When conducting or supervising exercise sessions you need to be aware of:
-
The signs and symptoms of Exercise Intolerance - This may be indicative of a more serious medical condition.
-
Pre-existing medical conditions - Certain cohorts of clients, such as children, older people, or women who are pregnant, postnatal or menopausal, may have specific needs and conditions which may affect their exercise ability.
Whilst some pain and discomfort is normal during exercise, especially for newcomers who are unfit, there are some instances where exercise should be immediately ceased and medical assistance sought. These include if the client is suffering from:
-
Chest pain.
-
Unusual fatigue or shortness of breath/breathlessness (including asthma).
-
Significant bone, muscle or joint pain.
Defined as a condition or inability to perform physical exercise at a normally expected level or duration. It is not a specific disease or syndrome but can result from various disorders, some of which can be very serious.
Acute (sudden / immediate) symptoms of exercise intolerance include:
-
Fatigue – Organs and muscles of the respiratory system are affected during exercise and can result in dizziness and shortness of breath. As oxygen is no longer being processed efficiently, rest is required.
-
Muscle cramps – They can happen to anyone, however, if they occur in individuals with a minimal amount of exertion this may indicate an issue. Exercise intolerant clients (after stretching) may feel stiffness and pain a few minutes after beginning exercise which can be experienced for days. Other clients may experience these symptoms hours after exercise has ceased. Athletes will experience muscle cramps also, however when a client is exercise intolerant, they experience these symptoms for a longer period requiring a reduction in intensity or a break from exercise.
-
Insufficient heart rate – When the client’s heart rate does not increase to meet the intensity of the physical activity. Weight, age and medical history may add to this resulting, however, depending on the clients’ risk profile, this may be an indication of exercise intolerance.
-
Vomiting and nausea - Nausea may be caused by overeating before exercise, dehydration or overexertion during exercise but can also be due to something serious, such as a cardiac event or lung condition. Sufferers should be monitored and seek medical attention if feeling unusually ill.
-
Blue extremities or face - Discoloration of the extremities and face, appearing as a bluish pallor, can indicate abnormally oxygenated blood. This is a very visible sign of exercise intolerance but also a serious call for intervention. Sufferers should seek medical attention in the event of a serious blood-flow disruption.
Other more chronic or moderate signs and symptoms of poor exercise tolerance which may indicate an underlying condition and therefore should be referred to an appropriate medical or allied health professional include:
-
Recent extreme weight change - Can be related to extreme and potentially unsafe dieting, therefore a referral to a dietitian may be warranted. Other causes can include medication reactions, hormone disorders, and heart, kidney or liver conditions.
-
Frequent or persistent headaches - Can be caused by misaligned spine or muscle injury, therefore a referral to a chiropractor or physiotherapist may be warranted. Other causes can include nerve damage, dietary related, or neurological.
-
Visual problems such as diplopia (double vision) or visual aura (blobs or lights obstructing the client's vision) - Double vision can indicate a serious condition such as stroke, head injury, or brain tumour. Can also be due to severe dry eyes or corneal irregularities. Visual aura is commonly associated with migraines.
-
Balance or coordination deficit - Can be caused by problems with the inner ear such as Benign Paroxysmal Positional Vertigo or Meniere's Disease or Vestibular Neuritis. Can also be caused by migraine, motion sickness, or a head injury.
Exercise intolerant clients should be closely monitored and collaboration sort from medical professionals however they do not necessarily need to cease all exercise activity. If their medical professional is aware of their exercise program and has indicated that exercise will be beneficial for their condition then they can continue.
Ensure that you monitor these clients closely and be on the look-out for any of the conditions/injuries where the cessation of exercise is advised. Monitoring may include the use of technology such as heart rate monitors or apps on smartphones to help determine if the client is stable. Clients must also be aware that they are considered a moderate to high-risk client and that they must not overexert themselves and preferably not exercise alone.
Chest pain may be a result of poor blood flow to the heart leading to angina or restricted arteries resulting in a heart attack. If the client complains of pressure, tightness or pain in the chest and arms which may spread to the neck, jaw or back then immediately cease the exercise regime. Other symptoms include nausea, cold sweats, fatigue, light-headedness or sudden dizziness.
Other conditions, some of which are not as serious, may also cause chest pain or heart related symptoms:
-
Indigestion.
-
Reflux.
-
Muscle strain or inflammation in the rib joints.
-
Herpes zoster (shingles).
-
Panic attack.
Shortness of breath on exertion is a sign that the lungs are not getting enough oxygen or they are not expelling enough carbon dioxide. Whilst it is normal for people to become short of breath during exercising, especially if they are overweight or not very fit. However, any unusual instances of fatigue or shortness of breath, or if the client experiences severe breathlessness, feeling faint, dizzy or has a loss of balance may be due to a serious underlying medical condition.
Symptoms may begin as soon as five minutes or as long as twenty minutes into an exercise routine or up to ten minutes after exercise has stopped. Other symptoms, which may indicate that the fatigue or shortness of breath is unusual include:
-
Chest tightening.
-
Air hunger (the feeling that no matter how deep they breathe they cannot get enough air).
-
Wheezing.
-
Gasping.
-
Coughing.
-
Choking.
-
Sweating profusely.
-
Pale skin (pallor).
-
Bluish-coloured skin (cyanosis).
-
Confusion.
-
Dizziness.
-
Passing out or fainting.
Any unusual and/or severe changes in breathing should always be investigated by a medical professional and if already under medical care, the medical professional should be advised.
If the client suffers from asthma this should be noted on their training program and they should have asthma medication on hand. If, after exercise has been ceased and medication administered, the symptoms of asthma are persisting then call an ambulance.
The musculoskeletal system is made up of muscles, bones and joints. All of these can experience pain or injury during exercise sessions, especially if sudden unfamiliar exercise is undertaken.
Muscles that have not been exercised for long periods of time respond by getting sore if they are suddenly exercised. This soreness begins within a few hours but peaks one to two days after exercise. This is considered normal and will gradually reduce as exercising becomes more frequent. However, the sudden onset of pain and/or a limited range of movement and bruising or swelling may indicate a muscle strain.
Treatment options include:
-
Rest.
-
Ice.
-
Comfortable Support.
-
Elevation.
Tendons that connect muscles to bones may get irritated if they see too much stress too rapidly. They respond by getting inflamed, which is characterised by pain and sometimes swelling (tendonitis). Alternatively, a tendon rupture is accompanied by a snapping or popping feeling or noise and severe pain. Common areas of tendon rupture include Quadriceps; Achilles; Rotator cuff; Biceps. Medical attention is required if a tendon rupture is suspected.
Bones that see increased amounts of stress, particularly in the foot and leg, are susceptible to pain and stress fractures.
Joints is a structure that allows movement at the meeting point of two bones. Cartilage is a cushioning substance that covers the end of the two bones, absorbing shock and enabling the bones to glide smoothly over each other. Arthritis is a condition which affects the cartilage and thus the joints and can cause pain, stiffness and inflammation.
Clients with pre-existing conditions which may or may not be chronic (ongoing) can participate in and definitely benefit from exercise, however, certain considerations and additional care is usually required when determining goals, developing plans and conducting actual sessions.
In all cases, conducting a pre-exercise health screening questionnaire is required. This assessment helps to determine the intensity level recommended for certain individuals and also provides a risk stratification process that you will need to follow to prevent injury or incident. The process for conducting pre-exercise health screening is covered in detail in the next section.
In addition to conducting the pre-exercise health screening, it is highly recommended that you work in conjunction with the client's medical or allied health care team. If the client already has a treating physician then ask them to provide a letter or other communication from their doctor outlining recommended exercises and anything that must be avoided. If they are not currently under any medical care plan and you suspect a pre-existing condition then talk to the client about a possible referral to an appropriate medical or allied health care professional.
The following conditions are not a complete list of all pre-existing conditions that you may encounter, however, they are a summary of some of the more common ones.
Asthma is a restrictive condition of the respiratory system and can cause clients to have difficulty breathing and, shortness of breath, chest pain and in extreme conditions bronchial spasms which can result in the client not being able to breathe. The most common types of asthma medicines are preventers, which are work by making airways less sensitive and help to dry up mucous, and relievers, which are fast-acting medications that reduce symptoms quickly. Often medication is administered by a hand-held inhaler.
When providing physical training to a client with asthma it is essential that the following considerations have been made:
-
Doctor approval is obtained for exercise and exercise type.
-
The client has medication handy.
-
The client is confident that they are aware of their symptoms and controls needed.
-
A full warm-up is undertaken.
-
A warm and moist environment is the best circumstance for a person with asthma to exercise in.
-
The client is encouraged to calmly breathe in and out through their nose in the event of an asthma attack or incident.
Incontinence is the loss of bladder or bowel control resulting in urine or faecal leakage. Urinary incontinence is quite common, especially amongst women who are pregnant or postnatal, children, and also older individuals. The severity of urinary incontinence can range from small leaks to complete loss of bladder control.
Certain types of exercise regimes are more likely to result in some form of leakage in clients who suffer from urinary incontinence, these include running, jumping, lunges, squats, heavy weight lifting, and sports or activities that involve rapid direction change such as tennis, netball, and hockey. According to the Continence Foundation of Australia, safer exercise choices for clients prone to incontinence include:
-
Walking.
-
Swimming.
-
Seated cycling.
-
Low-intensity water aerobics.
-
Low-impact exercise classes.
Strengthening the pelvic floor muscles by performing Kegel exercises can prevent or control urinary incontinence and other pelvic floor problems. To perform Kegel exercise the client must:
-
Identify the pelvic floor muscles - This can be done during urination by stopping the flow mid-stream. This action requires the use of the pelvic floor muscles.
-
Regularly practice - Once the pelvic floor muscles have been identified the action of using them must be practiced (not during active urination) every day. The client should aim to tighten the muscles and hold them for three seconds at a time. Three sets of ten repetitions is recommended each day. Remember, clients should not hold their breath whilst tightening the pelvic floor muscles and should not tense their stomach or buttocks. Ideally there should be no outward indication that the individual is actually exercising these muscles at all.
While we all feel sad, moody or low from time-to-time, some people experience these feelings intensely, for long periods of time (weeks, months or even years) and sometimes without any apparent reason. Clinical depression is a mental health disorder resulting in persistent low mood and loss of interest in activties. It can cause significant impairment in daily life. Biological, psychological, or social distress factors can cause depression resulting in changes to brain function and neural circuit activity.
Symptoms include changes in sleep patterns, appetite levels, energy levels, concentration, self-esteem, sadness, and thoughts of suicide.
According to the Black Dog Insitute research suggests that regular exercise may increase the level of brain serotonin and also the release of mood lifting endorphins. Exercise helps alleviate depression by:
-
Increasing energy levels.
-
Improving sleep.
-
Distracting from worries and rumination.
-
Providing social support and reducing loneliness.
-
Increasing sense of control and improving self-esteem.
Important Note: Whilst studies have shown that exercise is definately beneficial to improving depression the long-term care of a person with severe melancholic depression should be managed by a medical professional and may require the prescription of medication and/or participation in psychological therapies in addition to regularly partaking in exercise activities.
Cholesterol is a waxy substances found in your blood that is used to build healthy cells, it is carried through the blood attached to proteins known as lipoproteins.
There are two types of lipoproteins which transport cholesterol:
-
Low-density lipoprotein (LDL) - Also known as bad cholesterol. This type of lipoprotein leaves cholesterol behind in the arteries which can build up against the walls making them hard and narrow and causing heart problems.
-
High-density lipoprotein (HDL) - Also known as good cholesterol. This type of lipoprotein picks up excess cholesterol and takes it back to the liver.
Both types of lipoproteins are required in certain quantities, however, in some individuals the levels of LDL can become too high resulting in a condition known simply as high cholesterol. Cholesterol levels can be raised by certain foods, and therefore a healthy balanced diet and regular exercise, and in some cases medication, is essential for maintaining health.
Foods that are high in saturated fat have high levels of LDL or bad cholesterol and therefore should be avoided, whereas foods with high levels of HDL or good cholesterol should be increased.
| Foods with high levels of LDL (bad cholesterol) | Foods with high levels of HDL (good cholesterol) |
|---|---|
| Meat pies, sausages and other fatty meat. | Oily fish such as mackerel and salmon. |
| Butter. | Nuts such as almonds and cashews. |
| Lard. | Seeds such as sunflower and pumpkin. |
| Cream. | Vegetable oils and spreads such as sunflower, olive, corn, walnut and rapeseed oils. |
| Hard cheese. | High fibre fruit such as prunes, apples and pears. |
| Cakes and biscuits. | Avocado. |
| Foods that contain coconut or palm oil. | Soy. |
When working with clients who have high cholesterol consider the following:
-
Ensure that the client has GP approval or referral.
-
Follow GP advice regarding the level of intensity allowed.
-
Follow intensity guidelines from the pre-screening tool.
-
Ensure sufficient warm-up.
-
Provide referral to a nutritionist.
-
Build intensity slowly over time.
Also known as high blood pressure. It is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems such as heart disease. Blood pressure is determined both by the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries. The more blood the heart pumps and the narrower the arteries, the higher the blood pressure will be.
Symptoms can be hard to detect until blood pressure becomes quite high, but may include:
-
Early morning headaches.
-
Nosebleeds.
-
Irregular heart rhythms.
-
Vision changes.
-
Buzzing in the ears.
Treatment of hypertension includes making improvements to diet (reducing salt and saturated fat intake), eliminating smoking, reducing alcohol intake, taking medication, and increasing physical activity.
When working with clients who have hypertension consider the following:
-
Regularly test blood pressure, portable machines are available from chemists and other suppliers.
-
Ensure that the client has GP approval or referral.
-
Follow GP advice regarding the level of intensity allowed.
-
Follow intensity guidelines from the pre-screening tool.
Prenatal is before birth (ie. pregancy) and postnatal is after birth and lasts for approximately six weeks.
Pregnant women are encouraged to pursue 20-30 minutes of moderate intensity exercise each day, this recommendation is based on expectant mothers who are healthy with no apparent risk factors to themselves or the foetus. Risk factors to be aware of include vaginal bleeding, premature rupture of membranes, and pre-term labour.
Moderate intensity exercises can include walking, swimming, stationary cycling, yoga, pilates, strength training, and low-impact aerobics.
Exercises that should be avoided during pregancy include:
-
Contact sports.
-
Activities with a high risk of falling.
-
Scuba diving.
-
High impact aerobics.
-
Cycling.
-
Hot yoga.
-
Heavy weight lifting.
During the postnatal period a slow return to full physical activity is advised. The type of delivery that occurred, vaginal or caesarian, will impact on exercise choices as the latter involves major abdominal surgery and comes with serious risks associated with wound maintenance and blood clotting if strenous exercise is commenced too soon. Nursing (breast feeding) mothers may also experience breast discomfort associated with engorgement from milk production.
Guidelines for postnatal exercise regimes include:
-
Obtaining medical clearance.
-
Beginning gradually with low impact, low intensity exercises such as walking.
-
Avoid excessive fatigue.
-
Wear a supportive sports bra and pants that support the stomach.
-
Stop session if unusual pain is experienced.
-
Stop session if vaginal bleeding is more than normal.
-
Drink plenty of water.
.jpg)
Menopause is a natural decline in reproductive hormones in women and generally occurs in the late 40s and early 50s. Common indications that menopause is occurring include:
-
Irregular periods.
-
Hot flushes.
-
Vaginal dryness.
-
Sleep disturbances.
-
Mood swings.
Whilst exercise is not a specific way to relieve menopause symptoms it can help in the maintenance of a healthy weight and the regulating of mood which does have a positive impact. A mix of endurance, strength, and balancing exercises is recommended.
When working with a client who is menopausal consider the following:
-
Potential GP referral if symptoms are extreme.
-
Risk assessment based on symptoms.
-
Strength training.
-
Cardio.
-
Good warm-up.
-
Pelvic floor exercises.
-
Avoid overheating.
Metabolic syndrome is a cluster of conditions, which occur together and increase the risk of heart disease, stroke and type 2 diabetes. The specific conditions include:
-
High blood pressure.
-
High blood sugar.
-
Excess weight around the waist.
-
Abnormal cholesterol levels.
One of these conditions on its own does not indicate metabolic disease however when multiple occur simultaneously (metabolic syndrome) there is a significant risk of life-threatening complications. Prevention and/or reversal of symptoms includes:
-
Regular exercise.
-
Eating recommended portions of vegetables, fruits, lean protein and whole grains.
-
Limiting saturated fat, sugars and salt in the diet.
-
Not smoking.
One of the complications of metabolic disease is diabetes which is a condition where a person has high blood glucose (also known as blood sugar) levels. This condition is caused because the body is not producing or not regulating insulin properly. Insulin is a hormone produced by the pancreas that helps the body use glucose for energy, insulin can be supplemented as a treatment method.
Diabetes is divided into two types:
-
Type 1 is a chronic condition in which the body mistakenly attacks or kills the cells of the pancreas thus preventing insulin production, it is always treated with insulin. This type of diabetes is NOT linked to metabolic disease and it cannot be reversed or cured.
-
Type 2 is a progressive condition in which the body becomes resistant to the normal effects of insulin and/or gradually loses the capacity to produce enough insulin. It is often associated with obesity. This type of diabetes CAN be controlled through diet and exercise (and in some cases insulin) and is possible to reverse.
When a client presents with diabetes it will be necessary to make the following considerations:
-
Work in conjunction with medical professionals.
-
Encourage the client to drink extra fluid to avoid dehydration.
-
Clients may require extra carbohydrates before and during exercise to prevent hypoglycaemia (low blood sugar).
-
Ensure the client is monitoring their blood glucose levels before, during and after exercise.
-
If the patient has Type 2 diabetes then also manage the other symptoms associated with metabolic disease.
Obesity is a treatable condition that is characterised by the excess amount of body fat and the recording of a Body Mass Index (BMI) score of 30 or more.
Body mass index is an approved method of determining a healthy weight range. BMI is calculated by dividing the client's weight in kilograms by their height in meters squared. Depending on the BMI value calculated a person may be underweight, healthy weight, overweight or obese. Being either overweight (with a BMI of 25 or above) or underweight (with a BMI lower than 18.5) can affect a person's health.
The Heart Foundation has developed an user friendly BMI Calculator. It is accessible here.
It is useful to consider BMI alongside waist circumference, as waist measurement helps to assess risk by measuring the amount of fat carried around the middle.
Whilst obesity is primarily caused by an imbalance of calories/kilojoules, not enough burned through activity to compensate for the level of consumption through food, there are other factors such as genetics, psychological factors, sleep deprivation, and hormone imbalances which can contribute to obesity.
Dieting and physical activity are the main treatment options for obesity. In morbidly obese individuals, who may also be suffering from associated conditions such as metabolic disease, the care plan should include consultation with medical and or allied health professionals. These individuals may require drastic interventions as part of their treatment.
It is important to undertake a pre-exercise health screening and fitness appraisal with clients who are obese and commence exercise programs with low-impact, low-intensity exercises and gradually increase the difficulty. Be mindful of self esteem issues that may affect obese clients and offer encouragement, education, and support in a respectful manner.
Osteoarthritis occurs when flexible tissue at the end of bones, known as cartilage, wears down causing joint pain most commonly in the hands, neck, lower back, knees, and hips. Low impact exercises are recommended for people suffering from osteoarthritis, examples include:
-
Walking.
-
Cycling.
-
Swimming.
-
Tai Chi.
-
Yoga.
-
Water Aerobics.
Osteoporosis (meaning porous bone) is a condition in which bones become weak and brittle and are prone to fracture. It can be caused by dietary deficiancies such as a lack of calcium.
Suitable exercises to help prevent and improve osteoporosis include:
-
Strength training.
-
Walking.
-
Cycling.
-
Swimming.
-
Tai Chi.
-
Yoga.
-
Water Aerobics.
A condition that consists of sore joints due to an increase in synovial fluid production as a result of inflammation in the joint. When a client presents with rheumatoid arthritis it is important to make the following considerations:
-
Pre-exercise health screening.
-
Follow all risk stratification procedures.
-
Refer to a GP (if they are not already under a care plan.
-
Start with low intensity.
-
Low impact exercise is recommended.
-
Reduce intensity if joint swelling increases.
-
Avoid over stretching.
-
Avoid hypermobility.
Chronic neck pain is often caused by poor posture and accompanying muscle strain in particular amongst clients who spend many hours sitting at a desk operating a computer or hunched over a laptop or phone / tablet. Specific symptoms of this type of injury include:
-
Pain or difficulty holding the head in a particular position or the feeling of a heavy head.
-
Muscle tightness and spasms.
-
Decreased ability to move the head.
-
Headache.
In these instances the pain can be eliminated by correcting postural alignment of the upper spine / neck area (cervical spine). Occassionally neck pain may be related to a more severe type of injury, such as whiplash sustained during a car accident or due to an awkward fall. This type of acute injury can severely damage joints, muscles, and/or nerves. If the client says that their pain is severe, has persisted for several days without relief, is spreading down arms and legs (nerve pain) or is accompanied by severe headache, numbness, weakness or tingling then a referral to a medical or allied health professional is warranted.
Some common neck strengthening exercises include:
-
Chest Stretch - From a standing position interlock your fingers behind your back, with straight arms and palms facing up. Draw your shoulders back and down keeping your arms straight. Don't arch your back. The stretch should be felt across the chest and front of the shoulders.
-
Neck Stretch - Gently lower your left ear towards your left shoulder and hold for between 10 and 15 deep breaths. Repeat on the opposite side.
-
Neck Rotations - Slowly turn your chin towards one shoulder. Hold for between 10 and 15 deep breaths. Repeat on the opposite side.
As a fitness instructor, it is important that you have adequate training and experience and use professional judgement to determine if a medical or injury situation should result in the cessation of exercise and the referral to/collaboration with medical or allied health professionals. If such as decision has been made there are some key actions you should take include:
-
Explain calmly and without causing undue panic, the risks of exercising in their situation. Don't offer a diagnosis unless you are certain of the problem and ensure they know that it is only your professional opinion, not a medical diagnosis.
-
Remove them from the exercise floor/area to a safe resting place (if they are able to walk).
-
Administer first-aid or other treatment if required.
-
Advise them to consult a medical professional and/or call an ambulance if required.
It is important to understand your scope of practice and ensure you don't overstep your area of expertise. Remember your duty of care which is to prevent harm, which could reasonably be expected to occur in the course of providing advice or instruction to clients.
If an adverse medical event has occurred, stay with the client and ask a colleague or bystander to call an ambulance. If no one else is available then quickly get a phone (preferably a mobile) and return to the client before making the call.
Ensure relevant information is obtained for the call to emergency services such as the client's full name, age, particulars of the incident including any first aid administered, any relevant medical information (if known), and their current status (ie. conscious).
Stay with the client until the ambulance officers arrive, you may be provided with instructions on actions that are required.
