Not all persons can readily join and receive benefits from a traditional group exercise class. The recognition of groups with unique needs has increased the offerings of “speciality classes” for seniors, persons who are overweight, pregnant women, and those with cardiac problems. However, the specific needs of those with physical disabilities have not been fully addressed by any of these classes. Some of these (e.g., cerebral palsy and spinal chord injuries) arc complex conditions that make exercise response quite unique, and limited. Research is available to guide fitness programming for them.
Therefore, the purpose of this chapter is to outline some of the physiological implications and related concerns associated with activity for those who are in need of special attention, including those with specific disabilities, and provide helpful instruction and safety tips. This is a clientele with complex and unique conditions requiring instructors with advanced training and certification, who should work in conjunction with physical therapists to provide effective, safe, and enjoyable maintenance exercise programs for participants who have successfully completed a therapeutic exercise program. Activity for such persons should also be rendered only in conjunction with a health care provider’s prior approval and after consultation. Services must be rendered with the explicit understanding that the non-medically licensed fitness professional is providing service only to improve levels of fitness and physical well-being of clients-not for medical treatment, as that would be outside the fitness instructor’s professional scope of practice.
Physiological Responses to Exercise
Without a basic understanding of how disabilities can affect physiological responses to exercise, the fitness instructor has no way of judging whether the aerobic needs of the disabled participant are being met. While both acute and chronic physiological responses to exercise can be predicted for able-bodied men and women, such responses cannot necessarily be generalized for the disabled person. Depending upon the extent and the type of disability, the degree of physiological response possible will vary from the able bodied norms.
The rationale for an aerobic workout is to exercise the body hard enough to create a demand for a targeted amount of oxygen to be consumed (V02), thus positively stressing the cardiovascular system. It is the role of the cardiovascular system to deliver oxygenated blood to the working muscles and remove the waste products of the energy metabolism from these muscles. With the able bodied population, the limiting factor during aerobic workouts usually involves the efficiency of the cardiovascular system. In simple terms, conditioning (training) strengthens the heart muscle, allowing it to pump more blood per stroke, and improves the efficiency of the skeletal muscles in extracting and utilizing the oxygen.
During exercise, arterial circulation redistributes blood and oxygen from inactive organs to active muscles to support aerobic metabolism. If the ox-ygen demands exceed the ability of the heart to supply oxygenated blood, then the aerobic metabolism will be limited, resulting in fatigue and diminished work capacity. Thus, any condition or disability that affects the control of the heart rate (HR), blood pressure, or myocardial contractibility can reduce the cardiac output response and the overall ability to perform aerobic exercise.
In some cases of spinal cord injury (SCI) above the sixth thoracic vertebra, the autonomic nervous system (ANS) may be damaged to the extent that the HR cannot be stimulated above 100-110 bpm, obviously impairing the ability to distribute large quantities of oxygenated blood in a timely manner. Additionally, lack of sympathetic nervous control affects the maintenance of blood pressure through improper regulation of vasodilation and vasoconstriction. With any lower body paralysis, the skeletal venous pump is absent, resulting in venous pooling and edema which further limits the circulating blood volume.
The amount of oxygen utilized during exercise, and ultimately the degree of stress to the cardiovascular system, is determined by the amount of muscle activity. The more muscle mass working, the higher the demand for oxygen, the more “aerobic” is the activity. If a person is limited in the amount of functioning muscle available, then a large oxygen demand cannot be created and the cardiovascular system will not be fully stressed. Such conditions that limit functional muscle mass include full or partial paralysis, such as with spinal cord injury, spina bifida, polio or cerebral vascular injury (CVA), muscle denervation as with multiple sclerosis (MS), atrophy as with muscular dystrophy (MD), muscle spasticity, common with head injury (Hl), CVA or cerebral palsy (CP), or amputation. In these cases, both the acute and chronic responses to an exercise session would be limited.
If a reduced muscle mass is attempting to do the work of what is normally conducted by a larger muscle mass, then the energy cost of the relatively high work load on the remaining musculature may actually result in an anaerobic, rather than an aerobic, response. Because of the relatively smaller muscle mass involved, the physiological responses to maximal exercise are less for upper body work than for whole body or even lower body work. While the maximal, aerobic potential from exercise may be limited, research has shown that even spinal cord injured quadriplegics can benefit with increases in their cardiac output from an upper body training program.
Assuming that enough muscle mass can be utilized to create an aerobic demand and that there is no damage to the ANS, then long-term physiological responses/improvements will be dependent upon adherence to training principles. When a progressive disability is involved, long-term improvements in fitness level may not be seen. To date, no definitive research has indicated that exercise participation either increases or decreases the speed or severity of the rate of progression.
If an individual is slowly losing muscle functioning due to MD, exercise should help to prevent added loss caused by deconditioning. ft is important to remember, however, that a temporary worsening of the condition may occur in cases such as MS and MD if the muscle is worked to total fatigue. Thus, resistance work should be submaximal and not to fatigue. With rest, a complete return to the participant’s pre-exercise condition should occur. In almost all cases, health care providers and medical associations have supported the participation in regular exercise programs for persons with progressive physical disabilities.
To achieve a training effect from exercise participation, the FITT (Frequency, Intensity, Time, and Type of activity) principle is generally recommended. For apparently healthy adults, the American College of Sports Medicine (ACSM, 2010) recommends an exercise frequency of 3-5 days a week, but takes it a step further regarding heart rate. The reconunended maximun exercise heart rate (HRmax) range for persons who are:
- sendentary/extremely deconditioned is 57-67%. minimally active is 64-74%.
- periodic exercisers is 74-84%.
- regular/habitual participants is 65-80%.
(For more detailed information, refer to ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities which accompanies AFAA’s self study course on this subject matter.)
While the frequency of exercise should not be affected by most disabilities, the recommended intensity levels will be changed with many. Typically, the target heart rate (THR) for exercise is determined using a percentage of the maximal heart rate, estimated by the formula of “220-age.” Because the upper body is not capable of working to the same maximal levels as the lower body, ACSM recommends using the adapted formula of 200 minus your age to determine the HRmax for upper body work rather than the traditional formula.
The HR may not always be a reliable guide to use to set target heart rates for participants with some disabilities. The use of the THR during group exercise classes is based on the linear relationship between HR and V02 established during lower and full body work. With upper body work, when the arms are raised above shoulder level for prolonged periods, the HR may be inflated relative to V02 due to the increased stress on the heart, which is not coincident with an increased oxygen demand. Thus, the use of the rating of perceived exertion (RPE) may be more accurate than the HR in most seated group exercise classes.
The RPE is recommended for use with persons with a spinal injury above the sixth thoracic vertebra, for persons who have limited tactile sensation, persons with attention deficits, and for persons with coordination difficulties that cause them problems in finding their pulse. The use of the RPE should be carefully explained before it can be utilized effectively. With patience and practice, persons who are developmentally and intellectually disabled can also successfully use the RPE scale.
Regardless of whether the HR or RPE is used, persons with MS and MD should be encouraged to work at the lower end of their target zone. If they begin exercising at too high an intensity, fatigue may develop early and preempt the remainder of the workout. At other times, they may not realize that they have overexerted until several hours later when total exhaustion occurs causing a temporary worsening of their condition. With rest, a complete return to the participant’s pre-exercise condition should occur; therefore, an added rest period may be required for them on days of exercise.
The time and duration of aerobic exercise is recommended to be 20-30 continuous minutes or an accumulation of several 10-minute bouts for the sedentary participant. The ACSM recommends beginning a new exercise program for sedentary, deconditioned adults using discontinuous intervals of “hard” to “easy” exercise bouts. Since the sedentary, disabled person will likely be even more deconditioned than the sedentary, able-bodied person, an exercise program should be started conservatively. Over time, the length of the “hard” phase should be increased while the length of the “easy/recovery” phase is reduced until a continuous period can be achieved. When muscle paralysis or weakening, or a progressive disability is involved, a continuous period may never be achievable and intervals may always be the best option. Further discussion on intervals will be addressed later in the section on movement adaptations. Keep in mind, that it is highly recommended that fitness instructors refer certain participants with conditions they are unfamiliar with or untrained to address to other professionals (e.g., clinical exercise physiologists).
Other associated concerns may accompany some disabilities. The prevention of most of these problems is the responsibility of the participant. However, an instructor should be aware of the potential for such occurrences. Exercising in high heat and humidity can be dangerous for anyone, especially persons with injury to the ANS, which might occur with a spinal cord injury or MS. Such individuals may have a reduced ability to sweat. The production of sweat and its evaporation is one of the ways the body rids itself of excess heat to maintain the core body temperature.
Another source of heat dissipation is the radiation that occurs as vasodilation and blood flow diversion bring the heat to the body surface. With ANS damage, both of these sources of heat reduction may be absent or reduced, thereby increasing the risk of heat exhaustion or heat stroke. Overheating may also increase the fatigue Level for persons with MS and limit their endurance and ability to work hard. Conversely, working out in cold environments can tighten arthritic muscles or the spastic muscles of someone with cerebral palsy, making fluid movement even more difficult.
Persons with impaired circulation need to be cautious of creating skin irritations that can take a prolonged time to heal. If impaired sensation is involved, the individual may be unaware that an abrasion has developed until a large sore appears. Persons with amputations can develop irritations from sweat increasing friction against the prosthesis. If severe enough, such sores can prevent the ability to wear the prosthesis until healing occurs.
Pressure sores from prolonged sitting are serious problems for wheelchair users who should relieve the pressure with frequent chair “push-ups.” A full bladder may increase the heart rate and/or blood pressure of someone with a spinal cord injury. Emptying the bladder or catheter bag before exercising may also help prevent a bladder accident. Should such an accident occur, the fitness instructor should try to minimize any embarrassment to the participant and call as little attention as possible to any necessary clean up.
Seizure disorders may be an associated condition with many disabilities.
While medication controls the majority of seizures, the fitness instructor should be aware of any class members who have a history of seizures. Seizures are not medical emergencies and do not require medical attention unless they continue for prolonged periods (10-15 minutes) or seem to be following one after another. Long-term exercise tends to reduce seizure activity. Seizures during exercise itself are rare, but post-exercise seizures are fairly common. Multiple seizures may also occur. Following a grand seizure, an individual will likely be tired and need rest. Therefore, the fitness instructor should discourage the person from leaving the facility immediately and alone. It is not uncommon during a grand mal seizure for an individual to lose control of the bowel and bladder. The most important intervention during a seizure consists of protecting the individual from injury without restraining him or her. Remove any objects nearby that could cause injury. Help protect the head from banging on the floor, but again, do not restrain. The fitness instructor can also play an important role in helping relieve any embarrassment that a seizure may cause.
The more a fitness instructor knows about his/her participants prior to the start of a class, the better prepared the instructor can be to help meet the participants’ needs. While it is time consuming, a pre-class interview with a new participant is very beneficial.
Do not assume that a physical disability causes a person to be unhealthy or at unusual cardiovascular risk. Many disabilities are stable, non-progressive, and cause no more inherent risks than occur with an able-bodied person. Follow the guidelines established by AFAA to determine when a physician’s clearance is needed. Increased legal liability should not be an undue concern provided fitness instructors work in consultation with the participant’s health care provider, are properly trained, and follow established guidelines.
A medical history/health risk screening should be required of all new fitness class participants. A few extra questions may elicit helpful background information which need medical clearance prior to the start of a program or special programming. Questions might address whether any special assistance is needed in class or in the locker room, whether or not the individual can transfer in and out of his/her wheelchair independently, and/or whether the individual is currently under a therapist’s treatment. The usage of medication should be noted and any possible effects related to exercise, overexertion, or heat should be determined. Fitness instructors should refer certain participants with conditions they are unfamiliar with or untrained to address to other professionals (e.g., clinical exercise physiologists).
A pre-class interview is a good time to check the degree of balance and stability of the person while standing or sitting. Although the participant may be active in other sports activities, the group exercise class may involve many new movements. A seat or chest belt may provide an added measure of security, provided the material has some give and is not constrictive. Immobilization of a wheelchair may or may not be desirable depending upon personal preference. Certainly, the power switch to an electric chair should be shut off before exercise is begun.
Many movements in a group exercise class can be easily adapted almost automatically to fit someone who is exercising while sitting down, while other movements will need special adaptation. At the pre-class interview, alternative moves can be explored. Any movement in which the majority of the power/aerobic demand is being created by the lower body will need adjustment for someone exercising while seated.
Even though an individual may walk unassisted or even with the use of canes, he or she may not have enough balance to perform cardio movements to tempo while standing. Many ambulatory persons who have had a stroke, head injury, or who have CP may not be able to control their balance while attempting co perform the cardio routines. Thus, sitting for at least part of me class may provide better stability, allow freer movement, and contribute to a more aerobic workout.
Traveling moves. Effective in a traditional cardio class, traveling moves are difficult to perform for those who are seated. On a level surface, a wheelchair is very efficient-even several pushes would not likely be very aerobic for most wheelchair users. Additionally, most classes incorporate traveling moves in sets of four to eight counts. Such short-duration travels consist of only one or two pushes on the wheelchair before braking to reverse the movement direction. Such stop and start moves will be anaerobic at best. During traveling moves, the seated participant will need to find an upper body alternative. Similarly, many low impact classes utilize power moves that involve flexion/extension of the knees and hips to work the body up and down against gravity. It is not recommended that someone seated attempt to mimic this type of move by raising up and down with the trunk-a move that would undoubtedly compromise the back.
Intervals. The use of intervals is an important part of most adapted routines.
Because the upper body musculature is relatively small, even when unaffected by disability, overuse of the muscles can easily result in fatigue. If a disability is involved, over fatiguing the muscle’s could result in an inability to complete the workout and obtain the cardiovascular benefits. This is especially a risk in individuals with muscle weakness and muscle paralysis. Interval usage of the muscles will help reduce the fatigue risk. The important point is to avoid prolonged repetition using the same muscle group. Repeated moves with the arms raised overhead should be followed by moves in which the arms are kept low, allowing the deltoid muscles to relax. Intervals of repeated biceps furls could be followed by triceps work (opposing muscle group). Large movement patterns should be followed by smaller patterns, fast moves by slower.
Balance and coordination. A different problem occurs with ambulatory and non-ambulatory persons with balance and coordination problems, such as found with CP, HI, and CVA. Transitioning from one movement pattern to the next can be quite difficult. Often, persons with balance/coordination problems will lag a few counts behind the rest of the class due to their difficulty in coordinating all the components of the movement. If the movement pattern is changed too quickly (e.g., every 8 counts), the reaction delay and slowness in coordinating the new movement may make it very difficult for the person to keep up. Thus, prolonged repetition is more appropriate. Persons with balance/coordination problems may also have trouble with any intricate foot patterns, dance moves, or multi-part combinations. Simplicity of movement patterns is the key to a successful workout.
Warm-up and cool-down. During the warm-up when lower body limbering or static stretching is being conducted, seated individuals who will not be doing any leg work may substitute arm/shoulder limbering and stretches. Many classes incorporate floor work near the end of class before the final cool-down. If a person does not have any voluntary movement in the lower body, he or she may want to leave class when the floor work begins. If this occurs, the fitness instructor has a responsibility to explain to the participant the importance of a full cool-down and encourage him/her to conduct some stretching out of the wheelchair once at home. Most wheelchair users have chronic tightness from prolonged sitting and are vulnerable to contractures of the hip and knee flexors. Additionally, many paraplegics and some quadriplegics do have some active abdominal muscles and should be encouraged to do as much of a curl-up as possible, even if the shoulders can just barely be lifted off the floor.
Most wheelchair users can benefit from some floor work, but many need some assistance in transferring in or out of their chairs. Proper technique must be followed in assisting in a transfer to prevent injury to the disabled participant or to the person conducting the transfer. Body mechanics in a good lift include using the leg muscles (not the back), keeping a wide base of support, keeping a firm grasp on the individual, and keeping the weight close to the body. For safety of the individual being assisted with the transfer, care should be taken not to scrape the body against the wheelchair or drop the person on the floor. Transfers should be done on soft (matted) surfaces.
The disabled individual should give the directions and feel comfortable with the transfer, There are several different ways transfers can be conducted, utilizing partial to total assistance. Before attempting to give assistance in a transfer, proper training and practice is important. Consultation with a physical therapist or other health care provider for instruction in how to safely perform a transfer may be necessary.
Within a traditional fitness class, much concern is given to proper postural a1ignment in order to prevent undue stress and injury. Malalignment is a symptom of some disabilities, thus postural deviations may be seen and need to be accepted. It is not the role of the fitness instructor to try to correct such deviations, rather the instructor should help the participant achieve as effective and safe a workout as possible. For example, a person with a quadriplegic SCI may need to lean back in the chair for stability due to lack of trunk and abdominal muscles. Toe walking due to excessive tightness in the Achilles tendon and internal rotation of the legs due to tightness in the hip adductors are common with CP. Therefore, many people with CP will not be able to stand in “proper alignment” during class. A fitness instructor is not a therapist and should not attempt therapeutic intervention, since it is outside their scope of practice. On the other hand, the instructor must be aware of contraindicated movements that could have adverse results. When in doubt fitness instructors should refer partici pants to more advanced trained professionals or seek consultation.
Several issues that are not directly related to the fitness instructor’s abilities can affect the success of an integrated program. Such issues include facility accessibility, advertising/promotion, and the type of class taught.
Legal advice concerning service requirements dictated by the Americans with Disabilities Act and similar state laws should be obtained by each programmer.
Advertising and promotion. Spreading the word that a program is open to persons with physical disabilities can be an arduous task Many may feel intimidated to attend a club that is perceived to be a place for “perfect bodies” only. Others may not wish to attend if they think it is going to be a “special” segregated class. Probably the best marketing approach to take is a varied one. Use as many different media sources as possible. If one or two disabled persons are already interested in the class, arrange to have them involved in a photo with the fitness instructor. A resource for participant referrals includes local physical, occupational, or recreational therapists and any local affiliate of Disabled Sports USA or the Veterans Administration. If there is a rehab center nearby, offer to conduct several free sample classes for the patients who are nearing discharge. Some facilities have had success in recruiting by holding demo classes in area malls. As with any new program, word of mouth will probably be one of the best advertisers.
Type of class. If a class limited to those with special conditions is to be considered and is going to be offered, careful thought must be given to the time and day it is scheduled. Most facilities’ “down time” is also the time that is most inconvenient for working adults.
Once the participant is ready, the type of class he/she enters will affect successful integration. For obvious reasons, step classes will probably be the hardest to adapt for persons who are lower body mobility impaired. Similarly, a class that utilizes a predominance of traveling moves will put the disabled member at a disadvantage when it comes to achieving a good workout. Classes consisting of movements that stay in one spot and offer variety in arm and leg moves are more easily adapted for disabled participants. A circuit class may be the best alternative, with a few of the stations modified specifically for the disabled members. Such stations could include arm cycling (with a bicycle secured to the top of a table and the pedals turned by hand) or a rower machine (with the seat stabilized).
If a large number of participants are disabled, a team teaching approach may be beneficial, fun, and initially easier than teaching solo. While the main instructor is teaching class as usual, the co-instructor can make modifications for the disabled participants where necessary. Team teaching can allow for a much more individualized approach, as well as increase motivation and excitement in the class. The ideal technique would be to utilize a properly trained disabled person as a co-instructor if such a trained person is available. To promote the feeling that all participants are equal members of the class, the lead may be changed at times (e.g., have the main instructor teach seated, with the constructor providing alternatives for those standing). Over time, as the participants learn to make adaptations on their own, the co-instructor may be phased out.
Instructor Attitude. A fitness instructor can make or break any class. An instructor can make a workout fun, during which participants are motivated and challenged, or make it an hour of pure sweat and strain. Likewise, an instructor’s attitude can determine whether a person who is disabled participates successfully in a fitness class. Disabled persons are not “special” or amazingly brave just because they carry on in life with a disability. Persons with disabilities are not always friendly, just as those who are able-bodied are not always friendly. The instructor needs to be relaxed and comfortable and treat a person with a disability as he or she treats any other participant.
The bottom line is that a person is a person first, the disability is secondary. A specific comment does need to be made regarding persons with communication problems. If a fitness instructor does not understand an individual’s speech, then he or she should say so. Pretending to understand is condescending, and will not be appreciated by the individual.
It would be difficult in this chapter to describe all the specific concerns and adaptation suggestions for various disabilities. The fitness instructor is encouraged to learn as much as he or she can about the disability, think through the implications, and most importantly, seek additional training. Providing adapted classes can be rewarding for both the instructor and the participant. Proper training can help ensure that it is also safe and effective. Check out the resources that follow for updated information from experts on these medical conditions.