Repetitions are performed within 30 s with the arms crossed over the chest.
Arm Curl	The client flexes the forearm with a 3.5 kg weight in 30 s. The result is the number of repetitions.
Back Scratch	The client tries to join the hands behind the back, leading one hand from the top, and the other from the bottom. The result given in centimeters indicates the distance between the middle fingers. The value may be negative when the client reaches further than the fingertips.
Chair Sit & Reach	From a sitting position on a chair, the client tries to reach the toes with the leg straight in the knee joint. The result in centimeters shows the distance between the fingers and the toes. The value can be negative when the patient is out of range of motion.
6-Min Walking Test (6M2WT)	The test result is the number of meters the patient walked along a 30-m corridor in 6 min.

Balance testing

Many elderly clients or those with balance issues may have goals on improving these aspects of their fitness.

• The Fullerton Advanced balance scale
• The Romberg’s Test proprioception balance assessment
• The 4-stage balance test

Let's look at some examples of programme modification for common special population groups.

Programme modification for an elderly client

The following programme has been designed specifically for an elderly client getting back into exercise.

Joan's programme

Weekly schedule

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Walk	Programme (PT session)	Rest	Aqua aerobics	Rest	Programme	30-minute waterfront walk

Weekly accountability checklist:

• 5,000 steps per day (average)
• At least 12 exercise sessions over the month
• Maximum of one chocolate biscuit per day

Programme

Warm-up: Watt Bike 3-minutes

Mobilisation: 10 reps of Open the Gate, Cat-Cow, Thread the Needle, Walk the dog

Exercise	Rest	Set 1, Reps	Set 2, Reps	Set 3, Reps	Load	Notes
Swiss ball squat	60s	12	12		4kg dumbbell	Down to 90, push through heels
Glute bridge	60s	15	15			Pause and squeeze at top
Wall push-up	60s	10	10			Keep spine neutral
Band pull apart	60s	10	10		Green band	Squeeze shoulder blades together
Ab crunch	60s	10	10			Eyes on ceiling
Reverse crunch	ss	12	12			Superset with the above movement

Cool-down and mobility: 5-minute walk on the treadmill followed by 30-seconds of the following stretches:

• Cat-Cow
• Childs Pose
• Downward Dog
• Cobra
• Lotus
• Forward Fold

Explanation

As you can see, this programme is designed to be a gentle re-introduction to exercise. Some points to be considered: 

• Most exercises are regressed (scaled down) versions of some standard movements that general clients may use (e.g., Swiss Ball Squats, Wall Push-Ups). 
• There are no high-impact exercises due to the decrease in bone density. 
• No unilateral (e.g., lunges) or exercises where balance has a major impact. 
• No overhead movements due to the impact on blood pressure and hypertension.
• Most exercises are still primarily free weight movements to keep the programme functional.
• There is a significant mobility section at the conclusion of the programme to help keep the client mobile.
• Aqua aerobics is included in the client’s weekly exercise regime because it is easy on the client’s joints and has a social component, an important aspect of exercise for the elderly. 

Programme modification for an adolescent client

The following programme has been designed specifically for an adolescent client who is new to the gym and resistance training. The client wants to build strength and develop muscle.

Tamati's programme

Weekly schedule

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Rest	Weights (PT session)	Football practice	Weights (PT session)	Football practice	Rest	Game

Weights Programme

Warm-up: Rower 1,000m

Mobilisation: 10 reps of Leg Swing, Cossack Squat, Calf Pumps

Activation: 10 reps of floor glutes bridge

Exercise	Rest	Set 1, Reps	Set 2, Reps	Set 3, Reps	Load	Notes
Goblet squat	60s	10-12	10-12		12kg kettlebell	Down to 90, push through heels
Walking lunge	60s	12	12		BW	Back knee towards floor
Push-up	60s	8-10	8-10		BW	Keep spine neutral
Inverted row	60s	8-10	8-10		BW	Squeeze shoulder blades together
Bench dips	60s	15	15		BW	Back close to bench
Farmers walk	60s	100m	100m		15kg dumbbells	Small fast steps
Russian twist	60s	10	10		5kg dumbbells	Entire torso rotates
Plank	ss	60s	60s		BW	Engage core

Explanation

As you can see, this programme is designed to be a functional, minimal load-bearing introduction to weight training. Some points to be considered: 

• It is a full-body programme. The client is too inexperienced for a multi-day split programme.
• No excessively heavy loads to begin with.
• There is a focus on functional movements with a big emphasis on correct technique. 
• All the primal patterns are included in the programme. 
• There are a lot of BW (body weight) or light-loaded closed kinetic chain exercises to teach him fundamental movement patterns.
• He has only been prescribed 2 resistance training sessions a week. A higher volume will come with time.
• It’s important to have a personal trainer to supervise him as adolescents (particularly boys) can be tempted to ‘ego lift’, which can create bad habits or even injuries.

Programme modification for a client with obesity

The following programme has been designed specifically for a client with obesity client. He has hypertension and has a busy, stressful job in the CBD. He has used alcohol and food as a way to try to manage stress.

Carl's programme

Weekly schedule

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Rest	Programme (PT session)	30-minute walk local park (HR 120-140bpm)	Rest	Programme (PT session)	30-minute walk local park (HR 120-140bpm)	Yin Yoga Class / 40-minute swim

Weekly accountability checklist:

• 8,000 steps per day (average)
• At least 12 exercise sessions over the month
• Limit alcoholic beverages to 4 per week

Programme

Warm-up: Assault Bike 20 calories

Mobilisation/activation: 5 reps of Cat-Cow, Thread the Needle, Walk the dog

Exercise	Time	Rest
Assault bike	30	30
Goblet squat	30	30
Glute bridge	30	30
Treadmill (brisk walk)	30	30
Incline push-ups	30	30
TRX rows	30	30
Rower	30	30
Ab crunch	30	30
Leg lowers (single leg alternate)	30	30

2 rounds with 2 minutes in between.

Cool-down and mobility: 5-minute walk on the treadmill followed by 30-seconds of the following stretches:

• Cat-Cow
• Childs Pose
• Sphinx
• Lotus
• Recline Pigeon

Explanation

Some points to be considered:

• The programme is based on circuit training. Often trainers are overly focused on weight training. We need to ensure we get the right balance of resistance training and cardio. This circuit allows both to be included.
• There are no high-impact exercises due to the loading on joints, bones, muscles, and ligaments. 
• All exercises are catered to a deconditioned client new to exercise. There is nothing too advanced. 
• No overhead movements due to the impact on blood pressure and hypertension.
• There are relatively short work periods and long rest periods. We can alter these as the client adapts to exercise. 
• Yoga has been recommended for the client as a positive way to reduce stress. 
• Low-intensity steady state (LISS) training is included client’s weekly exercise regime.    
• There is still room for some of the clients’ vices (e.g., drinking) but in moderation. Cutting out all together is seldom adhered too.