CASE #2 – BODY MECHANICS

There are many factors to consider when designing an exercise program for an obese individual
who suffers with joint pain and gait abnormalities. The program should be based on a low-
intensity activity where the duration can be progressively increased and where there is minimal
stress placed on the joints and the activity produces minimal muscle fatigue. Gait and balance
training will also be a vital link in maintaining autonomy for these individuals. Guidelines to
consider should include activities that will restore joint range of motion, flexibility, and balance;
increase muscle strength and endurance, and enhance joint stability.

Initially, exercise can be done in the water and will provide many benefits. Using a recumbent
bike should wait until the client is feeling stronger, has improved their balance and gait, as well
as having some relief from the joint pain. Placing too much stress on the joints in the early
stages of exercise will only discourage the individual and put them off from engaging in a
regular fitness routine.

For this individual, the boyancy of water provides an unloading of weight bearing joints of the
spine, knees, and hips. This is helpful for those who cannot tolerate exercising on land due to
joint pain. Water also provides assistance and resistance while exercising so that one can
progress through various levels of activity while increasing strength. People who suffer from
arthritis often have an improvement in range of motion from exercising in the water and
overweight patients also enjoy water exercise by burning calories in an environment that assists
in cushioning their joints.

As the client achieves greater levels of fitness, you can gradually engage them in land-based
weight and cardio training programs. Simple, basic movements are best and can be performed
by using weight machines and lighter dumbbells. Resistance training will help strengthen bones
and muscles and thereby improve functional fitness -- the ability to perform everyday tasks and
activities with greater ease. Furthermore, a higher muscle-to-fat ratio increases metabolism for
greater caloric expenditure. When prescribing cardio exercises, treadmills or recumbent bikes
are best since they can be done with a minimal amount of effort.

Exercising three days a week is a good starting place. As the client adjusts to the program, you
can progress their workouts up to five days per week. You may have to start the client with
three ten-minute bouts of exercise – ten minutes of cardio, ten minutes of strengthening, and
ten minutes of flexibility. As they become more capable and comfortable with the exercise, you
can add minutes to each area of fitness.

WATER EXERCISE EQUIPMENT: There is a variety of exercise equipment that can be used
to increase resistance in the water as the client gets stronger and needs a greater challenge:

 Buoyancy Belt - helps maintain proper vertical position in the water

 Water dumbbells for upper body resistance exercises
 Foot cuffs for leg resistance
 Kick boards
 Noodles
 Sample Starter Water Exercise Program:

Monday Tuesday Wednesday Thursday Friday

Warm Up Water Walking Warm Up Water Walking Warm Up

Gait Training … Body Toning … Balance & Core Body Toning … Gait Training …
Balance & Range of Upper & Lower Strengthening Upper & Lower Balance & Range of
Motion Body Strengthening Body Strengthening Motion

Wall Stretches Wall Stretches Wall Stretches Wall Stretches Wall Stretches

Tips for performing Core Stabilization: Before performing any strength exercise begin by
tightening the core without changing the position of the spine. Instead of “pulling the belly in”
think of creating an abdominal brace creating no physical change in the core. Working in the
aquatic environment provides an ideal environment to focus on increasing endurance of the
abdominal and erector spinae groups critical for good posture and back health as well as proper
movement execution while performing strength training exercises.

Muscle Groups to Strengthen and Stretch: Strengthen weak muscles, typically the upper
back (rhomboids, middle & lower trapezius, serratus anterior & posterior deltoid); abdominals;
buttocks (gluteals); and back of the upper thigh (hamstrings) and front of the thigh (quadriceps);
upper arms biceps and triceps. Resistive exercises can be done by using water dumbbells,
noodles, or simply by pulling limbs through the water since the water offers resistance all on its
own. As the participant gets stronger, using the strengthening devices will help to increase the
challenge. Stretch typically tight muscles including the chest (pectorals); back (latissiums dorsi,
lumbar erector spinae); hip flexors; and muscles of the inner thigh (adductor group).

Gait and Balance Consideration: Gait training refers to helping a patient relearn to walk
safely and efficiently. Gait training employs such techniques as strengthening and balance
training to improve stability and body perception as these pertain to the patient's environment.
Gait training often incorporates the use of such assistive devices as parallel bars, walkers or
canes to promote safe and proficient ambulation. Minor gait and balance issues can be safely
addressed by having the client work in the water. They may use the side of the pool for stability
and practice in the shallow end by walking in place, walking forward and backwards, and
walking in circular patterns. As their balance and mobility improves, they can add upper body
movements to increase the challenge. In addition, the patient can practice strength training
techniques which will also serve as balance exercises such as squatting, heel lifts, and lunges.
Additionally, the client can work on the treadmill at a very slow pace, practicing their heel stride
and walking cadence in the presence of a therapist for support.