Exercise Prescription for Special Populations

By now, we have ensured a robust process for gathering information on a client and their condition by:

• Pre-screening the client
• Researching their condition
• Liaising with their relevant health professionals
• Conducting baseline assessments on the client.

It is now time to put pen to paper and design an exercise programme.

We're going to look at the 3-steps for this.

• Step 1: Prescribe their weekly exercise routine by using the FITT principles
• Step 2: Design a specific, individualised exercise programme that is safe and effective.
• Step 3: Lead a client towards their health and fitness goals through that programme.

We will also look at several areas to help us effectively train our special populations client/s.

The first step before we start thinking about individual exercises, sets, reps, load, distance, time, etc., is to think about the FITT principles for our client.

Many new trainers mismanage these FITT principles, usually via overprescribing, which can lead to an undesirable training response. Let's have a refresher on the FITT principles.

Watch the following video tutorial to remind you of the fundamentals of FITT principles.

Let's consider how you can adapt these FITT Principles from a special populations perspective.

Frequency

As we know, frequency refers to the amount of times our clients exercise, usually over the course of a week.

Whilst it is likely that we, as exercise enthusiasts, train 5+ times a day it is unrealistic to expect that a deconditioned, special populations client who is new to exercise should do the same.

From a physical point of view training too often could prove to be a bit much initially but we also need to consider exercise adherence from a behavioural point of view. Many clients do not enjoy exercise like we do, in fact, many have a really poor relationship with it. Our job is not necessarily to make them love exercise (some may learn to) but to them to few it as less of a chore and something they can sustain.

We're going to look into ways we, as trainers, can help out with exercise adherence but we can start by prescribing a manageable schedule. 2-4 dedicated exercise sessions per week is a great place for a special populations client to start with. If a client can train twice a week for 30-40 minutes, consistently, they can make noticeable results, especially if they focus on other areas of their holistic health (nutrition, NEAT, sleep, water etc).

Intensity

Intensity refers to how 'hard' a session is. We all know that intensity is an extremely important variable for clients to achieve their goals. We should all be familiar with the General Adaptation Syndrome (GAS), where we must stress our bodies to make positive changes. If we add optimal stress to our body and recover sufficiently, we should be able to 'bounce back' to above the original baseline (super-compensation).

If we don't ensure sufficient intensity, then the body will not respond and change, therefore we need to ensure that we push our clients to a suitable level. The flip side of this is that if we push our clients too much, they may suffer from an undesirable training response (more on this topic later), which physically and behaviourally can affect their ability to move forward with their exercise routines.

Once again trainers can struggle to manage this part of the FITT principles appropriately. What we view as 'a walk in the park' exercise-wise could be a major struggle for a new or deconditioned client. Finding that optimal level of intensity can be difficult early on. Ways we can monitor intensity can include:

• % of Max Heart Rate whilst performing cardiovascular activity. The Karvonen formula is the most accurate way to monitor this.
• % of 1RM whilst strength training. This may not be valid for a Special Populations client as you would unlikely have performed a 1RM test on them.
• The Rate of Perceived Exercise (RPE) scale is a subjective but useful way to monitor cardio and resistance training intensity.
• General observation is another good way to monitor intensity. If a client performed a set and the last repetition seemed as easy as the first rep, then it's likely that the weight is too light for them.

Of course, intensity should be increased as the client gets used to the training. We know this as progressive overload. Increases in intensity must be gradual so the client does not experience an undesirable training response. There are many ways we can progressively increase the intensity of a workout. The following lists a few for resistance and cardio training.

Resistance Training	Cardio Training
Increase load	Increase distance/time
Increase reps	Increase pace
Increase sets	Change terrain
Increase frequency	Increase frequency
Decrease rest time	Add resistance
Include supersets (I.e. two or more exercises performed on top of each other with no rest in between)
Increase range of motion (a great way to overload for special populations clients with poor mobility)
Increase time under tension (TUT)

Time

Time refers to how long a workout is. Once again, this needs to be managed carefully with a special populations client. Sometimes a 30-minute session is ample. Long, gruelling sessions for someone not experienced with exercise can have an adverse effect on them both physically and behaviourally.

When designing a programme for a client it's important to allocate some margin for those unexpected issues during a session. This could include:

• Extra coaching is needed for clients struggling with technique
• Discussion about the other areas of their health (e.g. nutrition, NEAT, sleep, stress, etc.)
• A personal issue that the client may want to share with you
• A busy gym environment.

It's best not to overprescribe and focus on quality not quantity. With resistance training compound exercises will mean that the client is targeted to multiple muscles with one movement and essentially get a 'better bang for their buck' with the programme. Some compound movements may be a little too advanced for a special population client or beginning clients like deadlifts or pull-ups, but there are many gentle compound exercises that we can include such as goblet squats, bodyweight lunges, or inverted rows.

Type

Type refers to the modality or modalities of exercise that you select for your client. This is probably the most important aspect of the FITT principles, selecting the modality or modalities of exercise for your client.

Firstly, you need to ensure that the training is specific to your client's goals and aims (you wouldn't prescribe long duration cardiovascular training to someone who wanted to build muscle). You also need to factor in the principle of individualisation and ensure that the modality of training is suitable for your client's level (you wouldn't give a deconditioned beginner with mobility issues Olympic Lifting).

One of the most important considerations for selecting an appropriate type of exercise for your client is the enjoyment factor. Not everyone (especially special populations clients) love exercise like we do, so if we can find a form of training that our client 'clicks' with, then they are more likely to 'stick' with it. Some different types of training we can select from (factoring in specificity and individualisation) include:

• Steady-state cardiovascular training
• Standard resistance training
• Advanced resistance training
• High-intensity interval training (HIIT) or Moderate-intensity interval training (MIIT)
• Mobility training
• Group exercise
• Combat training (boxing, kickboxing etc)
• Fartlek training
• CrossFit type training
• SAQ.

It is also important that we get the correct balance of exercise types to cater to our clients' wants, needs and preferences. Often trainers will gravitate to what they like to do, which can be to the detriment of the client. For example, if you have an obese client and just prescribed resistance training for them, it would not be ideal to maximise their progress. Sure, resistance training is important and effective, but they need to perform cardiovascular exercise too.

Once you have established your clients' weekly schedule by deciding on the FITT principles, it's time to get a bit more detailed with the actual programming.

Remember, the nature of the programme needs to be determined by the principles of specificity and individualisation. However, in many cases with special populations clients, it will be around health improvement, fitness increase and weight loss. If your client has a more general focus, we can use many options. There is no one-size-fits-all-all for our clients. Therefore, it's a good idea to try and discover your client's preferences regarding exercise.

Let's look at a variety of training options and examples of each programme.

Standard resistance training

Resistance training is an excellent form of training that has numerous health benefits, including:

• Increased strength
• Improved muscle tone
• Hypertrophy (gaining muscle mass)
• Improved movement
• Rehabilitation/Pre-rehabilitation
• Many mental health benefits
• Improved posture
• Increased bone density.

When implementing resistance training with a special populations client, it's important to consider their goals, training history/experience, and condition. Often, trainers over-prescribe with weight training and can get a little 'split-happy'. Remember, a deconditioned client new to exercise will not need an advanced split workout. Initially, a full-body workout with simple, functional exercises is appropriate. It's suggested to keep the reps reasonably high, sets low, load low and rest short.

Ensure that any contraindicated exercises are excluded from the programme for your special populations client. For example, you wouldn't give a morbidly obese client plyometric lunges. It's also essential that programmes are well-balanced, and that agonists and antagonists are targeted evenly.

Cardio Training

Often trainers struggle to get the balance right between weights and cardio. Yes, weight-training is a great modality of exercise, even for an obese client however cardiovascular training is the most effective when it comes to improving heart health and reducing body fat.

We'll look into interval training in the next section but steady-state cardio training is great for clients wanting to improve health and lose weight. These steady-state cardio sessions do not necessarily need to take place in the gym or be supervised by a trainer. In fact, getting outside in nature for these sessions is great as it adds to the enjoyment factor and increases the number of feel-good hormones produced.

It is important to ensure that you prescribe a suitable intensity for these sessions. Initially, we should aim to keep it between 65-75% of our client's max heart rate. It's important to note that for an unfit, deconditioned client it doesn't take much to get their heart rates at this level. So even a pace which we would consider a gentle stroll can be enough initially. Of course, as they get more accustomed to this form of exercise we can utilise the progressive overload principle and increase the pace, the distance/duration, the frequency, and change the terrain (e.g. hills etc).

Interval training

Interval training is a very popular modality of training for Personal Trainers these days. Usually, it consists of High-Intensity Interval Training (HIIT), however, HIIT training may be a little intense for most special populations clients or deconditioned clients so we may have to utilise Moderate Intensity Interval Training (MIIT). MIIT is similar to HIIT training but programmed at a lower intensity. To reduce the intensity trainers can do the following:

• Select exercises that are not too intense or advanced
• Monitor heart rate and keep it at a moderate level
• Monitor RPE throughout the workout
• Reduce work periods
• Increase rest periods

In the example programme below you can see that it is based around a 1:1 work:rest ratio, in this instance Franklin is working for a 30-second period followed by a 30-second rest period. As he gets fitter and more accustomed to exercise both of these variables can change (I.e. increase the work time and reduce the rest time). The programme is based on classic circuit training but other methods of MIIT training can include:

• EMOM (every minute on the minute)
• Tabata (20 seconds on 10 seconds off)
• AMRAP (as many rounds as possible)
• Chipper (high rep training, where you chip away at the reps).

One of the great benefits of using MIIT (or HIIT) training is that we can combine both resistance training and cardiovascular training at the same time.

There are several areas that will help us effectively train our special populations client. The specific areas we will focus on include:

• Session structure reminder
• Effective coaching
• Undesirable training responses
• Exercise adherence
• Stages of change.

Session Structure

The way we structure a PT session with a special populations client is essentially the same as with any other client. There just should be a little more emphasis on certain aspects of the session, such as:

• Verbal screening at the start of the session, particularly around the condition the client is suffering with
• Showing empathy and understanding to any challenges they have faced during the week, without pandering to any lack of discipline. We need to be strong and standards but gracious with people.
• Accountability checks with the health habits/goals you've established for your client, e.g.
  • Exercise sessions per week
  • Steps per day
  • Water consumed
  • Nutritional habits set
  • Sleep hygiene, etc
• Drip feeding the technical coaching points. A lot of special populations clients have not really exercised before or for a long time, so don't expect them to pick everything up straight away. If we over coach at the start it can be quite overwhelming for them so we gradually feed them the key information over time as they progress with their training.

Here's a reminder of the 3 phases of an exercise session with a bit of consideration for a special populations client:

Phase 1: Start

• Greeting
  This should be tailored to your client (e.g. it could be a firm handshake for a business client or a high five for an adolescent). Be sure to break the ice and follow up on anything you connected on in the last session
• Verbal Screen
  When conducting verbal screenings with clients, it is essential to go beyond a generic inquiry about their well-being. Instead of a broad "How are you feeling?" consider more specific and targeted questions to gain insight into any potential ailments or specific areas of concern. Engage in a thoughtful check-in, asking questions that are open-ended. Consider checking on your client's energy levels, and areas of discomfort, seek feedback on past sessions and their lifestyle and daily stresses.
• Accountability Check
  This is an important part of all sessions with any client but crucial for a special population client, particularly one who struggles with keeping up with their exercise schedule. Check in to see if they have done their 'homework' since the last session. Some trainers will check in with their clients electronically in between sessions to do this too. Encourage and congratulate them if they have stuck to their schedule and aim to problem-shoot if they haven't.
• Outline the Session
  Once you've reviewed how they are feeling and how their week has been it's time to start looking forward. Aim to get them excited about the session and highlight any changes or goals that you have for the session.

See the following on how you can implement this first phase. Flip each card to view the examples.

Phase 2: During

We're going to look into the best coaching strategies during a session in the next sub-topic but having a structure to your sessions is really important

• Warm-Up
  Crucial aspect of the workout. Ideally it should follow the RAMP model and be designed specifically for the sessions.
• Main Portion
  A specific, individualised programme being coached using the 4 Cs model (more information in the new section).
• Finisher
  An option aspect in the workout that is usually different from the main portion. Be careful not to make this too intense too early for a special populations client.
• Cool-Down
  Great way to finish. Good time to include static or PNF stretches.

Phase 3: End

• Feedback
  This is about getting and giving feedback. Find out how they found the session and if there was anything they struggled with, perhaps what they enjoyed most. Then give them some feedback. Ensure it is mainly positive but if there is an areas you'd like to see them improve on them ensure you mention it too.  
• Remind them of their schedule
  It's always a good idea to remind them of what they are expected to do without you, this can include exercise sessions, NEAT, nutrition or lifestyle factors
• Confirm the next session and farewell
  Ideally, the majority of your clients will be scheduled in the same timeslots but it's still good to confirm. A nice cheerful farewell is a great way to conclude the session.

See the following on how you can implement this last phase. Flip each card to view the examples.

The 4 Cs of Personal Training

Now that we've had a refresher on how to structure a session, let's look at the key elements to ensure you run an awesome session with your special populations client. Effective personal training hinges on a dynamic blend of coaching, cheerleading, connecting, and caring, creating a holistic approach that fosters both physical and emotional well-being, the latter of which is extremely important when working with your special populations client.

Coaching

Coaching forms the backbone of any successful session, especially early on in the process. This is where you guide your client through their exercise programme with a facilitative approach. It's important to note that with special populations clients, too much information at once can be quite overwhelming for them, so take your time with the technical points. It can be a good option to drip-feed the technical information over time rather than in one hit.

The NAMEDCAT model is a great way to coach a client on a new exercise, with extra attention on a really strong demonstration of the movement and a few concise coaching points (be sure not to bombard them with technical jargon).

• Name the exercise. E.g. goblet squats.
• Area of the body that it targets. E.g. a lower body movement.
• Muscles that it targets. E.g. quads, glutes, hamstrings, and core
• Equipment set up. E.g. how to hold a kettlebell, posture, stance, etc.
• Demonstration (at least 6 reps demonstrated, the first 3 in silence so the client can focus on the visual demonstration.
• Coaching point (e.g. hinge through hips, drive knees out, squeeze glutes at top, etc.  Imagine cues can be really effective but don't overcoach here.
• Action (take your client through a full set with a conservative weight, motivate them and remind them of the key technique points)
• Tips (this is where we get and give feedback and from there offer a few tips to make the movement more effective e.g. 'if you slow the movement down, you'll get a better burn by increasing the tension of the muscles').

Cheerleading

Cheerleading plays a pivotal role in a personal training session. It encompasses motivation, encouragement, energy and support. Beyond the physical exertion, personal training is an emotional journey, often requiring a push past mental barriers. Positive reinforcement and encouragement during challenging moments inspire clients to push through discomfort, fostering a mindset that extends beyond the gym. It's important to bring that cheerleading type of energy to each and every session.

Connecting

Connecting with your client on a personal level enhances the training experience. Building rapport creates a supportive environment, encouraging open communication and trust. Any opportunity you have to find out information about your client is important. Areas such as family, work, hobbies, sports can help you find a common ground and help you connect on a personal level with your client. This connection also morphs into a professional friendship which can help the client elicit positive feelings towards coming to the gym.

Caring

Caring is the foundation that underpins all successful personal training relationships. Genuine concern for clients' well-being goes beyond physical achievements, extending to their overall health and happiness. Trainers who invest emotionally in their clients tend to have better retention rates than those who just focus on the physical aspect of personal training. This empathy creates a positive feedback loop, as clients feel valued and supported, enhancing their commitment to the fitness journey.

In essence, the key to effective personal training is forming a combination of coaching for technical proficiency, cheerleading for motivation, connecting on a personal level, and genuinely caring about the client's holistic well-being. This multifaceted approach not only drives physical results but also cultivates a lasting and positive impact on clients' lives.

Undesirable Training Responses

An undesirable training response is a negative reaction to exercise. This response could be physical, emotional or mental, and it could be an acute or chronic response.

• Acute would be a sudden onset response, usually as a result of a single session. An example of this could be a client feeling nauseous after being pushed too hard by their trainer.
• Chronic would be a bit more gradual over time. An example could be a client suffering from lower back issues due to following an unbalanced programme from a trainer.

There are signs and/or symptoms that can identify undesirable training responses. A sign is seen externally (e.g., a client appearing pale and sweaty), whereas a symptom is felt internally (e.g., feeling faint or nauseous).

The following example broadly lists different undesirable training responses that are both acute and chronic:

ACUTE	CHRONIC
Red-faced	No progress
In pain	Lack of commitment
Negative about workout	Chronic fatigue
Anxious/edgy	Regularly cancelling sessions
Dizziness	Negativity towards trainer
Closed body language	Struggling to complete workouts
Acute injury	Chronic injury
Excessive sweating	Hostility towards trainer
Inability to complete workout	Constant complaining

Some of these reasons could be external environmental factors such as the heat or an overcrowded gym, whereas often it is due to the client, some reasons could include:

• Client has poor nutritional practices
• Client has an undisclosed medical condition
• Client is highly stressed
• Client has poor sleeping patterns.

However, an undesirable training response is usually due to the trainer mismanaging the FITT principles. This is even more true when dealing with a new, deconditioned, or special populations client.

Exercise Adherence

Having a focus on exercise adherence (sticking to exercise) is very important for personal trainers. Many clients, especially special populations clients, struggle to maintain their exercise routines. Often it takes only a minor life obstacle to get them out of the swing of exercise. Some common examples of these obstacles could be:

• The client is getting busier at work
• The client has family commitments
• The client is feeling stressed and/or tired
• The weather is getting colder
• The client is getting bored with the exercise routine
• The client has a busy social life.

It's essential to understand the potential obstacles for our clients and have strategies in place to mitigate the likelihood of them slipping backwards.

Here are five strategies we can use to assist with exercise adherence:

1. Set clear and realistic goals
   Finding out your client's emotional driver and then setting some SMART goals based off that will help keep your client focused and on task. Make sure these goals are specific, measurable, and realistic. Having a clear destination and checking in on progress regularly can motivate your clients to stick to their exercise program.
2. Include group exercise
   Avoid monotony by incorporating other modes of training to their schedule. Group Exercise is a fun, motivating form of training that has a much higher adherence rate than exercising solo. If the gym you work at has a strong group exercise program, look to incorporate some classes into your client's schedule. 
3. Consistent scheduling
   Help your clients establish a consistent exercise schedule. Consistency builds a habit, making it easier for clients to adhere to their routine. Discuss the best time of day and days of the week for their workouts. Consistency is key.
4. Accountability and support
   Stay connected with your clients between training sessions. Offer regular check-ins, provide feedback, and encourage them to keep going. Consider using fitness apps, texts, or email to maintain a sense of accountability.
5. Click'n'stick
   If you can find a modality of exercise your client clicks with, they are more likely to stick with it. Not everyone loves exercise, but sprinkling some enjoyment into the sessions will help with adherence. The training must still be specific to the client's goals and aims, but the more they enjoy it, the more likely they will keep at it.

Remember that motivation can fluctuate, and setbacks are common. As a personal trainer, your role is to guide your clients physically and provide emotional support and strategies for overcoming obstacles. Building a solid trainer-client relationship can significantly impact exercise adherence.

Stages of Change

As a trainer, it is important that we know which stage of change our clients are in. We learned about the stages of change model in the level 4 course, here is a reminder of the different stages and also some advice on how we as trainers can support our clients during the various stages.

Prochaska and DiClemente's Stages of Change model is a widely recognised framework for understanding and facilitating behavioural change. Developed in the late 1970s by James Prochaska and Carlo DiClemente, this model outlines a series of stages that individuals typically go through when trying to modify problematic behaviours or adopt healthier ones. The model consists of six stages, which are often presented in a cyclical fashion, reflecting the non-linear nature of behaviour change. We'll look at this from the point of view of a PT client who has struggled to put health as a priority in their lives.

Stage 1: Precontemplation	In this initial stage, clients are not yet aware or do not acknowledge that they have a problem or need to change. They may be resistant to change and may not see the benefits of altering their behaviour. Trainers will not have a large role to play here as the client has not yet contemplated changing their behaviour, however if we do get the opportunity to liaise with a potential client who is in this stage then we want to be able to give them a reason for wanting to change without being too pushy. It's about planting that seed with the client and informing them of the benefits of focusing on their health.
Stage 2: Contemplation	At this point, clients recognise that they have a problem and are contemplating change. They may weigh the pros and cons of making a change but have not committed to taking action yet. Trainers play an important role in this stage, we need to help magnify the pros and encourage them to explore further. Be available to assist them getting to that next stage without coming on too strong.
Stage 3: Preparation	In this stage, clients are preparing to take action. They may start making plans, and gathering resources or support to make a change. This is where trainers will start the process with their clients, the pre-screening, baseline testing and goal setting are all important parts of this stage. Ensuring the goals follow the SMART model and are based on the client's emotional driver are crucial. Putting in to place some habits around NEAT (e.g. steps per day), exercise and nutrition will help out in the long run. Identifying the possible barriers or obstacles during the pre-screening process will help reduce the client of relapsing.
Stage 4: Action	This is the phase where clients actively engage in behaviours to bring about change. They modify their behaviour, environment, or circumstances, and this phase requires significant effort and commitment. This phase is where trainers do what we do. We offer guidance and support during this phase, providing direction, motivation, accountability and help monitor progress. The goal for trainers is to help maintain the client's momentum to get to the next stage.
Stage 5: Maintenance	After successfully implementing the desired changes, clients enter the maintenance stage. During this phase, they work to sustain the new behaviour and prevent relapse. This stage can be challenging, as individuals must develop strategies to avoid slipping back into their old habits. Trainers keep up the strategies for exercise adherence to keep our clients heading in the right direction. By now trainers should be having established a strong relationship with their clients and be able to keep them accountable. If commitment or motivation begins to regress, then the trainer should aim to turn that around promptly.
Stage 6: Termination or relapse	Relapse is a common experience for many clients, especially special populations clients who have had a checkered relationship with exercise. Trainers should be aware of the client's barriers or obstacles and put systems in place for the relapse not to occur. An example would be a trainer prescribing a 'hotel-based band workout' for clients travelling for business. However, relapses will happen from time to time. If a client goes through this stage and stops training/focusing on their health, trainers should stay in regular touch and encourage clients so that they can get back into the swing of things.

The Stages of Change model emphasises that not all clients progress through these stages at the same rate or in a linear fashion. Clients may move back and forth between stages, and the process of change is highly individualised. A trainer who understands this model and finds solutions to help keep clients in maintenance will more likely have a successful PT career and help change many lives for the better.

Now that we've completed the first two special populations assessments and gone through all the content for designing your programme and delivering the sessions it's time to put it into action. Check out Assessment 1C for an assessment guide video and instructions on submitting your assessments.

This assessment will require you to apply the knowledge you have learned by completing the following tasks:

• Design a series of 8 session plans that are created to meet the client goals including an overview that outlines the programme approach you will take with the client.
• Deliver your 8 exercise sessions on the client over 4 weeks, including an evaluation statement after each session
• Conduct a post-programme re-test of baseline assessments
• Provide an evaluation of the programme's success.