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EXERCISE & NUTRITION AS THERAPY ASSESSMENT 2
SPECIAL POPULATION CASE STUDY
BACKGROUND AND RISK STRATIFICATION
CLIENT INFORMATION: (Background)
Name Mrs Mrudula Joshi.
Health & fitness goal:
1. Feel good every day and stay healthy.
2. Improve strength in arms and legs.
Personal information:
Age: 81 years & 2 months. Gender: Female.
Birth Date: 8/6/1938. Occupation: Teacher.
Height: 147 cm. Weight: 53 Kg.
Medical history:
1. Present: 2. Past:
Hypertension (1998) Right leg femur bone multiple fracture Osteoporosis (2004) (2007) Left hand wrist fracture (2013)
Family history:
The reason behind the father’s death was heart problems: died because of cardiac arrest.
The reason behind the mother’s death was old age. Few members in the family had blood pressure/hypertension issues. No one used to smoke but neither they did any sort of physical exercises but the lifestyle was not sedentary.
Other readings:
1. RHR: 78
2. Blood pressure: 145/95 mmHg.
3. Total cholesterol: 151 | HDL: 76 | LDL: 63 | VLDL: 12 | Triglycerides: 61
4. MHR: 220-age = 220-81 = 139 bpm (Calculate Your Maximum Heart Rate, 2018)
5. BMI: Weight in kg/ (Height in m)2 = 51/ (1.47)2 = 23.6 (Calculating BMI Using the Metric System, 2014)
Any restrictions or suggestions: (by the GP)
1. Nutritional suggestions: Reduce sugar, sodium, oils, spicy food intake.
2. Physical suggestions: No heavy object lifting, walk with a stick in hand, no jerks to joints, Strengthening of muscles necessary.
3. Lifestyle suggestions: Socializing important, be as active as possible.
Observations: (by the client)
1. Can’t bend down fully (both forward and backward bend)
2. Can’t sit on the floor. (only on a chair or a bed but can’t with legs crossed)
3. Slower actions, the speed of movements has been reduced drastically.
4. Reduced strength and breathing capacity.
5. Can’t turn to a side if sleeping on the back easily.
Note:
The client is 81 years old, short but more in weight. We need to consider a few factors which can affect a person’s physical as well as psychological health ; fitness. Those can be stated as Age, Gender, Body composition, past and present medical conditions, lifestyle etc. Her BMI is under 30 but resting heart rate is high could affect her performance.
The client does not smoke nor does consume any sort of alcoholic drinks. The lifestyle of the client is sedentary. Because of old age, cannot climb up or downstairs. According to medical history, the client has high blood pressure since 1998 (145/95 mmHg) and osteoporosis since 2004 which resulted in bone fractures in 2007 and 2013. The client was bedridden for 6 months because of Femur bone multiple injuries and later client’s hand was in plaster for 4 months because of wrist fracture injury. Rehabilitation and physiotherapy had been taken by the client for a year after the injuries. Till now the client has not been hospitalized post these accidents. The client was having an inactive or sedentary lifestyle for more than 10-15 years because of the mentioned situations. Household works are the main source of any physical activity for the client. Sometimes, short walks around the society for 15-20 minutes. The client has negligible experience in resistance training nor any sports.
According to nutritional records, full meals consumed 4 times per day with a less quantity of proteins, a larger quantity of carbs and a negligible quantity of fats.
The client has filled the SIT Private Health Risk Questionnaire form in which she has answered all the fundamental questions regarding her health and lifestyle so as to help trainer understand, assess and plan an exercise program for a particular period.

Sport & Exercise
Private Health Risk Questionnaire
According to (SIT, 2018) following a private questionnaire will help us to decide whether or not it is safe for you to participate in an exercise test. If you answer yes to any of the following questions (except #26), you may increase your risk of experiencing some unpleasant side effects or even evoking a heart attack during the test.
Part 1 – Known Diseases (Medical Conditions)
1.

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List the medications/drugs you have taken within the last 72 hours or take on a regular basis.
1. Hyperlipidemia: Clopivas 75
2. Heart problem: Cardace & Aztor 5
3. BP: Nebicard 2.5
2.
Please list any drug allergies you have.
1. Rablet Yes
3. Do you have diabetes? No
a) If yes, please indicate if it is insulin-dependent diabetes mellitus (IDDM) or non-insulin-dependent diabetes mellitus (NIDDM).
IDDM
NIDDM
b) If IDDM, for how many years, have you had IDDM? N/A Years
4. Have you had a stroke? No
5. Has your doctor ever said you have heart trouble? Yes
6. Do you have asthma? No
a) Do you get exercise-induced asthma? No
b) Do you use an inhaler? No
7. Are you or do you have reason to believe you may be pregnant? No
8. Is there any other physical reason that may prevent you from participating in an exercise test?
Osteoporosis

Yes
9. Has your doctor ever advised you not to do strenuous exercise?

Yes

Part 2 – Signs and Symptoms

10. Do you often have pains in your heart, chest, or surrounding areas, especially during exercise?
No

11.
Do you suffer from bone or joint problems, or any other complaint that may be made worse by strenuous exercise?
No

12. Do you often feel faint or have spells of severe dizziness during exercise?
No

13. Do you experience unusual fatigue or shortness of breath at rest or with mild exercise?
No

14.
Have you had an attack of shortness of breath that came on after you stopped exercising?
No

15. Have you been awakened at night by an attack of shortness of breath?
No

16.
Do you experience swelling or accumulation of fluid in or around your ankles?
No

17. Do you often get the feeling that your heart is beating unusually faster, racing, or skipping beats, either at rest or during exercise?

Yes
18.
Do you regularly get pains in your calves and lower legs during exercise which are not due to soreness or stiffness?
No

19. Has your doctor ever told you that you have a heart murmur? No

Part 3 – Cardiac Risk Factors
20. Do you smoke cigarettes daily, or have you quit smoking within the past two years?
No

If yes, how many cigarettes per day do you smoke (or did you smoke in the past two years)? N/A per day
21. Has your doctor ever told you that you have high blood pressure?
Yes
22. Has your father, mother, brother, sister had a heart attack or suffered from cardiovascular disease before the age of 40?

Yes
If yes,
a) Was the relative male or female? __Male
b) At what age did he or she have the stroke or heart attack? __40
c) Did this person die suddenly as a result of the stroke or heart attack?

Yes
23. Have you experienced menopause before the age of 45? Yes
If yes, do you take hormone replacement medication? No
Page 4 – Lifestyle
24. Does your job involve you sitting for a large part of the day? Yes
25. What activity pattern best describes your lifestyle?

Sedentary
26. Do you exercise/train regularly No
If yes,
a) Frequency (number of sessions): ___N/A per wk
b) Duration (per session): ___N/A minutes
c) Intensity: Low Moderate High
d) History: 12 months
e) What types of exercise/training do you do? N/A
27. Do you feel that you may be unaccustomed to strenuous exercise? Yes

Part 5 – Injury
28. Have you a current/recent/long-term injury? Yes
If yes, please explain (history, treatment details, clearance to exercise)
1. Right leg femur bone multiple fractures (2007)
2. Left-hand wrist fracture (2013)
29.
Please list any illness, hospitalization or surgical procedure within the last two years?
No
Part 6 – General
30. Are you feeling unwell, or suffering from a viral infection, or cold? No
31. Do you suffer from any blood-borne infectious disease e.g. hepatitis, HIV etc.? No
32. Do you have any allergies and/or intolerances?
Please specify if answered Yes:
Lactose intolerance Yes
33. Did you have any difficulty in understanding any of the above questions? No

This form is totally confidential to the individual concerned, and the information will not be made available to the Southern Institute of Technology. (Adapted from “Pre-Exercise Health Screening Guide”, Olds & Norton, 1999)

HEALTH RISK ASSESSMENT: (Risk Stratification)
Any person planning to start any kind of physical activity should go through a health risk screening and risk stratification process. This screening is important and the reasons according to Niemann (Nieman, 2011, p. 23) are:
1. To identify individuals needing a referral to a health care provider for an extensive medical evaluation.
2. Ensuring the safety of exercise testing and participation.
3. Determining appropriate exercise programs and tests for the individuals.
The following are the risk stratification categories, according to ACSM risk levels, considered for this study: (Nieman, 2011, p. 23)
1. Low Risk: A young person (less than 45 years old men, less than 55-year-old women), with no more than one coronary disease risk factor and without symptoms or known disease. Tests: Sub-maximal and Maximal.
2. Moderate Risk: An older person (more than or equal to 45 years of age in men, more than or equal to 55 years of age in women), or with two or more coronary disease risk factors. Tests: Sub-Maximal
3. High Risk: A person with one or more symptoms of the cardiopulmonary disease, or with cardiovascular, pulmonary and/or metabolic disease Test: No tests without a doctor present, no exercise without a doctor’s clearance.
According to the Private Health Risk Questionnaire filled by the client, she currently comes under the category of high risk. According to the ACSM guidelines for risk stratification mentioned above, the client is ‘HIGH RISK’ as stated above. Therefore, no tests and exercises should be done without any clearance from GP.
As the client is declared as a high risk, she should be given an exercise program based on 40-60% of VO2max. (Nieman, 2011, p. 23). Considering her age, gender and medical conditions, the trainer should aim for 40% of VO2max initially.
Considering all the above factors, a trainer should take safety under consideration first. The client needs to be under supervision continuously while exercising or doing any physical activity.

LITERATURE REVIEW
CURRENT SCENARIO FOR HYPERTENSION AND OSTEOPOROSIS:
Globalization, urbanization, an upgrading information technology and artificial intelligence, quick access to the world using just 3 letters; www.; all these improvements and achievements are replacing human activity and integrating, changing human being’s life and lifestyle rapidly now-a-days. Even if these things are improving our so-called hectic life reducing down the physical activity, these are actually shattering our physical, psychological, intellectual health. The results are in front of us. Chronic illnesses, unnecessary injuries, depression, nutritional frauds etc. are some of the examples of how our enhanced lifestyle is actually downgrading our life.
Hypertension also called as high blood pressure (abbreviation HT or HBP or HTN) and osteoporosis are one of the main diseases or physical conditions which affect human beings. According to the World Health Organization, hypertension or heart-related disease are increasing day by day and they are nothing but the world’s largest killer until now (Q;As on hypertension, 2015). Men, as well as women nowadays, suffer from such chronic conditions because of their poor lifestyle. Studies have shown that more than 7 million deaths have been found because of HT that can be shown in percentage as 12.8 of all the deaths totals. If calculated considering adults, globally, less than 50% of the total young adults are suffering from HT. (Global Health Observatory (GHO) data- Raised blood pressure- Situation and trends, 2018).
According to the National Institute of Health (NIH) “osteoporosis is nothing but a skeletal disorder. It is considered as compromised osteo power inducing the risk of bone cracking or simply fracture.” (Smith S., 2009, p. 270) Here osteo power is nothing but bone strength and bone density and bone quality which can be found reduced over a period of time in case of osteoporotic patients. Studies have shown that osteoporosis is affecting more than two hundred million women globally (greater number than men because of physiological reasons) in which elderly women are getting affected the most and estimated number is: 1 in every 3 women but 1 in every 5 men to get osteoporotic problems worldwide (FACTS AND STATISTICS, n.d.)
However, these conditions can be treated and prevented if we learn about them by opening our eyes. Let us see how these conditions are affecting humans and how can they be handled so as to improve human performance.

INTRODUCTION OF HYPERTENSION:
Hypertension or high blood pressure is nothing but a chronic heart condition or long-term medical condition which nothing but increases the pressure of blood in human being’s arteries, as the name suggests. High blood pressure would not cause any damage to a person but what damages human’s physiology is if the high pressure remains in the body for a longer duration. It affects arterial health, heart health, vision, kidney and vascularity problems etc. (Q;As on hypertension, 2015). HT is known as ‘the silent killer’ because it shows no symptoms. Such asymptomatic nature results in delaying in actions to get it checked by the doctor and disease remain undiagnosed ; untreated (Moore, 2005).
Difference between systolic and diastolic blood pressure:
Unit for BP is mmHg which stands for millimetres of mercury and usually, the first value is nothing but a systolic pressure and second value can be read as diastolic pressure. Its value can be written as 120/80 mmHg. Let’s compare these BPs.

Figure 1 Difference between systolic and diastolic BP (Systolic vs. Diastolic Blood Pressure)
Clinical diagnostic norms for HT:
There are specified norms to diagnose if one has high blood pressure. According to the American Heart Association, (AHA, 2014):
1. Normal BP: Systolic – & less than; 120 mm Hg, Diastolic – & less than; 80 mm Hg
2. Prehypertension BP: Systolic – 120-139 mm Hg, Diastolic – 80-89 mm Hg
3. Hypertension Stage 1: Systolic – 140-159 mm Hg, Diastolic: 90-99 mm Hg
4. Hypertension Stage 2: Systolic – ? 160 mm Hg, Diastolic – ? 100 mm Hg
5. Hypertensive Crisis: Systolic – & greater than; 180 mm Hg, Diastolic – & greater than; 110 mm Hg.
These norms are based on blood pressure measurements calculated using a sphygmomanometer or blood pressure gauge, inflatable cuff and stethoscope.
Types of HT:
As per Chris Iliades, MD, stated in one of his articles, ‘different types of hypertension’, there are 2 main types but further can be added more based on specific diagnostic criteria as follows:
1. Primary high blood pressure (can be called as essential)
2. Secondary high blood pressure
3. Isolated systolic
4. Malignant
5. Resistant
According to Chris, (Iliades, 2009), most individuals diagnosed are primary and remaining people are of secondary HBP type. Essential HBP is asymptomatic in nature, therefore, GP will suggest 3 or more tests so as to get to know if the individual has HBP. Primary or essential is nothing but hypertension occurred because of lifestyle and genes or heredity. Whereas, secondary HBP is caused due to an abnormality of arteries, hormones as well as thyroid problems, past or present diseases etc.
Signs and symptoms of HT:
In any case, an individual should not diagnose himself or herself. Being a silent killer, hypertension will show some or other signs but those would not be severe for the patient to know what is happening and why. As per stated in an article published on Heart.org (What are the Symptoms of High Blood Pressure?, 2016), facial flushing, dizziness, blood spots in the eye are the direct signs but nose bleed or headaches are not the signs for most of the people who suffer from HT.
Prevention & treatment for HT:
According to the World Health Organization, (Q&As on hypertension, 2015), any individual can prevent initially HBP problem by implementing these four steps as follows:
1. Positive lifestyle changes such as healthy diet, consistent physical activity, mindfulness so as to reduce anxiety and tension level.
2. If considered perfect diet: avoid extra sodium, reduce saturated fat intake as well as opt for more fruits and vegetables.
3. Say no to tobacco and same like items.
4. Reduce your alcohol consumption or take it down to zero percent if possible.
INTRODUCTION OF OSTEOPOROSIS:
Definition: It is nothing but a skeletal disease which is systematic in nature, which later results in reduced bone mass and microarchitectural deterioration of bone tissues. (Li G., 2017). As the name suggests, ‘osteo’ stands for bone or bone structure and ‘osis’ can be defined as a deformity in that particular region. Osteoporosis generally diagnosed by measuring BMD which stands for Bone Mass Density.
Types of osteoporosis:
Susan S. Smith, PhD, and Susan A. Bloomfield, PhD states mainly 2 types of osteoporosis as follows (Smith S., 2009, p. 271):
1. Primary: This type can occur in all the sexes as well as in any age but most probably it occurs postmenopause in women and one of the reasons could be a deficiency of estrogen. (typically, between 50 to 80 for women and 70 and older for men) (Smith S., 2009, p. 271)
2. Secondary: secondary osteoporosis is nothing but a result of various drugs or medications, if a person has had any disease earlier or in present then late complication could be osteoporosis, also other conditions like athletic amenorrhea etc. (Smith S., 2009, p. 271).

Risk factors for Osteoporosis:
Gender or sex, certain races, family history, improper body composition, less estrogen levels in women, smoking, amenorrhea, history of fracture, alcohol consumption, reduced calcium and vitamin D intake, overdose of protein and caffeine as well as salt and vitamin A, inadequate exercises, some specific illness or diseases and mainly age (Smith S., 2009, p. 271).
Sites on human body which are at the highest risk of damage are nothing but:
1. Back (cervical, thoracic and lumber)
2. Hip complex and surrounding bones
3. Wrist complex
Sign and symptoms of osteoporosis:
As the name suggests, signs of osteoporosis are to be diagnosed in an individual using his or her bone mass density. Common signs for osteoporosis are nothing but weak bones, low bone mass in a skeletal system that means it increases bone fragility and fracture risk (Li G., 2017).
Prevention & treatment for Osteoporosis:
The disease can be prevented by improving one’s nutritional habits first and lifestyle changes can be made so as to complement the nutrition plan. Studies have shown that there are few ways through which one can reduce the chances of getting osteoporosis in an older age which can be compiled as follows:
1. The client must increase the intake of calcium, protein, fruits and vegetables. People suffering from the disease should eat more calcium, protein ; vitamin, mineral-rich food on daily basis. Protein will help recover the body as well as reduce the age-related bone mass loss. Calcium is the main source to increase the bone density as bones are made up of calcium mainly. (FACTS AND STATISTICS, n.d.)
2. There are supplements available in case required for patients to add more vitamins and calcium. (vitamin D especially) (FACTS AND STATISTICS, n.d.)
3. Patients should expose their skin under the sun so as to get the benefit of free vitamin D from sun rays. Vitamin D and calcium work together in the body to improve bone health. (FACTS AND STATISTICS, n.d.)

EXERCISE AS A THERAPY:
Exercise, as well as nutrition, can be used as medicine and therapy over conventional, modern, non-organic medicines. As we grow old we tend to lose muscles, strength, agility, overall functionalities and bodily capabilities. According to the New Zealand government, studies have proven that exercises can restore our motor functions and can help us grow old in a better way as follows:
1. It will improve the client’s overall strength and endurance (physical as well as mental) (physical-activity-for-older-people-factsheet, 2013, p. 1).
2. Reduces the risk of illness and falls by improving immunity, balance and coordination. (physical-activity-for-older-people-factsheet, 2013, p. 1)
3. Flexibility, mobility around joints as well as sleep pattern will undergo positive changes. (physical-activity-for-older-people-factsheet, 2013, p. 1)
4. If performing any group activity, it will surely social interaction resulting in an improvement in physical and mental wellbeing & quality of life. (physical-activity-for-older-people-factsheet, 2013, p. 1).
There is a direct relation between exercises and diseases like cardiovascular diseases (CVD), HT, diabetes mellitus (DM), osteoporosis, stroke, obesity or metabolic syndromes etc. that any kind of physical activity can improve these conditions in a positive way showing reduced symptoms and recovery. (Thompson, 2014, p. 9)
Exercise prescription & guidelines:
According to Ann and Heather, A mix of high-impact action, quality preparing, and adaptability work out, in addition to expanded general everyday movement can lessen medicine reliance and human services costs while keeping up practical freedom and enhancing personal satisfaction in older people. Be that as it may, patients regularly don’t profit from such practices and remedies since they get unseemly directions and sometimes false instruction. Successful exercise solutions incorporate proposals on Frequency, Intensity, Type and Time which narrow down to FITT principle. Changes in physical action require numerous motivational techniques including exercise direction and objective setting, self-observing, and critical thinking instruction. Through patient contact for network support, trainers can design an advanced way of life that is fundamental for healthy aging. (McDermott, 2006, pp. 437-444).

There are many risks associated with exercising, if not done in a correct manner, such as:
Sudden death because of heart attack/ failure which can be also called as myocardial infarction, physical injuries or fractures, increased heart rate (HR) etc. therefore, the trainer must be aware of these conditions while teaching exercises. (Thompson, 2014, p. 9)
Hypertension (Gordon, 2009, pp. 107-113):
1. Important medication:
Beta Blockers nothing but attenuate heart rate (HR) by roughly 30 contractions/minute. Alpha 1 Blocker, Alpha 2 Blockers, Calcium Channel Blockers ; Vasodilators may cause post workout hypotension which results in seizures sometimes or dizziness (Gordon, 2009, pp. 107-113).
2. Contraindications:
No exercise for clients having a resting Systolic BP of above 200 mm Hg or Diastolic BP of Above 115 mm Hg. No overhead, head below 90-degree position or head-low position and jumping exercises to be given as they may elevate the levels of BP. (Holmes, 2013).
No breath holds which is known as Valsalva Maneuver breathing technique (famous in bodybuilding, powerlifting, weightlifting like sports) as it may lead to a rise in BP (Holmes, 2013)
3. Precautions:
If the BP response is well controlled by the use of drugs, the client could start with the exercise program. Goals must be realistic and possible in the short as well as the long run. (Gordon, 2009, pp. 107-113).
Osteoporosis:
1. Important medications:
With calcium and vitamin D supplements, there is hormone replacement therapy (HRT), Bisphosphonates and zoledronic acid, selective estrogen receptor modulator (SERM), calcitonin like medications available which heals bones and increases mineral density so that risk of fracture reduces. (Osteoporosis overview, 2018) these can cause nausea, indigestion, the risk of cancers and blood clots.
2. Contraindications:
It is a degenerative bone disease; therefore, the trainer should not ask the client to do any high-intensity dynamic movements as well as trunk flexion-extension, trunk twisting as it can damage the spine by loading trunk with unnatural weight. (Rohmann, 2017)

3. Precautions:
Most importantly, wear proper training gear so as to avoid falling or any injury. In case of exercise which has a risk of fall, perform in front of the mirror and beside a wall or pole. (Moreira, 2014).
According to AHA and ACSM, physical activity recommendation chart:

Table 1. physical activity recommendation (Heyward, 2014, p. 3)
In the human body, there is a combination of large and small muscle groups irrespective of age and gender. According to the guidelines provided by the American Heart Association (AHA), an exercise program should consist of major muscle first that too 2 -3 days/week. (Pollock, 2000, p. 831). For older adults or veterans, repetition range should be between 10-15 so as to adapt to the movement patterns. Coordination and balance exercises should be included while stretching. The program must not be lengthy and should stay under 10 to 12 exercises maximum. The range of motion (ROM) should be full so as to build functionality for day-to-day activity (Pollock, 2000, p. 832). Flexibility is one of the main factors to be focus on when planning an exercise program for veterans because, because of the degradation of the human body ROM also reduces with tightness in joints and muscles. 2 to 3 days/week plan for mobility would complement resistance training as well as aerobic training in a better way (Pollock, 2000, p. 829).
Benefits associated with exercises:
As per stated in the book written by Vivian Heyward, the volume of the training is the major factor which contributes to the improvements in physical health benefits which is known as ‘Dose-response relationship’. That means if an individual suffering from chronic disease wants to advance in a positive manner in his/her lifestyle or wants to recover from the chronic conditions, then the person should increase the total amount of physical movements he/she is doing. (Heyward, Physical activity, health and chronic diseases, 2014, p. 4) some of the benefits of exercises are as follows:
1. Lower risk of: dying prematurely, strokes, fractures, metabolic syndrome, adverse blood lipid profile, various types of cancers etc. Reduces tension level, nervousness levels, obesity or subcutaneous/ visceral fat on the body etc. Benefits in: healthy weight loss, intellectual function, recovery, sleep value, bone as well as muscle mass etc. (Heyward, Physical activity, health and chronic diseases, 2014, p. 6)
2. Benefits in cardiorespiratory function: increases VO2max uptake, lowers RHR by slowing down heartbeats, increases training thresholds and pushes cardiovascular limits, improves capillary density in tissues of muscle etc. Lowers CVD risk factors: reduces insulin need, improves glucose acceptance, reduces swelling, lowers resting BP etc. decreases morbidity ; mortality. (Thompson, 2014, p. 10)
3. Overall it changes body composition by reducing fat and increasing muscle mass, increases HDL and lowers LDL, increases stroke volume in heart, submaximal and maximal endurance time as well as ups the metabolic rate or basal metabolism. (Pollock, 2000, p. 829).
Conclusion:
Gathering all the information one can conclude that exercise is nothing but a therapy or a medicine to a person suffering from any medical problems or health hazards as well as to an individual who is living a healthy lifestyle in absence of any adverse medical condition. ‘Exercise’, If done in a correct manner and honouring all the rules, will definitely improve anyone’s health and fitness regardless of his/her age, gender and body composition.
Collecting all the data together one can conclude that chronic and degenerative conditions are to be handled very carefully while executing exercises. Pre, during and post assessments, feedbacks, medications and nutrition are very important so as to avoid the risk of the unwanted situation. While performing exercises keep all the required equipment handy.

FITNESS ASSESSMENT & STRATEGIES AND GOALS
Fitness assessment and testing:
Considering first condition as hypertension for the client, which is lifestyle-based disease, trainer should assess the client with taking safety measures into consideration and should follow following steps: if any client has mild or borderline HT, he/she can exercise but if its severe then one’s ability to do any strenuous physical activity decreases automatically and that person should not exercise too much. (Skinner, 2005, p. 307) if one wants to assess any patient with HT then trainer should test them when the patient is on drugs rather than testing them when they are not consuming a drug. Also, interpretation of electrocardiograph (ECG) is mandatory so as to work in a safer environment (Skinner, 2005, p. 308).
Considering second condition as osteoporosis for the client, which is skeletal-disorder, trainer should assess the client with taking safety measures into consideration and should follow following steps: according to Kerri M. Winters-stone ; Christine M. Snow, skeletal status, as well as fall risk, should be included in the assessment which can further be classified by using bone mass density BMD, dual-energy X-ray absorptiometry (DXA), quantitative ultrasound (QUS), bone turnover and leg strength (chair sit-to-stand), balance (standing or dynamic walking), gait (up and go test), vision, hearing, medication interaction etc. respectively. (Skinner, 2005, p. 175)
A continuous requirement for drugs or medication without any physical activity or exercises to balance health problems may prove fatal and complicated in the long run (Ilyas, 2009, pp. 3-6). These conditions can be improved by following simple rules we stated before and implementing and incorporating physical exercises and adequate nutritional food to your lifestyle.
Purpose and concept for physical assessment:
David Nieman (Nieman, 2011, p. 26) comments on the purpose of assessing the client pre, during as well as post-exercise plan for the following reasons.
1. To measure strength as well as weaknesses at that particular situation.
2. For the evaluation of progress.
3. To get knowledge of special needs for a client so as to develop the program which will help the client achieve results faster.
4. To teach or educate the client as well as get the client’s fears out and motivate her/him.
5. To develop future fitness assessment and tests based on previous results and build a progressive fitness plan.
Assessment strategies:
Considering the client’s background, family history and body composition, the trainer should contemplate some basic things before starting with the exercise regime. Fitness assessment should be done on basis of medical reports, interview of the client and a Health Risk Questionnaire. The client lives in India currently. So physical testing/assessment and analysis are impractical. Notwithstanding, few guidelines for fitness testing ; assessment in line with the ACSM’s guidelines could be given.
The most important thing is, be sure to assess the client in the presence of a cardiologist, a GP and a trainer. All the required equipment, such as a heart rate monitor, blood pressure digital machine (for faster measurements) or sphygmomanometer, in this particular case, should be kept handy in an emergency. Pre, during and post-exercise health checkup, constant monitoring and feedback are necessary so as to keep an eye on the above-listed risk factors. A trainer should ask questions, communicate with the client, motivate the client to do activities and help achieve their goal/goals.
Physical tests to be performed:
When carrying out tests explain with demonstration and inform them about the tests that are to be performed. The client is a very old person, in this case, the trainer should not force the client to complete the sets or repetitions. For the senior client, it is important for them to be functionally fit so as to do their own work in day-to-day activity and therefore we need to assess them for these few tests before starting with workout regime (Keick, n.d.).
1. Arm curls: Bicep curl test with suitable weight as many times as the client can. (weight must be decided by asking the client to hold and analyze). This test is for the client’s arm strength. (Keick, n.d.) (Wood, 2018)
2. Chair sit-to-stand: Ask the client to squat down to touch the hip an sit on the chair and then get up as many times as the client can. This test is for the client’s leg (mainly thigh and hip) strength. (Skinner, 2005, p. 175)
3. Back scratch: Ask the client to touch one hand on the back keeping it beside the ear and another hand beside the obliques so as to touch both hand’s fingers behind the back. Then measure the distance between the finger. This test is for the client’s arm or shoulder mobility (Keick, n.d.).
4. Chair sit and reach: Ask the client to sit on a chair keeping the legs straight ahead and simply touch the toes. This test is for the client’s hip, lower back, hamstring and waist mobility (Wood, 2018).
5. Brisk walk test or 8 foot up and go test: Ask the client to get up and touch one of the corners as fast as he/she can and come to the original point or start point. Measure the timing. This test is for the client’s speed, agility, balance and coordination (Wood, 2018).
These tests can be performed on the client before the start of the exercise program as well as at the end of the exercise program so as to determine the progress and physical & mental response to the program designed.
SMART goal:
Client’s goal should be S: specific | M: measurable | A: achievable/attainable | R: realistic/relevant | T: timely/time bound. That is what SMART stands for.
Main fitness goals to focus on for the client:
1. Improve overall muscle strength and strength-endurance (specifically, in arms and thighs).
2. Improve breathing technique (belly or full thoracic breathing technique).
3. Weight management (reduce weight by 3-4 kgs) with help of proper nutritional plans.
4. Improve joint health (mainly shoulder, wrist and fingers, knee).
5. Flexibility and mobility around joints (hip or waist, shoulder and knee).
Program do’s and don’ts: (for the trainer)
Mainly, the trainer should focus on making the client feel happy and relaxed post exercise. Communication and motivation will play a big role in this case. To achieve these goals, the trainer must teach client 3 things:
1. Breathing technique (belly breathing)
2. Form and technique (of the exercise being performed)
3. Muscle focus (contraction of the muscle being used)
Don’t:
1. Heavyweight training (Nieman, 2011, p. 26)
2. High impact exercises (HIIT, any type of aerobic activity) (Nieman, 2011, p. 26)
3. High-intensity training (Nieman, 2011, p. 26)
4. Sudden movements or jerky movements
5. Head low position exercises (Holmes, 2013)
6. Long duration exercise program (DerSarkissian, 2017)
7. High set or high repetition program (DerSarkissian, 2017)
8. Static hold for a longer duration or with weights (Skinner, Cardiovascular condition, 2005)
Do’s:
1. Preferably sitting exercises (Factora, 2013)
2. Without or less weight or load movements or exercises (DerSarkissian, 2017)
3. Breathing focus more and no breath holding (no Valsalva maneuver breathing method) (Holmes, 2013)
4. Easy static or passive (if the client allows) stretching exercises (DerSarkissian, 2017)
5. Meditation and mindfulness techniques (Factora, 2013)
6. Posture correction exercises
7. Keep heart rate monitors handy every time
8. Pre and post exercise nutrition important
9. Pre, during and post exercises feedbacks are important/ talk test (DerSarkissian, 2017)
10. Exercises in front of mirror and trainer so as to ease the movement by observing self visually while working out.
11. Check if the client has appropriate clothes and footwear before starting workout sessions.
These are main exercise strategies trainer must focus on while conducting the workout session.
Note:
Aerobic training not taking under consideration as the client is suffering from HT (even if 5 days/week recommended by ACSM/AHA) as well as osteoporosis, both at the same time, has no previous experience of aerobic training. Clients goal is to improve strength at this moment and not aerobic capacity. The client is old enough to not run or even brisk walk. If done aerobic training, the risk will be the highest in this case. Therefore, all focus will be on gaining strength as well as ROM around main joints and coordination or balancing mechanism.
PROGRAMME
Physical fitness components: (on which the program should primarily focus on)
1. Muscular strength-endurance.
2. Flexibility and mobility (around joints).
3. Warm-up and cool-down
Client details:
1. Age: 81 years and 2 months (provided by the client)
2. Gender: Female
3. RHR: 78 bpm (calculated by the client after waking up immediately)
4. BMI: 23.6 (previously calculated)
5. Weight: 53 Kg (provided by the client)
6. Height: 147 cm (provided by the client)
7. BP: 145/95 mm of Hg (provided by the client)
8. MHR: 139 bpm (previously calculated)
9. RPE: in the range 1 – 3/4 (rate of perceived exertion) (RPE Scale – Modified BORG)
10. Training intensity: 40 to 60% of VO2max as the client is declared high risk. (Nieman, 2011, p. 23). Calculations as follows:
Using Karvonen formula: (Wood, Heart Rate Karvonen Formula, 2010).
“Target Heart Rate = ((maximum HR ? resting HR) × % of Intensity) + resting HR”
= ((139-78) * 0.4) + 78
@ 40% intensity = 102 bpm.
= ((139-78) * 0.6) + 78
@ 60% intensity = 115 bpm.
@ 40% – 60% of 1RM (repetition maximum) for resistance training:
1-2 Set of 8-12 repetitions (depending on client’s feedback using talk test as mentioned above) for at least 8-12 different exercises (excluding flexibility exercises).

Exercise Program:
Considering all the required information, gathered from an interview with as well as a questionnaire filled by the client and above calculations, an exercise program for 8 eight weeks can be carried out below:
Periodization:
1. Mesocycle: 8-week plans (divided into 3 main weekly cycles in this case, explained below)
2. Microcycle: per week or weekly plans
3. Individual cycle: daily plans (carried out below in exercise program charts)
The client needs to understand the basics of strength training as well as coordinate exercises with breathing pattern as the client is new to resistance training. Therefore, concluding that the client will need at least 3-4 weeks to adapt to new movement patterns before incorporating any progression in the decided workout regime. Therefore, dividing 8-week plan into 3 main cycles: 1st cycle will consist of 1st 4 weeks, the 2nd cycle will consist of 5th & 6th week and the 3rd cycle will consist of 7th & 8th week as follows:
In weeks 1st to 4th: 3 days per week (alternate days: example, Monday-Wednesday-Friday)
In weeks 5th and 6th: 2 days per week. (example, Monday and Thursday or Tuesday and Friday) as per the client’s comfort.
In weeks 7th and 8th: 2 days per week. (example, Monday and Thursday or Tuesday and Friday) as per the client’s comfort.
Note:
Even if suggested 10-15 repetitions for client >65 age with chronic conditions, the trainer must consider the rest of the factors (history and conditions) also before planning an exercise program. In this case, the client is unaware of the basic movements as well as old enough to get tired easily. Therefore, instead of 15 repetitions, 8 – 12 repetitions would be more beneficial initially. As the client progresses, all the suggestions and recommendations would be taken into consideration because progressive overload is the key to gain strength. (Progressive Overload: The Key Workout Requirement, 2018).

A workout program for weeks 1 to 4: (preprogram information, tests, safety equipment, consent forms and medical results gathered)
1. Warm up session: 5 min of walk around the house + warm-up drills for main joints + belly breathing technique practice (sitting).
2. Rest and intervals: 60 seconds. Question the client about RPE every time.
3. Full body strength focused exercise program:
no. Exercise name/description Sets Reps Load
1 Seated neck presses
(4 side presses)
(neck flexion) 1 8 each side Trainer’s help needed
2 Seated shoulder shrugs
(scapular + shoulder elevation) 1 8 No load
3 Standing/seated shoulder-blade pinching (scapular retractions)
(against the wall if possible) 1 8
(5 sec hold if possible) No load
4 Pec-dec final position presses
(palms touched together and presses)
(shoulder horizontal adduction) 1 8 Self-squeezes
5 Seated bicep curls
(hammer curls)
(elbow flexion) 1 8 Squeeze ball in hand
6 Seated wrist curls (flexion) and extensions and rotations 1 8 each variation Squeeze ball in hand
7 Seated waist twisting ; side bending
(truck horizonal rotation + lateral flexion) 1 8 A stick over traps
8 Seated leg extensions with toe raise
(knee extension + ankle dorsi flexion) 1 8 No load
9 Seated adductor/groin press/squeezes with leg extension hold
(towel fold presses)
(hip abduction) 1 8
(5 sec holds max) Towel rolled between knees
10 Standing leg curls
(knee flexion) 1 8 No load

4. Flexibility focused exercises program: (static stretching)
no. Exercise name/description Sets Reps Time hold (sec)
1 Trapezius stretch both ways 1 1 5
2 Forearm stretch (up ; down) 1 1 5
3 Overhead triceps stretch 1 1 5
4 Lateral shoulder stretch 1 1 5
5 Sitting forward bend (for lower back) 1 1 5
6 Sitting hamstring stretch 1 1 5
7 Sitting calf ; shin stretch 1 1 5
8 Overhead long hands stretch 1 1 5

5. Cooldown session: 5 min belly breathing technique practice with mindfulness or meditation (lying on back).
Total time period for the session: 30 – 35 minutes including warm-up, strength and flexibility program, cooldown and meditation and rest intervals.

A workout program for weeks 5 and 6: (preprogram information, tests, safety equipment, consent forms and medical results gathered)
1. Warm up session: 5 min of walk around the house + 5 min joint activation ; warm-up drills + belly breathing technique practice (sitting).
2. Rest and intervals: 60 seconds. Question the client about RPE every time.
3. Full body strength focused exercise program:
no. Exercise name/description Sets Reps Load
1 Seated neck presses
(4 side presses)
(neck flexion) 1-2 8-12 each side Trainer’s help needed
2 Seated shoulder shrugs
(scapular + shoulder elevation) 1-2 8-12 No load
3 Standing/seated scapular retractions
(against the wall if possible) 1-2 8-12
(5 sec hold if possible) No load
4 Pec-dec final position presses
(palms touched together and presses)
(shoulder horizontal adduction) 1-2 8-12 Self-squeezes
5 Seated bicep curls
(hammer curls)
(elbow flexion) 1-2 8-12 Squeeze ball in hand
6 Seated wrist curls (flexion) and extensions and rotations 1-2 8 -12 each variation Squeeze ball in hand
7 Seated waist twisting
(truck horizonal rotation) 1-2 8-12 A stick over traps
8 Seated side bending
(lateral flexion) 1-2 8-12 each side A stick over traps
9 Seated leg extensions with toe raise
(knee extension + ankle dorsi flexion) 1-2 8-12 No load
10 Seated adductor/groin press/squeezes with leg extension hold
(towel fold presses) (hip abduction) 1-2 8-12
(5 sec holds max) Towel between knees
11 Seated calf raises
(ankle extension/plantar flexion) 1-2 8-12 No load
12 Standing leg curls 1-2 8-12 No load

4. Flexibility focused exercises program: (static stretching)
no. Exercise name/description Sets Reps Time hold
1 Trapezius stretch both ways 1 1 5-10
2 Forearm stretch (up & down) 1 1 5-10
3 Overhead triceps stretch 1 1 5-10
4 Lateral shoulder stretch 1 1 5-10
5 Sitting forward bend (for lower back) 1 1 5
6 Sitting hamstring stretch 1 1 5-10
7 Sitting calf & shin stretch 1 1 5-10
8 Overhead long hands stretch 1 1 5-10
9 Balance: keeping both the legs together 1 5 10

5. Cooldown session: 5 min walk around house (talk test/ feedbacks) + 5 min belly breathing technique practice with mindfulness or meditation (lying on back).
Total time period for the session: 40 – 45 minutes including warm-up, strength and flexibility program, cooldown and meditation and rest intervals.
Workout program for weeks 6 and 8: (preprogram information, tests, safety equipment, consent forms and medical results gathered)
1. Warm up session: 5 min of walk around the house + 5 min warm-up drills for main joints & belly breathing technique practice (sitting).
2. Rest and intervals: 60 seconds. Question the client about RPE every time.
3. Full body strength focused exercise program:
no. Exercise name/description Sets Reps Load
1 Seated neck presses
(4 side presses) 1-2 8-12 each side Trainer’s help needed
2 Seated shoulder shrugs 1-2 8-12 1-2 Kg
3 Standing/seated scapular retractions
(against the wall if possible) 1-2 8-12
(5 sec hold if possible) No load
4 (Lying on the back) chest press 1 8 1-2 Kg
5 Seated bicep curls 1-2 8-12 ½-1 kg
6 Shoulder 45/90/180 degree raises
(front + 45 degree + lateral raises) 1-2 8 Squeeze ball in hand
6 Seated wrist curls and extensions and rotations 1-2 8 each variation ½ Kg
7 Seated waist twisting ; Seated side bending 1-2 8-12 A stick over traps
9 Seated leg extensions with toe raise
(sandbags in each ankle) 1-2 8-12 ½ Kg sandbags
10 Standing leg raises
(front + side + back)
(hip flexion + abduction + extension) 1-2 8-12 No load
11 Standing calf raises 1-2 8-12 No load
12 Standing leg curls 1 8-12 ½ Kg sand bags

4. Flexibility focused exercises program: (static stretching)
no. Exercise name/description Sets Reps Time hold (sec)
1 Trapezius stretch both ways 1 1 5-15
2 Forearm stretch (up ; down) 1 1 5-15
3 Overhead triceps stretch 1 1 5-15
4 Lateral shoulder stretch 1 1 5-15
5 Sitting forward bend (for lower back) 1 1 5
6 Sitting hamstring stretch 1 1 5-15
7 Sitting calf ; shin stretch 1 1 5-15
8 Overhead long hands stretch 1 1 5-15
9 Balance: keeping both the legs together
close eyes if possible (trainer must support) 1 1 5-10

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