Anatomy and Kinesiology

NYU Professor Julia Evergreen Keefer

This is an Anatomy and Kinesiology, not Physiology class. The focus is on the
musculoskeletal system in movement, which means we will also study the nervous
system that fires it, and the cardiorespiratory system that pumps the blood to nourish
the muscles and bones. We will not be going into the details of the urinary,
reproductive, endocrine, or digestive systems. In order to distinguish between
performance, everyday movement, disease, age, and illness, we will also cover
pathology as it related to specific joints and muscles.

Objectives: To learn the form and function of the muscles, joints, and nerves; to study
movement patterns in space in terms of physics, in an effort to improve function and
design exercise programs that make the transition between physical therapy and

performance training.

Requirements:
Weekly quizzes on anatomy/kinesiology based on the textbooks and Professor
Keefer's lectures
Weekly lab work to move joints, study pathology, and/or design sport-specific or
dance programs
Comparative Case Studies of your choice: midterm progress report and final project
Final Exams, written and practical

Breakdown

Classes meet twice a week, asynchronously online for the lectures, forums, and
quizzes, and once a week at the gym for the practicum. Attendance is crucial for
this hands-on work. Anatomy doesn't change, kinesiology is always improving,
pathology keeps getting worse, but your job is to learn the basics but come up
with innovative programs to solve problems based on your chosen case studies.

Week One: Feet and Ankles

Week Two: Knees

Week Three: Hips

Week Four: Lower Back

Week Five: Upper Back and Neck

Week Six: Shoulders

Week Seven: Elbows

Week Eight: Hands

Week Nine: Gait Analysis and Endurance Sports (running, cycling, hiking, skiing)

Week Ten: Ball Sports (trajectories and teams)

Week Eleven: Dance (ballet, modern, jazz, hip hop, Middle Eastern)

Week Twelve: Martial Artists (impact, contact, interaction)

Week Thirteen: Body Building

Week Fourteen: Final Projects Due. Demonstrate case studies.

Links

From Pain to Performance

Lower Body
Upper Body
Before going to Periodization for Performance  , you might want to ground
yourself with real life aerobics and EvergreenEnergy in Evergreen Fitness for
the Four Seasons , or get into great cardio-strength shape at home
with Evergreen's Knockout Workouts.

<julia.keefer@nyu.edu> Dr. Keefer is an NYU Professor, a kinesiologist,

massage therapist, fitness instructor, and creator of four trademarked classes,
(EvergreenEnergy: Stretch, Sculpt and Meditate, Aerobic-Gut-and-Butt,
Knockout Step/Slide/Strike, and Knockout Ballet 'n Box). In her private
practice, she specializes in rehab and prehab to keep you happy hab with
exercise and massage therapy, postural retraining, and ideokinesis. She has
worked for a neurosurgeon, a psychiatrist, an osteopath, a vascular surgeon, an
orthopedist, and a podiatrist, giving her a head-to-toe knowledge of the human
body. A former professional wrestler and dancer/actress, Dr. Keefer understands
the pain, perks, parameters, and perfectionism of performance and how to form
the bridge between physical therapy and performance training. She also teaches
electronic media performance and the Keefer Brain Gymnasium, thereby
making the mindbody connections necessary to optimal function.

Notes on Basics for Personal Trainers:

NOTES AND STATS

Summer 2007-07-19

THE NEUROMUSCULAR SYSTEM

Skeletal muscle is 36% to 45% of total body weight; there are over 600 different
muscles, and it is the most plentiful tissue in the body.

Skeletal muscles can be stretched up to 150% of their resting length.

Muscle fiber can be a few millimeters (in the eye) to 30 centimeters (12 inches) in the
sartorius, longest muscle in the body.

Type I fibers are fatigue resistant, with a larger number of mitochondria and
mitochondrial enzymes, slower calcium capability, lower myosin ATPase, inhibiting
speed of hydrolysis of ATP but producing more ATP. Most people possess 45% to
55% slow-twitch fibers in their limbs, although sprinters have more fast-twitch fibers
in their limbs.

Type II Fast-twitch fibers generate fast, powerful muscle actions because of speedy
calcium release, a high level of myosin ATPase, and a developed sarcoplasmic
reticulum. Type IIa or FOG are slow glycolytic, Type IIb, fast glycolytic.

Functional unit of the neuromuscular system is the motor unit, which consists of the
motor nerve (cell body, axons (signals away from the cell body), and dendrites
(signals to the cell body), covered by a myelin sheath made up of Schwann cells, with
gaps every one or two millimeters called the nodes of Ranvier, jumping along in
saltatory conduct-ion, sometimes at a speed of 100 meters per second (220 miles per
hour!). Vesicles containing neurotransmitters such as acetylcholine, norepinephrine,
dopamine etc, lie on axon terminals where they squirt their juice into the synapse, the
junction between two nerves, or a neuromuscular junction, between a nerve and a
muscle at the motor end plate, to continue an action potential. If the cell membrane's
electrical potential changes to a value of -50 to -55 millivolts, it reaches its electrical
threshold and will conduct an action potential along the axon to the target muscle or
organ. The membrane potential will change from the -70 millivolts to a value of +30
millivolts in an action potential, because sodium ions rush into the cell.

After depolarization, repolarization occurs as potassium ions move to the outside of

the cell to regain the -70 millivolt resting membrane potential. Then the sodium-
potassium pump restores equilibrium.

Proprioceptors are muscle spindles, (located in intrafusal fibers parallet to extrafusal

fibers) Golgi tendon organs, and Pacinian corpuscles (sensory). A sarcomere is the
functional unit of the muscle cell that runs from Z-line to Z-line. Within the
sarcomeres are thin protein, myofilaments (actin) and thick protein myofilaments
(myosin) that have cross-bridges or heads extended from them. Also attached or
surrounding the actin myofilaments are tropomyosin and troponin into which the
tropomyosin molecules are embedded. Each myosin myofilament is surrounded by six
or more actin myofilaments. A sarcomere has a striated appearance due to I-bands that
are light areas near the Z-lines consisting of actin myofilaments; A-bands that are dark
areas consisting of both actin and myosin myofilaments; and a H-zone that is a slight
variation in the shading of the A-band due to the absence of the actin myofilaments.

The Sliding Filament Theory:

Myosin and actin do not change length

Z-lines move closer together

I-band shortens

A-band stays the same length

H-zone disappears

SR contains calcium stores

Events of muscle action: rest, excitation-coupling, (action potential, across synapse,
into the interiror via the t-tubules, influx of calcium into the axon terminal signals the
rlease of acetylcholine from the axon, binding of calcium on troponin for force
production) contaction, recharge, relaxation

Roles of ATP: a) Myosin ATPase pulls off a phosphate from ATP to turn it into ADP,
which drives the power stroke of the myosin head; b) Binding of myosin crossbridge
heads to actin�power stroke occurs as force is developed; c) ATP is required to
actively pump calcium back into the SR to allow movement (release crossbridge).
Peak rate ot muscle contraction is dependent on myosin ATPase activity and the size
of the motor neuron. Maximal force or tension a muscle can generate is dependent on
the amount of actin-myosin binding taking place.Continuation of muscle contraction
is dependent on the ability to recycle ATP. Slow twitch are the easiest to stimulate,
fast twitch the most difficult. Force production is influenced by number of muscle
fibers, size and number of motor units, rate coding, or the frequency of neural
impulses, force-velocity curve or the speed of movement and distribution of muscle
fiber types, eccentric stronger than concentric. The length of a muscle fiber is related
to the overlap of contractile proteins. Pre-stretching fibers to 120% of their normal
resting length will optimize force production. Fatigability is due to the duration of the
activity, related to fiber type. Size principles�smaller cell bodies are recruited first.
The mechanical arrangement of muscles affects force production, pennation, which
effects speed of shortening, fiber packing, and altered force and power capacity.
Fatigue decreases force production with increased hydrogen ions, decreased pH,
reduced energy, reduced calcium release, reduced troponin's sensitivity to calcium.

THE SKELETAL SYSTEM

The skeletal system has over 200 bones in the axial and appendicular portions, made
up of 80% compact bone arranged into the Haversian system, designed for support
and protection, and cancellous or soft porous bone with trabeculae, good for
hematopoiesis and storage of calcium and phosphate. Osteoclasts, osteoblasts, and
osteocytes are involved in resorption, formation, and remodeling respectively.

Tendons (muscle to bone) are made up of collagen, an inelastic tissue with great
tensile strength consisting of three amino acids in a triple helix, which is the most
abundant protein in the body, and ground substances. Ligaments (bone to bone) are
made up of collagen and elastin, which permits some extensibility and return to
resting length.

 
There are three types of fascia�superficial, deep, and subserous or fluid-containing,
covering internal viscera like the heart�which bind muscle, transmit forces, and
insulate organs.

THE CARDIOPULMONARY SYSTEM

(SV) or Stroke Volume is the amount of blood ejected in milliliters by the left
ventricle, as a result of end-diastolic volume (amount of blood at end of filling phase)
a stretch reflex and the release of catecholamines, or hormones of the sympathetic
nervous system to allow for greater systolic emptying of the hear. (Q) or Cardiac
Output is the amount of blood pumped by the heart, determined by Stroke Volume
times Heart Rate.

Q=SV times HR. The vagus nerve of the parasympathetic system decreases HR. CO is
influenced by venous return, end diastolic volume which increases SV, strength of
cardiac contraction from sympathetic nerve activity of Frank-Starling principle,
parasympathetic to decrease, and mean arterial pressure in the body.CO is distribution
to skin and muscles during exercise, but brain and heart remain constant.

The SA node controls rhythm of electrical stimulation of the heart, discharging around
60 to 80 times a minute. ECGs consist of a P wave, a QRS complex, (recordings of
the electrical stimulus through ventricular myocardial tissue) and a T wave, which
represent atrial depolarization which initiates atrial contraction, electrical recovery
following ventricular depolarization.

SPp is the pressure exerted against the arterial walls as blood is forcefully ejected
during ventricular contraction or systole. Rate-pressure product, or double product, is
the estimate of the work of the heart.

rate-pressure product = HR times SBp

DBp is the pressure exerted against the arterial walls when NO blood is being
forcefully ejected through vessels, providing an indication of vascular stiffness or
resistance, decreased with vasodilation, increased with vasoconstriction. Blood
pressure falls progressively to nearly 0nnHg (millimeters of mercury) by the time it
reaches the termination of the right vena cava of the atrium. Hypertension is over 140-
90. Aerobic exercise can double this, while Valsalva can triple it.

Mean arterial blood pressure is the average blood pressure throughout the cardiac
cycle= [(SBp-DBp) divided by 3] + DBp

Men have about 15-16 grams of hemoglobin per 100 milliliters of blood.

Women have about 14. One gram of hemoglobin can carry 1.34 milliliters of oxygen.
Movement of gas across a cell membrane is diffusion, so the concentration gradient
results in the exchange of oxygen and carbon dioxide. The oxyhemoglobin
dissociation curve describes the impact of increased metabolism on oxygen
dissociation, because as blood temperature, concentration of carbon dioxide, and
acidity increase with exercise, oxygen more readily dissociates from hemoglobin, and
makes itself available.

Only about 5% of carbon dioxide produced during metabolism is transported out of

the cell by diffusion and subsequently transported by the plasma to the lungs. 70%
results form a process involving CO2 and water in the red blood cells and subsequent
delivery to the lungs in the form of bicarbonate.

Oxygen Uptake is the amount of oxygen utilized by the tissues of the body, dependent
on cardio output or volume of blood transported, and arteriovenous difference a-v02
difference or the difference in the oxygen content of the arterial blood versus venous
blood expressed in milliliters of oxygen per 100 milliliters of blood.

V02=Q times a-V02 difference, where Q equals cardiac output (HR times SV) in
milliliters per minute

V02 rest= (80 bests/min times 65ml blood/beat) times 6ml 02/100 ml blood

=312 ml02 min or

VO2 rest= (HR times SV) times a-V)2 difference

To get the usual results for oxygen uptake, ml/kg/min, one then divides the result by
the person's weight in kilograms. 312 ml02 divided by 75 kg= 4.2ml 02 kg min.

MOST IMPORTANT EQUATION IS THE FICK EQUATION: Q=V02 divided by a-

V02 difference

Q=312ml 02 min divided by 6 ml 02/100 ml blood

=5200 ml/blood/min

=5.2 l blodd/min

Since maximal oxygen uptake is somewhat theoretical, peak oxygen uptake measures
an actual measured value subject to change.

Resting oxygen uptake is generally estimated at 3.5ml02 kg/ min, or one metabolic
equivalent or MET. Peak oxygen might range from 35 to 80 ml kg min or 10 to 22.9
METs in normal, healthy persons.

Minute ventilation is the volume of air breathed per minute, measured by tidal
volume, the amount of air moved during inhalation or exhalation with each breath,
times respiratory rate. Inspiratory and expiratory reserve volumes measure the amount
of air beyond normal resting tidal volume. Forced vital capacity is the amount of air
moved from maximal inspiration and expiration. Residual lung volume is what is left
to prevent the lungs from collapsing. The total lung capacity is forced vital capacity
and residual lung volume. The normal volume of anatomical dead space in nose,
mouth, trachea, bronchi and bronchioles is 150 milliliters in young adults, increasing
with age. Physiological dead space refers to alveoli with poor blood flow, poor
ventilation, disease etc. At rest the partial pressure of oxygen in the alveoli is about 60
mmHg greater than in the pulmonary capillaries, to allow diffusion into the lungs.
Similarly C)2 diffuses in the opposite direction. Expired ventilation rate, carbon
dioxide production rate, and lactic acid production from glycolysis increase
exponentially (curvilinear) as workload increases up to max, while oxygen uptake and
heart rate tend to increase linearly.

The pons and medulla oblongata control dorsal (initiation and rhythm) and ventral
respiration (increased ventilation, inspiration, forceful expiration. Pneumotaxic center
controls rate and pattern of breathing.
Effects of training: Expired ventilation rate, carbon dioxide production rate, and
oxygen uptake are higher during maximal exercise, decreased during submaximal
because of efficiency, and no change at rest, although resting heart rate may go down.

BIOENERGETICS

Energy substrates are phosphagens (ATP and creatine phosphate), glucose, glycogen,
lactate, fatty free acids, and amino acids. Creatine phosphate can decrease 50% to
70% during the first 5-30 seconds, and be almost eliminated with very intense
exercise. Muscle ATP concentrations do not decrease by more than about 60% from
initial values. Postexercise phosphagen repletion can occur in a short period; complete
resynthesis of ATP appears to occur within 3 to 5 minutes; and complete creatine
phosphate resynthesis can occur within 8 minutes, largely as a result of aerobic
metabolism. About 300 to 350 grams of glycogen is stored in the body's total muscle,
and about 70 to 100 grams in the liver, which can increase with training. About 60%
of VO2 max, muscle glycogen is an important energy substrate, and it can be depleted
during intense exercise, and can be the limiting factor for heavy resistance training
with multiple sets. Repletion appears to be optimal if 0.7 to 3.0 gram of carbohydrate
per kilo is ingested every two hours following exercise. High eccentric components
may take more than 24 hours to replete.

ATP is composed of adenine, ribose, three phosphate groups, breaking down to

adenosine diphosphate and monophosphate with myosin ATPase. Only carbs can be
metabolized for energy without oxygen. Enzymes of the phosphagen system are
myosin ATPase and creatine kinase which catalyses the synthesis of ATP from
creatine phosphate and ADP. Glycolysis breaks down glucose or muscle glycogen to
ATP by enzymes located in sarcoplasm. In fast glycolysis pyruvate is converted to
lactic acid faster than with slow glycolysis, in which pyruvate is transported to
mitochondria, sometimes giving it the name aerobic glycolysis.

Glucose+2P+2ADP yields 2lactate+2ATP+H20

Slow glycolysis: glucose +2P+2ADP+2NAD

Yields 2pyruvate+2ATP+2NADH

NADH is nicotinamide adenine dinucleotide

Simply put, glycolysis produces two molecules of ATP from one molecule of glucose,
unless glycogen is used, which produces 3 ATP in phosphorylation.

The rate-limiting step is the slowest reaction in the series, which is the conversion of
fructose-6-phosphate to fructose-1,6 bi-phosphate by phosphofructokinase. Glycolysis
is stimulated by ADP, P, ammonia, slight decrease in pH and AMP. It is inhibited by
lowered pH, inadequate oxygen supply, increased levels of ATP creatine phosphate,
citrate, and free fatty acids. As lactic acid accumulates, there are more H ions which
can inhibit glycolysis, maybe the calcium binding to troponin or the actin-myosin
cross-bridge formation. Lactic acid is converted to its salt lactate by buffering systems
in muscle and blood, but lactate doesn't cause fatigue, as it is an energy substrate used
for Type I and cardiac muscles and gluconeogenesis, the formation of glucose from
non-carbs. Actually blood lactate concentrations reflect lactic acid production and
clearance. The Cori cycle occurs when lactate is transported in the blood to the liver.
Normal concentration of lactate at rest is 0.5 to 2.2. Peak blood lactate concentrations
occur five minutes after the cessation of exercise. The lactate threshold begins at 50%
to 60% of maximal oxygen uptake in untrained subjects and at 70% to 80% in trained
subjects. OBLA, or the second onset occurs when the concentration is near 4mmol l.

Oxidative system metabolizes carbs and fatty acids as substrates, only protein after 90
minutes or during starvation. Then it (usually branched chain amino acids) may
contribute 3% to 18% of energy requirements. Urea and (toxic) ammonia are by-
products. At rest approximately 70% of ATP is derived from fats 30% from carbs.
High intensity almost 100% from carbs. If there is enough 02 then pyruvate is not
converted to lactic acid but transported to mitochondria and converted to acetyl CoA
and then enter the Krebs cycle for further ATP production, along with two NADH
molecules produced during glycolytic reactions. The Krebs cycle produces two ATPs
indirectly from guaninetriphosphate for each molecule of glucose, and six molecules
of NADH from one molecule of glucose and two molecules of reduced flavin adenine
dinucleotide or FADH2. These molecules transport hydrogen atoms to the ETC. ETC
(Electron Transport Chain) uses NADH and FADH2 to rephosphorylate ADP to ATP.
One molecule of NADH can produce three molecules of ATP, whereas one molecule
of FADH2 can produce only two molecules of ATP�oxidative phosphorylation.
Oxidative system produces 38 ATPs from one molecule of glucose. The rate-limiting
step in the Krebs cycle is the conversion of isocitrate to a-ketoglutarate, a reaction
catalyzed by the enzyme isocitrate dehydrogenase, which is stimulated by ADP, and
inhibited by ATP.

 
Fats are broken down: Triglycerides stored in fat cells broken down by lipase, which
releases free fatty acids into the blood, where they can circulate and enter muscle
fibers, and undergo meta oxidation in the mitochondria, resulting in the formation of
acetyl CoA and hydrogen atoms. The acetyl CoA enters the Krebs cycle, and the
hydrogen atoms are carried by NADH and FADH2 to the ETC.

All 3 systems work together but one predominates, based on intensity and duration,
from 5 seconds to an all day marathon.

0-6sec: Very intense, Phosphagen, Rate of ATP (1), Capacity (5)

6-30sec: Intense, Phosphagen and Fast Glycolysis, Rate of ATP

30sec to 2 min: Heavy, Fast Glycolysis, Rate of ATP (2), Capacity (4)

2-3 min: Moderate, Slow Glycolysis, Rate of ATP (3), Capacity (3)

>3min: Light/Moderate, Oxidation of carbs, Rate of ATP (4), Capacity (2)

Longer duration aerobic activity: Light, Oxidation of fats and proteins, Rate of ATP
(5), Capacity (1)

Anaerobic contribution to exercise is oxygen deficit; post-exercise oxygen uptake is

oxygen debt of EPOC.

BIOMECHANICS

Torque is the magnitude of the force multiplied by the length of its moment arm. A
mechanical advantage greater than 1.0 means that the force exerted on the resisting
object by the lever is greater than the applied force, as in a second class lever (rising
on your toes). When the mechanical advantage is less than 1.0, as in a third class lever
(most synovial joint actions), the lever exerts a smaller force on the resisting object
than the force applied to the lever.
First class lever (seesaw, atlanto-occipital joint) �applied and resistive forces on
opposite sides of the fulcrum.

Work = Force times Distance

Power = Force times Distance divided by Time

Work = weight x vertical distance x reps (weight lifting)

Angled sleds: actual resistance =sine of the floor-to-track angle x weight of the sled
plus added plates

SI is French for systeme internationale.

Pounds x 4.448= newtons

Newtons x 0.2248= pounds

Kilograms force x 2.205= pounds

Pounds x 0.4536= kilograms force

Kilograms force x 9.807= newtons

Newtons x 0.1020= kilograms force

Feet x 0.3048=meters

Inches x 0.02540=meters

Miles x 1,609= meters

Foot-pounds x 1,356=joules

Foot-pounds per second x 1.356= watts

Horsepower x 745.7=watts

Miles per hour x 1,467=feet per second

Miles per hour x 0.4470=meters per second

Degrees x 0.01745= radians

Energy efficiency of muscular activity is in the 20% to 30% range, so energy

consumed is about four times the mechanical work produced. A person who can
maintain a power output of 200 watts for several minutes while running or cycling
may be able to average 1,500 watts during a vertical jump.

The strength-to-mass ratio equals the force the person can exert during a particular
movement divided by the mass of the body.

Resistance during exercise: gravity, inertia, friction, fluid resistance, and elasticity.

The force of attraction between any two objects is proportional to the product of the
objects' masses and inversely proportional to the square of the distance between them.

An object has the same mass wherever it is, but its weight is the object's mass times
the local acceleration due to gravity. Since the pound is a unit of force, it cannot
correctly be applied to a weight plate. Better to say, �He lifted 10 kilos.� The
moment arm of a weight is always horizontal because it produces a torque
perpendicular to the line of action of the force. The torque about a given body joint
when a weight is held is the product of the weight and the horizontal distance from the
weight to that body joint. Therefore the lifter must exert the greatest muscular torque
to lift the barbell in a biceps curl when the forearm is horizontal. In a squat, greater
forward trunk inclination positions the weight horizontally farther from the hip,
increasing the resistive torque about the hip, making hip extensors work harder. When
the bar is low on the back, trunk must be inclined forward, making hip extensors work
harder, knee extensors less. When the bar is high, there is less trunk inclination and
more work is shifted to knee extensors. Front squat requires less forward lean so that
greatest possible load is on quads. To mitigate stress on back the feet can be
positioned a foot or 30 centimeters forward of their normal position on the Smith,
making the trunk stay more upright, decreasing the horizontal moment arm about the
lower back, reducing the torque the back muscles must generate, making quads work
harder because the length of the horizontal moment arm about the knee is increased.
 

Machines can have levers, gears, cams, pulleys, cables, pressure so you can't
determine the force unless you weight the plates and analyze the leverage system. 
In cam-based weight-resisted machines, the moment arm through which the weight
acts (horizontal distance from chain to pivot point) varies during the exercise
movement. When the cam is rotated from position 1 to position 2, the moment arm of
the weight, and thus the resistive torque, increase.

A client's body weight is roughly proportional to body volume, ( a cubic measure)

while the ability to provide oxygen to working muscles is dependent on the cross-
sectional area (a square measure) of the blood vessels, so as body size increases, there
is a reduced maximal rate at which oxygen can be supplied to working muscles. A
smaller fit client may have better VO2 max than a larger one, given the same
variables.

Buoyant force pushing up on the body is equal to the weight of the water displaced by
the body.

Inertia is the resistance to acceleration, and acceleration is the change in velocity

divided by the change in time. Force equals mass times acceleration. Only when a
mass is supported in a static position or lifted and lowered at a constant rate is the
resistive force equal to the force of gravity on the mass, and the direction of the
resistance is only downward. However, if there is any acceleration at all, it is
accompanied by inertial resistance in addition to gravitational resistance. Inertia
equals mass times acceleration, and the direction of the inertial resistance is opposite
to the direction of the acceleration.

If the upward force on a bar drops to zero, the bar is in free fall, with its downward
velocity increasing every second by 32 feet 9.8 meters per second. If the lifter desires
to slow the downward velocity of the bar, then the lifter must exert upward force on
the bar that is greater than the bar weight. If the lifter waits until the bar is close to its
low point before slowing down its descent, and the bar must be brought to a stop in a
very short time, the force of deceleration can greatly exceed bar weight and cause
injury. During a power clean with a heavy weight, the strong leg, hip, and back
muscles accelerate the bar vertically to a high enough velocity that even though the
weaker upper body muscles cannot exert vertical force equal to the bar's weight, the
bar continues to travel upward until the force of gravity decelerates the bar to zero
velocity at the top of the lift. More work against gravity per unit time is done in the
body at a faster cadence and more work against inertia is performed per unit time due
to faster cadence and forces of acceleration.

Bracketing is a type of training with lighter- and heavier- than normal resistance
training speed and strength.

When two substances rub together they create friction. Belt- or brake pad-resisted
cycle ergometers and frictional wrist curl devices use this principle. The resistive
force is roughly proportional to the force pressing the two surfaces together, and it
takes more force to get it started than to keep it moving. Once the movement starts,
the resistance does not change much even as speed changes. The Slide uses friction, as
the work of the push-off leg depends on the weight of the client, the level of friction
between the board and booties, and the distance between the ends of the board. A cord
passed through a raking device provides concentric resistance.

Fluid resistance is used in swimming, skydiving, javelin throwing etc, although

properties of water differ from air. In hydraulic machines, the fluid is a liquid, while
in pneumatic machines it is a gas. Fluid resistance comes from surface drag, caused by
the friction of fluid molecules passing along the surface of an object, and form drag,
caused by the force of the molecules pressing against the front or rear of an object
passing through the fluid. Swimmers try to minimize form drag by offering the least
amount of cross-sectional area in the direction of travel. The angle of attack is the
angle of the swimmer's body relative to the horizontal, smaller angle, less drag.
Turbulence of water can work for or against movement. The longer the swimming
race, the more fat can help create buoyancy and insulate against cold. Aqua aerobics
seeks to increase drag, friction, and use buoyancy to increase resistance and intensity.
In water up to the neck, client supports only 10% of body weight, whereas at waist
level, she must support 50%.

Fluid-resisted machines are controlled by velocity of piston movement; cylinders

allow rapid acceleration early and less when high speeds are reached. The increasing
resistance with increasing speed limits the rapidity of the movement. Usually this is
concentric, unless specifically designed with pumps. Most fluid resisted exercise is
concentric/concentric unless special apparatus thwarts this tendency.

Boats must also be streamlined for speed or chunky for strength.

With elastic band resistance, the tension increases with the degree of stretching,
beginning with low, ending with high resistance to hold the position statically, the
opposite of most free weight exercises.

PTs use isokinetic dynamometers to maintain constant joint angular velocity by

matching resistive force to muscle force with variable resistance.

Gravitational potential energy is the product of the object's weight and the distance it
can fall, while kinetic energy is one-half the product of the object's mass and the
square of its velocity. The amount of negative work performed in decelerating a
moving object to zero velocity is equal in magnitude to the object's kinetic energy
before it is decelerated. The total negative work is the sum of the work of lowering
and of decelerating. Because power equal work divided by time, negative work results
in negative power. ACL tears from sudden stops or changes in direction.

Adaptations to Resistance Training:

For the first 8-12 weeks, hypertrophy of muscle fibers is usually not measurable but
neurological adaptations in terms of EMG amplitude, number of motor units etc have
increased, along with changes in myosin heavy chains and myosin ATPase to allow
for more rapid and forceful contractions.

Acute changes:

EMG amplitude and number of motor units recruited increase.

Hydrogen ion concentration, inorganic phosphate concentration and ammonia levels
increase.

No change of slight decrease in ATP.

CP and glycogen decrease from work performed.

Epinephrine, cortisol, testosterone, and growth hormone increase.

Growth hormone and insulin are protein/peptide hormones, while testosterone and
estrogen are steroid hormones derived from cholesterol, one reason that a diet of less
than 15% fat will often deplete anabolic hormones. Testosterone, insulin, and growth
hormone are anabolic, while cortisol is catabolic, but is essential to maintaining blood
glucose levels. Epinephrine increases fat and CHO breakdown so that more ATP is
available, as well as aiding CNS with motor unit recruitment.

Rate coding is the number of action potentials per unit of time; normally the faster the
firing rather, the more force produced. However small muscles like hands achieve full
recruitment at a low force output, while large muscles have higher recruitment and
lower firing rates like the quads, making the size of the EMG signal get larger during
a set of resistance training exercises to reflect changes in motor recruitment and firing
rate.

The size principle dictates that motor units that innervate slow-twitch fibers innervate
fewer fibers than units that innervate fast-twitch fibers, although the smaller neuron
size results in a lower threshold for activation. Fast-twitch fibers are recruited even
during slow contractions if the force demands are high enough.

Chronic Adaptations:

Muscle strength, power, and endurance increase, at different rates depending on focus
of training.

Phosphagen system and glycolytic enzyme concentrations and/or absolute levels

increase.

ATP and CP absolute levels increase, due in part to increased size. but ATP and CP
changes during exercise decrease as well as lactate.
Type I CSA, Type II CSA(cross-sectional area, i.e. hypertrophy, not hyperplasia) and
Type IIa increase, Type IIb decrease, Type I remains the same.

Fat usually decreases, while fat-free mass and metabolic rate increase.

EMG and motor unit recruitment and firing probably increase, while co-contraction
decreases.

Connective tissue strength and bone density mass usually increase.

Resistance training does not increase VO2max but is a good adjunct to get better
results from cardiorespiratory endurance.

Sarcopenia is loss of muscle mass, which occurs naturally after 30 unless mitigated by
weight training.

Isometric strength detrains quickly as does anaerobic metabolic tests like the Wingate.

Aerobic Adaptations:

VO2max, aVO2 difference, stroke volume, (because of changes in pre-load, afterload

and myocardial contractility), cardiac output, and oxidative capacity of muscle usually
go up, but resting heart rate and submaximal exercise heart rate usually go down. The
Frank-Starling effect is the stretch-reflex of the left ventricular that results in greater
force. Cardiac output can be as much as four times during maximal aerobic exercise in
an untrained person, six times in a male marathoner. Size of chambers increase about
40% in general with aerobics, and the ventricular wall thickens. Blood volume,
plasma and hemoglobin go up, leading to greater stroke volume at rest. Maximal heart
rate is not affected by training, just submaximal. There is an increase in density of
capillary beds, to allow for better diffusion of oxygen and metabolites, permitting
better oxygen uptake.

Acute adaptations are not that marked; chronic adaptations permit body to store more
fuel, and then to utilize it through enzymatic processes at the cellular level.

Enzymes increase:

Hexokinase�responsible for phosphorylation of glucose after entry in to the cell

Phosphofructokinase�rate-limiting enzyme of glycolysis

Lactate dehydrogenase�responsible for reversible conversion of pyruvate to lactate

Succinate dehydrogenase and Citrate synthase also improve

GLUT4 increases

Mitochondria get denser.

Pancreas, (production and release of insulin and glucagon for uptake or release of
glucose). Acute==increases insulin-stimulated whole-body glucose uptake for 48
hours postexercise. Increase in insulin sensitivity.

Adrenal cortex (cortisol) maintains blood sugar levels, stimulates protein conversion,
utilization of fats.

Adrenal medulla has a sympathoadrenal response to exercise releasing

catecholamines, epinephrine and norephinephrine, also a sympathetic nervous system
response. These eventually decrease as the body becomes more efficient at exercise,
reducing stress.

Studies show increase in bone mineral density site-specific at point of impact�tibia,

femoral neck etc. Wolff's Law states that bone will be laid down where needed.
Therefore high-impact weight-bearing activity is the most beneficial for increasing
bone mineral density and the health of articular cartilage is not jeopardized during
running, aerobic dance et. Adaptations occur to new stresses, then plateau.

Pulmonary ventilation obviously increases with exercise, but chronically, lung

volumes, carrying capacity of blood and diffusion ability improve.

VO2max peaks naturally between 12-15 in girls, 17-21 in boys, but five middle aged
men recovered 100% of age-related decline in power over 30 years after six months of
aerobic training.

 
Overreaching is the precursor or plateau before the decline that occurs in overtraining.

NUTRITION:

Dietary intake data can be obtained from dietary recall (24 hours), history (interview),
or records (3 days.)

Memorize food pyramid�fats, oils, sweets sparingly, milk, yogurt, cheese 2-3
servings, protein 2-3, vegetables 3-5, fruit 2-3, and bread, cereal, 6-11.

A serving is not a helping. Memorize:

Bread: one slice, or one dinner roll

Cereal: 1 ounce or ½ cup cooked cereal

Pasta and rice: ½ cup cooked

Raw leafy veggies: 1 cup

Other veggies: ½ cup

Fruit: one fruit

Juice: ¾ cup

Milk and yogurt: 1 cup

Cheese: 1/1/2 to 2 ounces

Meat: 2 or 3 ounces cooked (this is nothing!)

½ cup beans, one egg, 2 tablespoons peanut butter

RMR or resting metabolic rate accounts for 60% to 70% of daily energy, measure of
calories needed for metabolic activities. RMR is INCREASED by lean body tissue,
young age, growth, abnormal body temperature, menstrual cycle, hyperthyroidism etc.
RMR is DECREASED by low caloric intake, loss of lean tissue, hypothyroidism.
20% variation due to genetic differences.
Thermal effect of food is 7% to 10% of total energy requirement. Steve weighs 77
kilos, and is so active he needs 3,900 kcal a day. Or calculate Resting Energy
Expernditure, then multiply it by a factor based on activity level.

RDA for protein is .8 grams per kilo for men and women, but aerobic endurance
athletes can reach 1.4 grams per kilo, and resistance training may require 1.2 to 2.0
grams per kilo, unless you have bad kidneys, low calcium, restricted fluid etc.

50-100 grams of CHO prevents ketosis from incomplete breakdown of fatty acids.
Physically active people should consumer 60-70% CHO. Endurance athletes need 8-
10 grams per kilo or 600 to 750 grams or 2400 to 300 kcal from CHO per day for a
person weighing 165. This will restore skeletal glycogen within 24 hours. For
strength, sprint, and skill 5 to 6 grams per kilo per day is reasonable. (Fruits and
veggies are carbs.)

Fat: 3% from Omega 6, .5 to 1% from Omega 3. Less than 10% fat can make blood
lipid levels worse; less than 15% can decrease testosterone. Women of reproductive
age need at least 20% fat. Recommendations are 30% fat for average people, 35% for
athletes. 9kilocal�protein and CHO 4Kilocal.

RDA is the population mean plus two standard deviations, not the minimum number.

Water requirements change according environment, sweating, body surface area,

caloric intake, body size, lean muscle tissue, activity level, etc.

At least 1 pint two hours before exercise.

During and after exercise replenish fluids completely.

Muscle tissue is 70% water, 22% protein, 8% fatty acids and glycogen. 2500 extra
kilocal are required for each 1 pound increase in lean tissue. 350 to 700 kilocal above
normal are needed to support a 1 to 2 pound weekly gain in lean tissue as well as
energy requirements of training.
 

An average of 1 to 2 pounds a week represents a daily caloric deficit of 500 to 1000

kcal.

DON'T recommend supplements, aids, crash diets, herbs etc, or exclude food groups
such as protein, dairy, bread. Follow guidelines strictly and if there is any medical
problem, refer to nutritionist.

Excess iron can lead to hemochromotasis, excess zinc can increase HDL, and excess
calcium risk kidney stones. Healthy protein shakes with yogurt, fruit, flax seed etc are
okay. That is it. Many liability suits come from trainers acting as nutritionists
recommending specific things without a sufficient biochemical work-up.

PSYCHOLOGY

Exercise relieves trait and state anxiety, except when coupled with potential of injury
in martial arts or failure in team sports.

Stress can be measured by muscle tension, blood pressure, brain electrical activity.
With rhythmic aerobic exercise it is possible that cerebral cortical arousal is inhibited,
due to a volley of afferent rhythmic impulses from the skeletal muscles to a relaxation
site in the brain stem of the CNS. Also hypothalamus detects elevation in body's
temperature and promotes cortical relaxation effect, resulting in reduced muscle
tension. Release of beta-endorphins, increased serotonin and catecholamines also help
to alleviate depression and reduce anxiety. This neurotrophic effect, working with
oxygenation, helps preserve mental functioning.

Older men who were physically fit performed as well as young men on complex
battery of cognitive challenges and better than their sedentary counterparts. Fluid
intelligence (problem solving) in the frontal lobe executive processes is more affected
by exercise than crystallized intelligence, which is the ability to accumulate
knowledge and recognize words and recall facts.

Apolipoprotein e4 allele (APOE4) is the gene known to increase risk for cognitive
impairment in the elderly.
 

Mens sana in corpore sano

Goal setting�SMART

Short and long term

Challenging�50% chance of success

Behavioral reinforcement

Self-efficacy

Process goals�control

Outcome goals�little control

Performance goals�in between

Task-involved, ego-involved, other-involved

Goals should be specific, measurable, observable, with time constraints, moderately

difficult, but attainable, compatible, and prioritized. Record goals and monitor
progress. Diversify process, performance, and outcomes. Set short-range goals to
achieve long-range goals. Make sure goals are internalized.

Constructs are personality, ambition, and assertiveness, things we can't see but must
imagine and infer.

Motivation includes the directional aspect that influences choices, and the intensity of
pursuit of those choices.

Revisit BF Skinner, the outmoded operant conditioning man of behaviorism, with his
target behavior, the operant, the reinforcement, the punishment. People have intrinsic
or extrinsic motivation. Memorize following chart:

1. Amotivation
2. External regulation�just to avoid the whip
3. Introjected regulation�wants to please trainer, Oedipal transfer etc.
4. Identified regulation�still follows trainer rather than initiating exercise
behavior
 5. Integrated regulation�client internalizes goals and work together equally to
achieve them.

Memorize transtheoretical model for stage of readiness

1. Precontemplation
2. Contemplation
3. Preparation�finally doing 30 minutes one day a week
4. Action�following ACSM 30 min a day
5. Maintenance---keeps it up for six months or more

Bandura's self-efficacy is a person's confidence in his/her own ability to perform

specific actions leading to a successful behavioral outcome, influenced by
performance accomplishments, modeling effects, verbal persuasion, and physiological
arousal or anxiety.

a. Minimize procrastination

b. Identify false beliefs

c. Identify and modify self talk changing negativity to affirmations

d. Mental imagery including Jacobsen's progressive relaxation

e. Visualization from past, future, present states�ideokinesis�yeah!

Let the past go.

Do your best; don't be perfect.

Express yourself and keep track in a journal.

Go from familiar to unfamiliar.

Offer choices.

Provide feedback.

Use social support systems.

Have client create positive affirmation.

CLIENT CONSULTATION AND HEALTH APPRAISAL

Motivate, assess, train, educate, and refer.

Follow these exact steps:

1. Schedule interview.
2. Conduct interview to assess boundaries, roles, resources, goals, etc.
3. Complete health appraisal forms�PAR-Q and Health/Medical questionnaire,
lifestyle questionnaires, and informed consent, and/or assumption of risk
waiver.

7CAD risk factors: a. family history: if a myocardial infarction, coronary

revascularization, or sudden death occurred before 55 years of age in father or first-
degree male relative, or before 65 in mother or first-degree female relative.

b. cigarette smoking

c. hypertension (over 140-90) because of increased wall stress, which increases the
workload of the heart in pumping the extra blood required to overcome peripheral
vascular resistance.

d. hypercholesterolemia�LDL>130mg/dL or on lipid-lowering medication. Over 60

HDL is a negative CAD factor because some doctors use combined cholesterol over
200 as a cut-off.

e. impaired fasting glucose levels over 110mg/dL, confirmed on 2 occasions. Diabetes

mellitus, a metabolic disease, is characterized by hyperglycemia resulting from
defects in insulin secretion in type I, insulin action in type II, or both. Diabetes
increases risk for CAD, peripheral vascular disease, and congestive heart failure.

f. obesity�BMI =or>30, which is 30 kilograms bodyweight per height in meters

squared or a waist girth 39 inches or 100 cm.

g. Sedentary lifestyle is defined as people who do not participate in a regular exercise

program or meet the minimal physical activity recommendations of 30 minutes or
more of accumulated moderate-intensity activity on most, or all days of the week to
expend approximately 200 to 250 calories a day.
 1. Evaluate for coronary risk factors, diagnosed disease, and lifestyle.

In addition to interpreting questionnaires, PTs must evaluate signs and symptoms of

cardiovascular and pulmonary disease:

1. pain, discomfort, angina due to ischemia

2. shortness of breath at rest or mild exertion
3. dizziness or syncope
4. orthopnea or paroxysmal nocturnal dyspnea
5. ankle edema (that is not orthopedic)
6. palpitations or tachycardia
7. intermittent claudication (not due to muscular weakness or electrolyte
imbalance, but vascular problems)
8. known heart murmur
9. unusual fatigue with usual activities

COPD

Asthma: spasmodic contraction of smooth muscle around the bronchi that produces
swelling of the mucosal cells and an excessive secretion of mucous that constricts
airway paths caused by allergic reactions, exercise, air quality factors, and stress.

Chronic bronchitis: an inflammatory condition caused by persistent production of

sputum due to a thickened bronchial wall, which in turn creates a reduction of airflow.

Emphysema: an enlargement of air spaces accompanied by the progressive destruction

of alveolar-capillary units leading el elevated pulmonary vascular resistance, and
perhaps heart failure.

INITIAL RISK STRATIFICATION uses age, health status, personal symptoms, and
coronary risk factors to classify individuals into one of three risk categories for
preliminary decision-making purposes.

1. Low Risk. Younger individuals who have no more than one of the 7
CAD risk factors.
2. Moderate Risk. Men 45 years or older and women 55 years or older OR
younger people with two or more risk factors.
3. High Risk. Anyone with one or more of the subjective signs/symptoms,
or with known cardiovascular, pulmonary, or metabolic disease.

 
PAR-Q

Memorize: a. Has your doctor ever said that you have a heart condition and that you
should only do physical activity recommended by a doctor?

b. Do you feel pain in your chest when you do physical activity?

c. In the past month, have you had chest pain when you were not doing physical
activity?

d. Do you lose your balance because of dizziness or do you every lose consciousness?

e. Do you have a bone or joint problem that could be made worse by exercise?

f. Is your doctor currently prescribing drugs for blood pressure or heart?

g. Do you know of any other reason you should not do physical activity/

One yes�and go to the doctor for clearance.

Health/Medical questionnaires evaluates complete medical history, family history,

activity history, medications, goals.

1. Assess and interpret results.

2. Refer to health professional when necessary.

From the initial risk stratification�refer moderate risk individuals to physicians for
vigorous exercise (over 6 METS or greater than 60% maximal oxygen uptake) or
maximal testing, and high risk individuals for everything. Moderate exercise is 3-6
METS, and submaximal tests are field tests performed by PTs.

If a client gives YES to one or more questions on the PAR-Q, refer to a physician.
Pregnant�get clearance, as well.

1. Obtain medical clearance. Get a physician's referral form with an assessment of

individual's functional capacity, ability to participate, pre-existing conditions
that could be worsened by exercise, medications, and fitness program
recommendations. Some people must be medically supervised, particularly for
aerobically intense programs.
2. Informed consent describes the cardiorespiratory (stationary bike, treadmills or
step-up to a 12-inch step for submaximal and recovery heart rates) and
 muscular strength/endurance tests, which are 1-rep max on a bench press or the
number of curl-ups and/or push-ups in one minute.

TESTING

Base-line Data

1. For improvements or rate of progress

2. Identify strengths and weaknesses for program design
3. Establish correct intensities and volumes
4. Clarify goals
5. Identify potential injuries or contraindications
6. Legal record

Evaluate

Formative evaluations include formal assessment with a specified test protocol, and

subjective observations such as posture, comments, body language etc.

Compare performance with norm-referenced standards in percentile values against

other individuals in a like category, and criterion-referenced standards show whether a
health standard was met.

Summative evaluations represent the sum total of what the client did during a training
period, class, or season.

Assessment is the act of measuring a specific component using a well-constructed,

valid, (i.e., relevant and truthful, in terms of content, construct and criterion-related
validity), and reliable (repeatable) test with calibrated equipment, with a well-
prepared subject, and accurate, meticulous protocol and planning, given a standard
error of measurement.

If a client is sedentary, over 60, or has a functional aerobic capacity of five METS, or
is a preadolescent, the YMCA Step test, or 1.5 mile (2.4 kilometer) or 12 minute run
aren't appropriate. The bike or a one-mile walk test might be better.1RM testing
(squats and bench press) may be bad for untrained, overweight, arthritic individuals,
so that 10RM testing would be necessary.

Aerobic testing is impaired with temperatures over 80 degrees F or 27 C when

humidity exceeds 50%, or less than 25 degrees F or -4C. It can take 10 days to
acclimate to altitude even 1,900 feet or 580 meters. Indoors, room should be 68-72,
60% or less humidity, and air circulation of 6 to 8 exchanges per hour.

Indications for Stopping an Exercise Test in Low-Risk Adults

Angina

Significant 20mmHg drop in systolic blood pressure, or failure of blood pressure to

rise

Excessive rise in blood pressure >260/115

Light-headed, confused, ataxia, pallor, cyanosis, nausea, or cold, clammy skin

Noticeable change in heart rhythm

Client requests to stop

Severe fatigue

Failure of testing equipment

Client must get adequate sleep the night before and no vigorous exercise 24 hours
before test

Light meal or snack 2-4 hours before

6-8 glasses of water day before test and at least two cups of water in two hours prior
to test

Abstinence from chemicals

Proper attire

Knowledge of procedures and expectations

Conditions for terminating test

NSCA has a different test sequence than ACSM

General Fitness

1. Resting tests of HR, BP, height, weight, and body composition

2. Non-fatiguing tests of balance and flexibility
3. Muscular strength tests
4. Muscular endurance
5. Sub-maximal aerobic capacity tests such as YMCA step, Rockport walking,
Astrand-Ryming cycle ergometer test, 1.5 mile, 2.4 kilometer run, 12 minute
run

Athletes

1. Resting tests of HR, BP, height, weight, and body composition

1. Non-fatiguing tests of vertical jump, balance and flexibility

2. Agility tests like T-test
3. Muscular strength tests like 1RM bench press and 3RM power clean
4. Sprint tests like 40-yard 37 meter spring
5. Muscular endurance�sit-ups and push-ups
6. Anaerobic like 300-yard 275 meter shuttle run
7. Maximal or Sub-maximal aerobic capacity tests such as maximal treadmill,
YMCA step, Rockport walking, Astrand-Ryming cycle ergometer test, 1.5
mile, 2.4 kilometer run, 12 minute run

If possible, perform maximal aerobic tests on a separate day, or wait after an hour rest.

If client scores below average, begin 2-3 times a week at moderate intensity, and work
up.

 
Heart Rate (brachial, carotid, radial, or temporal)

Stopwatch

Stethoscope� Bell should be placed directly on the skin over the third intercostal
space just left of the sternum for 30-60 seconds.

Heart Rate Monitor

Shorter-duration during exercise�6, 10, or 15; 30-60 for resting

Blood Pressure

Listen for Korotkoff sounds with a mercury or aneroid sphygmomanometry�need an

inflatable air bladder, and a stethoscope (cuff or auscultatory method)

1.No smoking or caffeine 30 minutes before

2.Sit upright in a chair with back support, either arm exposed, supinated, and
supported, at level of heart.

3.Select appropriate cuff size by taking arm circumference measurements midway

between the acromion process of the scapula and the olecranon process of the ulna.

4.Rest for a minimum of five minutes.

5.Place the cuff on the arm so that the air bladder is directly over the brachial artery
and the bottom edge of the cuff is one inch or 2.5cm above the antecubital space. With
the client's palm facing up, place the stethoscope firmly, but not hard enough to indent
the skin, over the antecubital space. Use dominant hand to control the bladder airflow
by placing the air bulb in the palm and using the thumb and forefinger to control the
pressure release. The nondominant hand is then used to hold the stethoscope.

6.Position the sphygmomanometer so that the center of the mercury or aneroid dial is
at eye level and the air bladder tubing is not overlapping, obstructing, or being
allowed to freely contact the stethoscope head or tubing.

7. Once the cuff, the stethoscope, and the sphygmomanometer are in place, quickly
inflate the air bladder to 160mmHg or 20 mmHg above anticipated systolic reading.
Upon maximum inflation, turn the air release screw counterclockwise to release
pressure at 2-3 mmHg per second.

8.The first audible detection of Korotkoff sounds is SBP, and the last audible
detection of Korotkoff sounds is DBP. These sounds are similar to extraneous noises
made when the air bladder tubing is allowed to bump against the stethoscope bell so
avoid this.

9. Observe manometer for an addition 10 to 20 mmHg of deflation to confirm absence

of sounds, then release the remaining pressure, and remove cuff.

10. After a minimum of 2 minutes rest, measure BP again using the same technique. If
they differ by more than 5mmHg, take a third reading. Average the scores.

Check to see if stethoscope is on backward, if the stethoscope bell is under the cuff, if
the dial is not at the tester's eye level, or if the blood pressure cuff is positioned too
close to the antecubital space.

Body Mass is weight in kilos divided by height in meters squared.

Measure height with feet together, shoes removed, breath held, and then convert
inches to centimeters. Convert the weight in pounds to kilos. Pounds divided by
2.2046=kilos. Consult chart for BMI.

Skin-fold Measurement

1. Take all measurements on right side of body.

2. Skin should be dry, free of lotion, always before exercise.
3. Identify, measure, and mark skin fold site.
4. Grasp skin with thumb and fingers at least one cm or 0.4 inches from site.
5. Lift the fold by placing the thumb and index finger approximately eight
centimeters or three inches apart on a line that is perpendicular to the long axis
of the skinfold. The long axis is parallel to the natural cleavage lines of the
skin. The thicker the fat tissue layer, the greater the separation between the
thumb and fingers in order to lift the fold.
6. Keep the fold elevated while taking the measurement.
 7. Place the jaws of the caliper perpendicular to the fold, one centimeter away
from the thumb and index finger, and release the jaw pressure slowly.
8. Record the skinfold measurement after one to two seconds (but within four
seconds) after the jaw pressure has been released.
9. If the caliper is not equipped with a digital display, read the dial to the nearest
0.1, 0.5 or 1 millimeter.
10.Take a minimum of two measurements at each site. If the values vary bymore
than two millimeters ot 10%, take an additional measurement.
11.Sites: Chest, diagonal, Midaxilla, vertical, triceps, vertical, subscapula,
diagonal, abdomen, vertical, suprailium, diagonal, thigh, vertical, medial cal for
boys and girls, vertical.
12.3 site SKF: men�chest, abdomen, thigh, women�triceps, suprailium, thigh

Errors can be compounded by

BIA is Bioelectrical Impedance�not as accurate for very lean or obese

NIR is near-infrared interactance

Waist-to-Hip Ratio with a plastic or metal tape measure

Divide waist by hip circumference and consult chart. These range from <0.83 to >0.94

Cardiovascular submaximal testing

Cycle ergometer

1. Calibrate ergometer.
2. Adjust seat height so there is a 5 degree knee flexion at the lowest pedal
position with the ball of foot on the pedal.
3. Client should maintain upright posture with relaxed grip on handlebars.
4. Establish cadence�set metronome at 100 for a 50 revolutions per minute
cadence.
5. Set workload�units of kilogram-meters per minute or watts.
 6. Check resistance frequently, especially with mechanically braked
ergometers.
7. Monitor client for symptoms of stopping test.
8. Assess HR during the end of each stage or until steady-state HR is
achieved.

The YMCA Cycle Ergometer Test is a submaximal, multistage exercise test for
cardiovascular endurance, set at 50RPM, designed to progress client to 85% of
predicted maximal HR using three-minute stages of increasing work rate. The
following data is needed to plot the heart rate with charts, graphs, and equations:

Body weight in kilograms, age-predicted maximal HR, at least two

measurements at each work rate up to 85% of age-predicted maximal HR, a BP
measurement at each work rate, an RPE assessment at each work rate

The Astrand-Rhyming Cycle Ergomenter Test is a single-stage test lasting six

minutes with cadence at 50RPM, from >61 to <13.

The YMCA Step Test

12-inch step at 96BPM for 3 minutes, 24 steps per minute, Up, Up, Down, Down

Within 5 seconds, measure heart rate for three minutes

Compare this to normative values�70- 151�excellent to poor.

Distance Run and Walk tests

Running a greater distance in less time is a way to assess cardiovascular

endurance in healthy men under 40 and healthy women under 50.

12 minutes, 1 mile or 1.5 miles

12 min: 400-meter (437 yard) track or flat course with measured distances so
that the number of laps completed can be easily counted and multiplied by the
course distance.

Record the total distance in meters. (400 meters times 5.25 laps = 2,100 meters.)

VO2Max=[0.0268 times (D)]-11.3

Then compare to estimated norms in chart.

1.5 mile run is also a field test used in a regressive equation to estimate VO2max,

but the score is converted to minutes by dividing by 60 and then using this
equation: VO2max=88.02-(0.1656 times BW) �(2.76 times (time) + (3.716 times
gender) For gender, substitute 1 for males, and 0 for females.

Rockport Walking Test is good for everyone 18-69. After walking a mile as
briskly as possible, use a 15-second duration to count HR, then convert the
seconds to minutes by dividing by 60. Estimate VO2Max with another long
equation. <10-12 to <17.32 excellent to poor.

Muscular Strength

1RM Bench Press requires skill because a barbell is used.

•  Warm-up with a light weight for 5-10 reps.

•  1 minute rest.

•  Estimate load for 3-5 reps increasing 5-10% for upper body, 10-20% for lower
body.

•  2 minute rest.

•  Estimate a conservative, near max load for2-3 reps, increasing 5-10% for
upper body, 10-20% for lower body.
•  2-4 minute rest.

•  Load increase 5-10% for upper body, 10-20% for lower body for 1 RM.

•  2-4 minute rest.

•  Increase load and try again if client was successful. Decrease 2.5% for upper
body or 5-10% for lower body if client failed.

•  Divide the 1RM value by the client's body weight to determine relative
strength and then compare to normative chart�1.48 to 0.53 in men, 0.54 to 0.02
in women.

1RM needs a Universal leg press machine for the normative data, but you could
use an angled hip sled or horizontal leg press.

Standardize knee angle at approximately 120 degrees. Norms�2.27 to 1.16 for

men, 2.05 to 0.75 for women.

Muscular Endurance

YMCA Bench Press: Set resistance at 80 pounds (36.3kg) for men, 35 pounds
(15.9kg) for women. Set metronome at 60BPM for a rate of 30 reps per minute.
Have the client, beginning with arms extended and a shoulder-width grip, lower
the weight to the chest. Then, without pausing, the client should raise the bar to
full arm's length. The bar should reach the highest and lowest positions with
each beat of the metronome. Terminate when the client can no longer lift. Norms
are 44 to 0

Partial Curl-Up

•  Lie supine with the knees at 90 degrees. Arms are at the side on the floor with
the fingers touch a four-inch (10-cm) piece of masking tape that is placed on the
floor perpendicular to the fingers. A second piece of masking tape is placed 8 cm
or 3 inches (for those who are under 45) and 12 cm or 5 inches for those who are
over 45).
•  Set a metronome to 40BPM and have the individual do slow, controlled curl-
ups to lift he shoulder blades off the mat (trunk makes a 30 degree angle with the
mat) at 20 curl-ups per minute.

•  Perform as many curl-ups as possible without pausing, up to 75.

Norms are 75 to 0.

One Minute Sit-Up

•  Lie supine with arms crossed on chest, hands touching shoulders, heels
approximately 12-18 inches (30-45 cm) from the buttocks.

•  Using a stop watch for 60 seconds have client raise torso until it is
perpendicular to the floor. The chin should be tucked into the chest, and the
hands should stay in contact with the shoulders. The client then lowers the torso
until the shoulders are once again in contact with the floor. Rest periods are
allowed.

•  Compare score to norms�77-8.

Push-Up Test

This test becomes one for muscular strength rather than endurance when the
body weight is too heavy to complete multiple reps.

•  Assume push-up position. For men, the hands are shoulder-width apart, the
back is straight, and the head is up. Women can flex the knees to 90 degrees and
cross the ankles.

•  For a male client, place a fist on the floor beneath his chest, counting the reps
only when the chest touches the fist. For female clients, you can use a foam roller
and then raise body to full arm's length.

•  Record number of reps and compare to norms�41 to 2 for men, 31 to 0 for

women.

 
Sit and Reach

There is no test to measure whole body flexibility. Sit and reach can measure hip
and back flexibility, but, because of many variables such as torso-leg length ratio
etc., it is not always 100% accurate.

•  Warm-up and take off shoes.

•  For YMCA test, place a yardstick on the floor and place tape across the
yardstick at a right angle to the 15-inch (38cm) mark. The client then sits with
the yardstick between the legs, extending the legs at right angles to the taped line
on the floor. The heels should touch the edge of the taped line and should be
about 10-12 (25-30cm) apart.

•  When using a box, place the heels against the edge of the box.

•  Have the client reach forward slowly with both hands, moving as far as
possible and holding the terminal position. The fingers should overlap and be in
contact with the yardstick or the sit and reach box.

•  The score is the most distant point reached. Use the best of three scores. The
knees must stay extended, but the trainer should not press the knees down.
Norms are 22-4 for tape, 42-11 for sit and reach box. Women score better on this
test, finally!

Memorize high and low percentile values for common tests

VO2max Men 20-29 51.4

Women over sixty 20.8

So if a 39 year old woman's Vo2 max is 30.2ml kg min she needs to work on aerobics.

Muscles are elastic, tendons and ligaments can be elastic and plastic. Warm-ups can
be passive, general, or specific, stretching ballistic, static, dynamic, or PNF. NSCA
PNF technique is a 10 second passive stretch, followed by a 6 second isometric
contraction against partner resistance, followed by a 1-2 second rest, and another 30
second passive stretch followed by a deeper stretch. Since usable, functional strength
is crucial, dynamic stretches such as arm circles, arm swings, and hockey lunges are
important.

Ant.deltoids and Pecs : Hands behind back

Triceps and lats: Behind-neck stretch

Obliques, piriformis, ITB, erector spinae: Pretzel

Iliopsoas, glutes, quads, hams: Lunge

Glutes, hams, back: Knee to chest, walking knee tuck

Back, hams, gastroc: Semistraddle

Adductors, Butterfly, Knee over hurdle

Calves: Wall stretch

NSCA supports back extension and rotation lying prone.

Hands crossed over chest for curl-ups or squat chair test.

All stability ball exercises in every position including advanced pikes are okay for
core.

Grips are pronated, supinated, alternated,

neutral, open, closed

5 point contact: Head, Shoulders, Buttocks, Right Foot, Left Foot

 
Pronators: straight last, high motion control

Supinators: curved last, high motion flexibility

Cardio Machines

Treadmill: Quads, hams, glutes, iliopsoas, tibialis anterior, gastroc, soleus

Stair climber: Quads, hams, glutes, iliopsoas, tibialis anterior, gastroc, soleus. Don't
face out on climber. Excessive leaning can compromise posture and reduce caloric
consumption up to 20%. Avoid too much lateral sway. Reduce step depth or speed
until proper form is achieved. 43-95 steps per minute.

Elliptical: Quads, hams, glutes, iliopsoas, tibialis anterior, gastroc, soleus.

Don't let knees bend more than 90 degrees over toes.

Bike: Quads, hams, glutes, iliopsoas, tibialis anterior, gastroc, soleus

Less lower leg than treadmill, especially on reclining bikes. Seat height�slight bend
in knee when ball of foot is at 12 o clock. Strongest push from hip extension is
between 45 and 135 degrees. HR, BP, VO2 max, rate-pressure product, and RPE
lower in reclining bikes because back support alleviates postural workload, and
reclining position reduces need for heat to pump blood vertically against gravity.

Rowing Machines: Quads, hams, glutes, iliopsoas, tibialis anterior, gastroc, soleus,
biceps, brachioradialis, brachialis, rectus abdominis, delts, traps, lats, teres major,
flexor and extensor carpi ulnaris. 70% to 75% of pulling action must come from
stronger leg and hip muscles. Maintain lumbar lordosis. Torso leans forward with the
start and the recovery, and back with drive and finish, but if clients have bad backs,
keep torso upright and still. After hips and knees are extended in the drive, the arms
pull the handle to the abdomen. Cadence is 20 for recreational to 35 for elite rowers
per minute.

Walking

Stride length and stride frequency

Racewalking utilizes a pelvic roll�internal rotation on the reach of the striding leg,
neutral position in mid-stance, external rotation on propulsion.

For long distance, arms relax with a slight bend and swing; for racing the arms bend at
the elbows to ninety degrees. 2-4 times body weight.

Avoid braking from overstriding because too much time in the air with a staccato
landing is inefficient. Understriding prevents body from advancing naturally.

Increase rear leg drive by strengthening and stretching, as well as plyo.

Impact

SLOW overstride can create a harder landing and more chance of injury.

Low impact�1 to 1/1/4

Medium�2 to 21/2

High�often greater than 3 times body weight

Step�from 1.4 to 2.5 depending on step height and propulsive moves

Swimming can use every muscle in the body. Economize during entry/catch and
power phases with or without S stroke. Swimming tries to decrease drag, friction, and
turbulence, while aquatics to increase them by creating moves that make it difficult
(walking, jogging, kicking, jumping, and scissors in different directions and different
speeds) and using resistive equipment. A body submerged to the waist bears 50% of
its weight, to the chest 25%-35%, and to the neck 10%. LSD, pace/tempo, interval,
repetition, and Fartlek time intervals as well as DWR can be used in the water for
cross-training, rehab etc.

Initial consultation and assessment

Choice
Frequency

Order

Load

Volume

Rest

Variation

Progression

BEGINNER: 1-2 months. 1-2 times a week. Low intensity. 3-5 machine exercises. 4-6
months. 2-3 times a week. Low to medium. 6-10 machine core and assistance
exercises; 3-5 free weight assistance exercises.

INTERMEDIATE: 8-10 months. 3 times a week. 11-15 machine core and assistance
exercises; 6-10 free weight assistance exercises; 3-5 free weight core exercises. 1
year. Medium to high intensity. 4 times a week. 15 free weight and machine core and
assistance exercises.

ADVANCED: 1-1 1/2 years. 4 times a week. High intensity. 15 free weight and
machine core and assistance exercises. 3-5 power/explosive exercises.

More than 2 years: 5 times a week. Very High. 15 free weight and machine core and
assistance exercises. Most power/explosive exercises.

Progression

2 for 2 rule: If a client can complete two more repetitions than the repetition goal in
the final set of an exercise for two consecutive training sessions, then the trainer
should increase the load in all of the sets of that exercise for the next training session.
2.5% for core, 1-2% for assistance for Beginner A, 5% for core, 2.5-5% for assistance
for Beginner B

2.5-5% for Intermediate/Advanced Upper Body

5-10% for Lower Body

Core exercises involve two or more joints, and recruit one or more large muscle
groups (pecs) with synergistic help of smaller groups (triceps) like the bench press. A
core exercise that puts axial stress on the spine like the power clean, shoulder press,
back squat is called a structural exercise. Power or explosive are structural exercises
done very fast like push press, power clean, snatch, high pull. Assistance exercises are
isolated, one joint exercises, even with large muscles like dumbbell fly.

Split routine�4 times a week can include light and heavy days for upper and lower
body. Or 3 days on, one day off.

Potential sequences

Power, other core, then assistance

Multijoint then single joint

Large muscles then small muscles

Alternate push and pull

Alternate upper body then lower body

Core, then assistance, then alternate push/pull

Compound set is doing the same muscle�bench press, pec deck

Superset is agonist/antagonist

 
1RM

Limitations: Well-trained clients can sometimes exceed these limits because of

neuromuscular efficiency

Applies to one set

Usually relates to power clean, back squat, and bench press�machines are easier,
assistance exercises use less weight

But memorize relationships anyway:

100 1

95 2

93 3

90 4

87 5

85 6

83 7

80 8

77 9

75 10

70 11

67 12

65 15

Muscular endurance <67 >12, 2-3 sets, 30 seconds or less rest

Hypertrophy 67-85 6-12, 3-6 sets, 30-90 seconds rest

Strength >85 <6, 2-6 sets, 2-5 minutes rest

Light day is 80% of load lifted on a heavy day.

Progression

2 for 2 rule: If a client can complete two more repetitions than the repetition goal in
the final set of an exercise for two consecutive training sessions, then the trainer
should increase the load in all of the sets of that exercise for the next training session.

2.5% for core, 1-2% for assistance for Beginner A, 5% for core, 2.5-5% for assistance
for Beginner B

2.5-5% for Intermediate/Advanced Upper Body

5-10% for Lower Body

Aerobic Training

LSD�30 minutes to 2 hours or more. 50% to 85% or HRR, Talk test.

Pace/Tempo�Exercise at their lactate threshold, RPE of 13-14 or 4-5, only one ot

two times a week.

Interval Training�3-5 minutes with a rest period of 1:1 or 1:3.

Repetition�Very high intensity 90-100%, sometimes with 1:10 or longer rest periods

Fartlek�Intense bouts on an LSD base

Cross-training is good to overcome limitations of specificity and avoid injuries.

Circuit training is good when pressed for time. In general, periodization is based than
combined training, although both resistance and aerobic training are necessary at
different times, and even in periodization, neither program is entirely eliminated.

SEC or Series Elastic Component is composed mainly of tendons, acting as a spring,

during an eccentric muscle action, storing elastic energy. If the muscle immediately
begins a concentric activity, the energy is released; otherwise, it is lost in heat. Muscle
spindles are intramuscular organs sensitive to the rate and magnitude of a stretch,
which potentiate activity in the agonist muscle.

Resting position: Alignment and intent

Countermovement or eccentric phase: SEC undergoes a rapid stretch, muscles

spindles send a signal to spinal cord

Amortization phase: Signal reaches spinal cord and synapses, signal sent back to
muscle

Concentric phase: Jump up, as SEC shortens to resting length, signal reaches muscle
to cause concentric action

Plyo can increase bone density up to 7%.

Children should avoid plyo because of epiphyseal plates that have not closed yet, and
elderly with osteoporosis or arthritis could incur stress fractures or other problems.

In the strength training for plyo, make sure you include ECCENTRIC actions. It's not
just about jumping high, but landing well, acceleration/deceleration, and changing
directions efficiently and rapidly.

Needs Analysis
Age, resistance training, injury history, physical testing (vertical and standing long
jump), training goals, risk of injury at job or sport

Recovery time�48-72 hours

Recovery for depth jumps may consist of 5-10 seconds of rest between reps and two
to three minutes between sets.

Intensity ranges from low-level skipping to depth jumps. Beginners can do simple
skips, double leg jumps-in-place, double leg standing jumps.

Volume is expressed as number of foot contacts or throws and catches, ranging from
40 to 140.

General and specific warm-ups are required. (Whole body cardio, and lower intensity
rehearsal of tasks or sport.) Warm-up drills can include lunging forward, diagonal,
backward, toe jogging, straight-leg jogging, butt-kickers, skipping, and footwork like
sliding, shuffling, carioca, backward running or back pedaling.

STRENGTH: The client's 1RM squat should be at least 1.5 times his or her body
weight. For upper body plyo clients over 220 pounds (100kilos) should have a bench
press 1RM of at least 1.0 times their body weight, while those under 220 should have
1.5 times their body weight. Or perform 5 clap push-ups in a row.

SPEED: The client should be able to perform 5 reps of the squat and/or bench press
with 60% body weight in five seconds or less.

BALANCE: Beginners must stand on one leg for 30 seconds without falling,
intermediate a single-leg quarter squat, and advanced a single-leg half squat for 30
seconds.
 

SURFACE: Grass field, suspended floor, rubber mats are good but concrete, tile, and
hardwood are not. Excessively thick mats or mini-trampolines may extend
amortization phase, not allowing efficient stretch reflex.

Boxes must be sturdy with a non-slip top, 6-42 inches (15-107cm)

Shoes should have good ankle and arch support, lateral stability, and a wide, nonslip
sole.

Speed-strength is maximum force at high velocities like power clean, hang clean, and
snatch, and plyometrics. Speed-endurance is running speed and movement over six
seconds.

SPRINTING: Sprinting is a series of ballistic strides where the body is repeatedly

launched forward as a projectile. The body should lean forward approximately 45
degrees during acceleration and should quickly move upright to less than 5-degree
lean from the ground, not the waist, during maximal speed. Put weight over ball on
mid-stance, and increase height foot moves toward buttocks (heel kick). The hip then
flexes with the knee around 90 degrees then becomes nearly straight as the foot moves
down and forward during flight. At foot strike, hips over under and ground contact
time is minimal to allow for explosive movement. Arm swing is fast and aggressive,
with hands rising to nose in front and pass buttocks behind. Stride frequency is easier
to train than stride length, which is more dependent on body height and leg length.

Sprint-assisted training can be done with downgrade sprinting (3-7 degrees), high-
speed towing, a high-speed treadmill, a faster partner etc. This will increase the stride
frequency, but don't do more than 10% of client's natural speed.

Resisted sprinting can increase client's stride length by increasing the client's ground
force production during the support phase. Don't increase external resistance by more
than 10%. You can use upgrade treadmill, or resistance with sled, elastic tubing,
parachute, water, partner etc.

You can also sprint/walk/run with intervals.

 

Non-athletes could do speed 1-2 times a week, athletes 2-4 times, but not every day.

Speed recovery times: 1:5, 1:10.

Volume is expressed as distance covered.

Warm-up should be low intensity dynamic movements.

Either lower body plyo, speed training, or lower body resistance training on a given
day but you can combine upper and lower body with different modalities. Complex
training of plyo and resistance requires significant rest in between. A squat jump with
30% of 1RM is good for experts.

Skip: Low Horizontal and vertical.

Double-leg Tuck Jump: Medium. Vertical. Begin with a countermovement

Advanced�one-leg only

Split Squat Jump: Medium. Advanced�switch legs in the air.

Standing Long Jump: Low.

Double-leg Vertical Jump: Low. Advanced�one leg only.

Double-leg Hop: Medium. Horizontal and vertical. Advanced�one leg only.

Front Barrier Hop: Medium. Horizontal and vertical. Advanced�increase height of

barrier.

Alternate Leg Bound with double arms. Medium, Horizontal and vertical.

Jump to Box: Low. (6-42 inches.)

Jump from Box: Medium

Depth Jump: High. Step from box, land, and jump high and vertically.

Upper body

Chest Pass : Low. But you can increase weight of ball.

Depth Push-up: Medium. Begin with arms extended on ball in a push-up position.
Remove hands from ball, drop down, immediately push up to full extension. Quickly
place palms on ball and begin again.

45 degree sit-up. Medium.

Drills with butt-kicker and stationary arm swing.

Periodization

Macrocycle�training season�could be nine months or four years in Olympics

Mesocycle: Several weeks to a few months

Microcycle: One week to four weeks with daily and weekly variations

Five kinds of mesocycles:

Hypertrophy: Muscular and metabolic base, high volume, low intensity, 2-4 weeks, 3-
5 sets, 8-12 reps about 75% of 1RM with a one to two-minute rest

Strength: Sport-specific exercises of moderate volume and intensity, 2-4 weeks, 3-5
sets about 85% 1RM, 5-6 reps, 3-5 minutes rest

Strength/power: Integration of resistance and sport-specific power/explosive of low

volume and high intensity, 2-4 weeks, 3-4 reps, 3-5 sets, 90%-93%1RM, longer rest,
explosive exercises
Competition or Peaking phase: 1-3 weeks, Very high intensity, low volume, 1-2 reps
around 95%, 3-5 sets, 3-5 minute rest.

Active rest: Rest a week then cross training, light work, and return to hypertrophy

Linear (from high volume, low intensity to low volume, high intensity or undulating
on a weekly basis) and

Non-linear models�within the week microcycle vacillations�heavy, (85 to 95%)

light,(65 to 75%) power, (30-95% explosive to core) moderate (75-80%)

A sample four day program could be heavy, light, off, power, moderate, mon-fri.

3 adverse outcomes for pregnant women:

1) insufficient oxygen or energy substrates to the fetus

2) hyperthermia-induced fetal distress or birth abnormalities

3) increased uterine contractions

Benefits:

•  Improved cardiovascular and muscular fitness

•  Facilitated recovery from labor

•  Reduced postpartum belly

•  Reduced back pain during pregnancy

•  More energy reserve

•  Fewer obstetric interventions

•  Shorter active phase of labor and perhaps less pain

•  Less weight gain

•  Enhanced maternal well-being

•  Increased likelihood of adopting permanent healthy lifestyle habits

•  Perhaps avoid gestational diabetes

However, these benefits are all for the mother. There is also a lower birth rate, 10-12
ounces or 300 to 350 grams, and a 5 to 15 beat per minute increase in fetal heart rate
with vigorous exercise. So perhaps moderate exercise would be better.

RPE: 12-16

No supine exercises after first trimester to avoid supine hypotensive syndrome.

Pregnant women may increase their minute ventilation by almost 50%, resulting in
10% to 20% more oxygen utilization at rest. Fetus can press on diaphragm as well.
Avoid impact sports, downhill skiing, horseback riding. They need an extra 300kilocal
a day to meet homeostasis. Hydration. Avoid heat.

CONTRAINDICATIONS

•  Pregnancy-induced hypertension (preeclampsia)

•  Ruptured membranes

•  Premature labor during current pregnancy

•  Persistent bleeding after 12 weeks

•  Incompetent cervix dilating ahead of schedule

•  Significant heart or restrictive lung disease

•  Multiple-birth pregnancy that creates a risk of premature labor

•  A placenta that blocks the cervix after 26 weeks

•  Poorly controlled type I diabetes, seizures, hypertension, or hyperthyroidism

•  Extreme obesity

•  Extremely low body weight less than 12

•  History of a very sedentary lifestyle

•  Unevaluated maternal cardiac arrhythmia

•  Severe anemia

•  Heavy smoking

•  Chronic bronchitis

•  Orthopedic limitations

•  Bloody discharge from the vagina

•  Gush of fluid from the vagina

•  Sudden swelling of the ankles, hands, or face

•  Persistent, severe headaches, visual disturbances, fainting, dizziness

•  Elevation of pulse or blood pressure that persists after exercise

•  Persistent contractions (6-8 per hour) that may suggest premature labor

•  Unexplained abdominal pain

•  Insufficient weight gain�less than 2 pounds per month during the last two
trimesters

Guidelines

•  Perform 30 minutes or more of moderate exercise on most days of the week. ACSM

•  Avoid exercise in supine after first trimester.

•  Exercise should never continue past fatigue.

•  Cycling and swimming are preferred to weight bearing or high risk activities.

•  Cool environment, lots of fluid, loose, light clothing.

•  Resume exercise gradually after birth.

Older Adults

Over 50, perhaps with cardiovascular disease, cancer, diabetes, osteoporosis, low back
pain, arthritis, depression, obesity, and frailty. Resistance training decreases resting
blood pressure 3 % or 4% and improves blood lipid levels, and can even be used
postcoronary only with aerobic training. Exercise increases transit speed, which may
reduce risk of colon cancer. Resistance training enhances glucose utilization,
improves insulin response, and glycemic control, as well as preserving lean body mass
offsetting muscle myopathy. Bone loss can be changed to bone gain through regular
resistance training, mitigating the effects of osteoporosis and osteopenia.
Strengthening lumbar extensors may alleviate back pain. Stronger muscles improve
joint function and reduce debilitating pain. Strength training can alleviate depression
and improve body image. Adults lose about one-half pound of muscle per year during
their 30s and 40s and 1 pound after fifty, but the average aging American adds 4.5
kilos or 10 pounds of body weight which is 5-10 pounds less muscle and 15-20
pounds more fat, with a 2%-5% reduction in resting metabolic rate per decade.

Guidelines (These seem like suggestions for people over 70 or else medically
compromised; otherwise human potential is diminished.)

•  Resistance train 2-3 times per week on nonconsecutive days at 4-6 seconds per rep.

•  Demonstrate first. Give verbal and kinesthetic cues, assistance, positive

reinforcement.

•  Aerobic training 2-5 days a week from 20 to 60 minutes, at 60% to 90% but 75% is
best, unless on medication or compromised. Some may only do 5-10 minutes at 40%.
They could have 30 beats above or below formulas even with a healthy heart, so
perceived exertion may be better. 12-14

•  Begin with aerobic activity, cool-down, stretching, then resistance, then stretching.

•  Avoid lunges or step-ups.

 
Children as young as 6 can lift weights, and boys and girls have the same potential for
strength because the testosterone blast has not yet begun; hence they have neural
adaptations such as excitation-contraction coupling, myofibrillar packing density, and
muscle fiber composition, motor neuron recruitment, rather than hypertrophy.
Preadolescent youth can weight train but be careful of loading them during growth
spurts. Their natural rhythm is sporadic bursts of moderate-to-high intensity followed
by low intensity or rest. Use C-LPAM or the Children's Lifetime Physical Activity
Model. Children optimally expend 6-8 kcal per kilogram per day. So a girl who
weighs 88 pounds should expend at least 120 kilocal per day (3-4 minimum) and
optimally 280 in physical activity. They can get increased bone mineral density,
improved body composition, enhanced cardiorespiratory fitness, better speed and
skill, and lower elevated blood lipids.

To avoid 50% of injuries youth should engage in more primary fitness activities pre-
season.

Adults should supervise. One to three sets of 6 to 15 reps on single and multijoint
exercises with 5% to 10% progression on two to three non-consecutive days.

To calculate BMI using non-metric units, Weight divided by heigh squared times 703
For example a person who weights 164 pounds and is 68 inches tall has a BMI of 25.

To calculate BMI using metric units, weight divided by height squared.

Weight: 78.93 kilo, and is 1.77meters tall =25.

78.93 divided by 1.77squared =25.

Underweight is less than 18.5, normal 18.5 -24.9, overweight 25.0-29.9, obese over
30, extreme obese over 40.

Gynoid obesity is pear-shaped in hip and thigh. Android apple is fat in trunk and abs,
leading perhaps to Type II diabetes, hypertension, and CVD. Use waist circumference
and BMI rather than calipers with obese.

A reduction in calories of 500 to 1000 a day will achieve a weight loss of 1 to 2

pounds a week. Total fat should not be more than 30%, protein 15% (lean meats and
plants), carbs 55% or more, cholesterol less than 300 mg. 10% reduction of weight in
6 months.

1200 kcal, 800kcal�only with doctor's prescription.

Don't eat sweets, drink alcohol or soda, or processed foods.

Guidelines for Obese

Low impact aerobics �progress to five times 40-60 minutes, can begin with 2 daily
sessions 20-30 min each or intervals. Get wide seats on bikes and ergometers. 40-70%
VO2max. Weight train 2-3 times a week, 1-3 sets, 10-15 reps. Hold static stretches
10-30 s.

Disordered eating, anorexia nervosa, bulimia

Female Athlete Triad: Disordered eating, amenorrhea, (at least 3 consecutive cycles)
osteoporosis

Signs for Bulimia

Vomiting at least 2 times a week for at least 3 months

Laxatives, enemas

Excessive exercise

Overconcern of body shape

Weight fluctuations of more than 10 pounds

Odor of vomit on breath

Scabs or scars on knuckles

Swollen puffy cheeks

Sore throat and dental problems

Abdominal symptoms

Erratic performance at work, school

Irregular or absent menses

Lacerations of oral cavity

Diarrhea

Constipation

Fatigue

Electrolyte disturbances

Heart irregularities

Ruptures in stomach

Signs for Anorexia

15% or more below expected weight range

Denial

Avoidance of social situations with food

Obsession with exercise

Sensitivity to cold

Layers of baggy clothing

Fatigue

Decline

Lanugo or baby hair over face and body

Yellow tint to skin

Loss of muscle mass and tone

Amenorrhea
Slow pulse�light headed on standing

Constipation

Encourage client to consume 200 to 400 kcal of complex carbs during first 30-90
minutes after exercise

Encourage a healthy diet

DO NOT EXERCISE EVERY DAY

Be careful of impact�stress fractures

See immediate medical attention for cardio-pulmonary irregularities

Hyperlipidemia

TLC diet. Less than 7% of saturated fats and less than 200 mg of cholesterol a day
with lots of fiber and exercise.

<100LDL 130-159 Borderline high

Over 60 HDL is good.

Triglycerides <150 normal. 150-199 Borderline high

Metabolic syndrome is a cluster of major cardiac risk factors and abdominal obesity,
also called syndrome X, dyslipidemic hypertension, and insulin resistance syndrome.

Waist cir: 40 inches in men, 35 in women

Triglycerides: >150

Less than 40 HDL in men and 50 in women

>130/86mmHg
Elevated fasting glucose .110mg/dL

22% of population has metabolic syndrome�heart disease and strokes.

DIABETES

Increased thirst, urination, appetite, and general weakness

Two fasting glucose levels of 126 mg/dL or higher, or two 2-hour postprandial plasma
glucose measurements of 200mg/dL or higher after a glucose load of 75 grams.

Type I: Insulin-dependent diabetes mellitus

Pancreatic beta cell destruction by an auto-immune process, usually leading to

absolute insulin deficiency. Approximately 10% of patients with diabetes have Type I.
Must take exogenous insulin and are prone to ketoacidosis, which could lead to coma.

Type II: Insulin resistance in peripheral tissues and an insulin secretory deficit of the
pancreatic beta cells, associated with family history of diabetes, old age, obesity, and
lack of exercise. They can produce their own insulin however.

Gestational diabetes can occur during pregnancy. (2%-5% of pregnant women)

Exercise can increase insulin sensitivity and glucose utilization, lowering blood
glucose levels. A complication could be hypoglycemia, lower than 65mg/dL, but be
careful as soon as it approaches 70.

Stress cardiac testing by a medical pro must be performed for clients who are older
than 35, or those who have had Type II for more than 10 years, Type I more than 15
years, or with evidence of microvascular disease like retinopathy or nephropathy.
Other contraindications are glucose over 240 in Type 1, 300 in Type II, loss of
sensation in feet (may be able to swim or bike), and acute illness, infection, or fever.

The biggest deleterious side effect of exercise could be hypoglycemia from increased
intensity, longer time, inadequate fuel beforehand, insulin injection into the exercising
muscle, or severe cold. Hypoglycemia �loss of concentration, shaking, shivering,
sweating, tachycardia, loss of consciousness. So have juice, bananas, oranges on hand.

Glucose levels should be monitored before and after exercise, as well as every 30
minutes. Snacks are okay if levels are low, but wait a few hours after a meal.

PROGRAM: 4-6 days a week, for 20-60 minutes at 40% to 70% of VO2 max
(aerobic)

Resistance train 1 set, 8-12 reps, two to three times a week

5-10 minute warm-up and cool-down, hold static stretches 10-30 seconds

Over 50 million Americans age 6 and over have hypertension�over 140-90, 90% are
idiopathic, only 10 curable if caused by hyperthyroidism, pheochromocytoma,
hypercortisolism, hyperaldosteronism, and renal artery stenosis. They must have
medical evaluations for target organ damage or cardiovascular disease. You don't feel
it till it is too late�chest pain, visual blurring, neurologic deficits, i.e. strokes or heart
attacks.

High Normal 130-139/85-89: Lifestyle modification for Groups A and B, drug

therapy for those with heart failure, renal insufficiency, or diabetes, and lifestyle
modification

Stage I 140-159/90-99: Lifestyle modification up to 12 months for Group A, 6 months

for Group B, and drug therapy for Group C and lifestyle modification

Stages 2 and 3 160/100: Lifestyle modification, drug therapy

Goals are to bring it to as low as 125/75 for people with renal failure with proteinuria

Blood pressure has decreased 4/5/3.8mmHg with long term-resistance training, and
4.7/3.1 with aerobic training.

Program: Sleep, limit salt and alcohol, get enough potassium, aerobic 30-45 minutes
four or more days of the week, stop smoking, and reduce dietary fat and cholesterol
Drugs include beta-blockers, alpha-blockers, and calcium-channel blockers, possibly
diuretics. The blockers can cause blood pooling so there should be a longer cooldown.
Must use RPE as heart rates are not reliable.

PROGRAM: Low-intensity exercise at 40%-50% of maximal oxygen uptake is

efficient for reducing stress. RPE of 8-10 on the 6-20 scale with a goal range of
11-13, between 15-30 minutes then going to 30-60 minutes, 3-7 days a week,
weekly caloric expenditure of 700-2000 kilocal in 4-6 months. Resistance should
begin at 16-20 per set, 50% to 60% of 1RM, with a 2-3 minute rest between sets.
Can do 1-3 sets. Over time you can move to 6-12 reps. Two to three times a week,
between 30-60 minutes. Goals are to increase VO2max and ventilatory threshold,
maximal work and endurance, caloric expenditure, blood pressure, and
muscular endurance.

If a client suddenly comes to class with a Stage I pressure, you must cancel the
session and have him see the doctor. Don't treat post MI clients with CAD and no
angina because they may die on you all of a sudden.

Be careful of comorbid conditions such as musculoskeletal, neurologic, and vascular.

PROGRAM FOR MI:Begin at 40% of VO2max or RPE of 9-11, 15-40 minutes 3-

4 times a week. Additional time for warm-up and cooldown. Resistance begins at
20 reps, 1-3 sets, 2-3 days a week. Treadmill is okay.

PROGRAM FOR POST CVA: Consult CVA medical team. Ergometers may be
more important than treadmills because balance is usually off. Can begin as low
as 30% VO2max�they can be so deconditioned, you have to measure peak VO2.
Eventually they may do 40%-70%. Session can be 5-60 minutes, 3 times a week.
Resistance training is crucial to develop new pathways, and perhaps have a
crossover effect on the compromised limb. Eventually do 3 sets of 8-12 reps two
to three days a week. Daily ROM needed (even 5 minutes) to avoid contractures.
Do balance and coordination exercises.

PROGRAM FOR PVD: They can't walk for more than 2-5 minutes because of
the searing pain in their calves. They may take nitroglycerin for chest pain with a
bitter taste and soon-to-follow headache. If client has pain, ache, dyspnea, sit him
down, take nitro, and call EMS . Claudication is the rate-limiting factor. So walk
till it hurts, stop, rest, do it again, and try to proceed to 10-30 minutes. Low-
intensity exercise at 40%-50% of maximal oxygen uptake is efficient for reducing
stress. RPE of 8-10 on the 6-20 scale with a goal range of 11-13, between 15-30
minutes then going to 30-60 minutes, 3-7 days a week, weekly caloric expenditure
of 700-2000 kilocal in 4-6 months. Resistance should begin at 16-20 per set, 50%
to 60% of 1RM, with a 2-3 minute rest between sets. Can do 1-3 sets. Over time
you can move to 6-12 reps. Two to three times a week, between 30-60 minutes.
Goals are to increase VO2max and ventilatory threshold, maximal work and
endurance, caloric expenditure, blood pressure, and muscular endurance

Clients with severe angina and COPD must exercise in a medical setting.

Asthma: is reversible airway disease with associated hyperreactivity, characterized by

the ease of developing bronchospasm, constriction, or both. Some severe forms
require stronger meds (inhaled and oral steroids usually for late stage airway edema)
than the inhaled bronchodilators for early stage bronchoconstriction. Status asmaticus
is an acute mucus plugging of the airways.

EIA: Self-limited, can begin 5-20 minutes into a session, and has associated coughing,
wheezing, or both.

PROGRAM: RPR and sense of shortness of breath. Those taking steroids may
have muscular disease of the respiratory muscles. Better with mid to late
morning exercise because of the natural daytime release of cortisol from the
adrenal glands. Avoid temperature extremes. May not achieve THR but some
physiological improvements will occur. RPE 11-13, 1-2 times daily, 3-7 days of
the week, 30 minutes, but can begin 5-10 minutes. Resistance training can be 16
reps, 2-3 days a week. Flexibility, core strengthening and stretching etc.

Injuries can involve macrotrauma or sudden onset, or microtrauma or insidious

onset, which can relate to poor program design, suboptimal training surfaces,
faulty technique, insufficient motor control, decreased flexibility, or skeletal
malalignment.

Go from a acontusion, to a first, second, (partial), and third degree muscle strain
(complete tear), tendonitis, tendinopathy, joint sprain (first, second, and third
degree tear of ligaments), bone fracture, (avoid stress fractures through excessive
training on hard surfaces), subluxation, or dislocation (partial or complete
displacement of joint surfaces). 
Inflammation: Histamine and bradykinin increase blood flow and capillary
permeability causing edema which inhibits function. Two to three days after an
injury, but much longer after surgery or severe structural damage. RICE
Repair:3-5 days after injury up to two months. Damaged tissue regenerated as
scar tissue. New capillaries, connective tissue, collagen fibers parallel and
longitudinal to the line of stress. If fibers are laid down incorrectly, transverse
friction is good. Prevent muscle atrophy and joint degeneration, promote
collagen synthesis, avoid disruption of newly formed collagen fibers. Low-load
stresses. Avoid resistive exercises of damaged tissue, except submaximal, pain-
free, isometric exercise.

Remodeling:Increased loading allows collagen fibers to hypertrophy and align

themselves along lines of stress. Can last 2-4 or more months after surgery. Add
more advanced, activity-specific exercises that allow progressive stresses to be
applied to the injured tissue.

Organize a program with indications and contraindications, such as avoiding the

last 30 degrees of extension after an ACL graft, or a precaution, which requires
supervision.

Disc injury: Part of nucleus pulposus burst through annulus fibrosis, resulting in
inflammation and nerve damage if it damages the spinal canal. Client may feel
pain or weakness into the buttocks (sciatic notch), down the legs or even have a
foot drop in severe cases. Excessive flexion is contraindicated, because it may
push disc contents further towards spinal canal. Avoid full sit-ups, full or loaded
squats, (although plies are okay), rowing movements, and the deadlift. Watch
excessive flexion on the bike, the rowing ergometer, or aerobic dance, toe
touches. Do gluteal, hip adductor, and upper back stretches under
supervision�precaution. Avoid knee to chest, spinal twist stretches, extreme
flexion/rotation, especially passive assisted or resisted. (Psoas and piriformis
stretches are okay if isolated).

PROGRAM: passive lumbar extension, isometric abdominal and extensor

strengthening progressing to lumbar stabilization

Muscle Strain: Traumatic tears require three-stage tissue healing, avoiding

elliptical, rows, power etc during early stages) while insidious tears postural
retraining. Avoid exercise during inflammatory period, progress to gentle flexion
stretching, followed by extension strengthening.

Spondylolysis (a defect or fracture of the pars interarticularis region of a lumbar

vertebra) and spondylolisthesis (its progression into a forward slippage of one
vertebral body on another) often occurring in lumbar extension injuries such as
football, accidents, diving etc.: Avoid hyperextension, extend only till neutral,
avoid squat, shoulder press, and push press with heavy weights, although these
movements can be done with nothing, provided posture is good. Do ab crunches
and knee to chest. Avoid hyperextension with spinal stenosis, and try to
decompress with water activities in a good posture.

Shoulder: Impingement syndrome: Pinching of the supraspinatus, the long head

of the biceps, or subacromial bursa under the acromial arch. Strengthen
rotators, stabilize scapula, correct posture, fix glenohumeral rhythm, may begin
with decline bench press, do lateral raises in external, not internal rotation, avoid
upright row, Versaclimber, and be careful with ball sports

Anterior instability: The humeral head moves too far forward, resulting in
possible injury or dislocation. Following a dislocation of the shoulder,
redislocation can occur in as many as 90% of young, active people while only
30% to 50% of middle-aged. Surgical management can include arthroscopy, or
high tech instruments that shrink the joint capsule (thermal capsulorraphy) to
assist in stabilizing the head. Movements that involve greater than 90 degrees of
elevation, placing the hands and arms behind the plane of the shoulder may lead
to redislocation. The safe zone is below 90 degrees of elevation anterior to the
frontal plane of the body. These modifications must be permanent, including
avoidance of the freestyle, backstroke, and butterfly, and some racket sports,
hands behind back stretch and behind neck stretch.

Rotator Cuff debridement and subacromial decompression: Debridgement

means to scrape away at the edge of a tear until a clean, bleeding surface of
tendon is achieved. SAD involves scraping or shaving away the bone on the
anterior and inferior surfaces of the acromion to decrease the stress or
impingement of the rotator cuff tendons between the acromion and head of the
humerus. The shaved bone often takes 12 weeks or more to heal, creating
significant amounts of pain. ROM and gentle PT begin immediately. 4-6 weeks
after surgery clients can perfom rotator cuff exercises, and by 6-8 weeks PT is
over. They should continue rotator cuff and scapular strengthening.
Contraindications include high-resistance, low-rep upper extremity strength
training, and exercises outside the safe zone, and full ROM shoulder press, bench
press, pec dec, and behind the neck pulldown. Avoid throwing, swimming, and
racket sports.

Rotator Cuff repair: Surgical repair after a tear that is full thickness,
particularly supraspinatus�could involve open incision as well as arthroscopy.
Greater periods of immobilization in a sling (2 days to 6 weeks, depending on
age, tissue quality, and presence of additional injuries. Follow shoulder protocol,
but immobilization requires ROM in rotation and abducition.

Strengthen rotators side-lying, then prone shoulder extension, prone horizontal

abduction (rear delt flys), prone 90/90 rotation and then standing rotation (light
weights, high reps�15-20)

Stabilize scapula�upper and lower traps, serratus anterior, and levator scapula

Knee: Chondromalacia, iliotibial band friction syndrome, irritated plica, patella

tendonitis caused by overuse, including surfaces and gear, biomechanical faults,
(patellofemoral malalignment, improper patellar positioning, tightness of lateral
retinaculum or ITB, or excessive pronation or supination) and muscular
imbalance (relationship between VMO and vastus lateralis). Quads help clients
walk up and downstairs and decelerate on level surfaces. However, deep squats
or knee flexion beyond 90 degrees increase compression between patella and
femur and should be avoided so high impact, step are contraindicated in favor of
cycling and water exercise to reduce inflammation in anterior knee pain.

ACL: Limits anterior tibial translation and rotation relative to the femur. ACL
reconstruction has improved. Two different kinds of grafts�the
semitendinosus/gracilis grafts preclude immediate postoperative active or
resistive knee flexion exercise until 4-6 weeks following surgery. At discharge�4-
6 months from PT clients should have good strength and ROM. Translation of
the tibia relative to the femur is minimized because of the weight bearing and
muscular co-contraction during closed kinetic chain exercises which allow
multiple joints to be exercisesd. While both open and closed chain should be
performed, the greatest amount of anterior tibial translation occur in the final 30
degrees of leg extension in an open kinetic chain. Safe zone is 90 to 45 degrees of
extension for six months to one year after ACL. Use of unilateral stance, single-
leg squats, and step-ups insures that clients will not favor injured leg. Shallow
steps, biking, and swimming are preferred for aerobics.

TOTAL KNEE ARTHROPLASTY: Re: Degeneration and degradation of joint

surfaces of distal femur and proximal tibia, excessive valgus or varus, fractures,
meniscal pathology, instability. Following discharge, patients have 100 to 120
degrees of flexion and nearly complete extension. Cycling, swimming, endurance
with reduced impact, leg press, multidirectional hip strengthening, calf raises,
flexion and extension low resistance high reps are recommended. Avoid kneeling
or lunges performed too deeply. Focus on ROM.

TOTAL HIP ARTHROPLASTY: To relieve osteoarthritis, cemented (immediate

post-operative weight-bearing) and uncemented, (weight-bearing restrictions 6-
12 weeks) lasting at least 15 years with techniques posterior, (risk of dislocation)
anterolateral, and transtrochanteric. No hip flexion greater than 90 degrees, no
hip adduction past neutral, no hip adduction machine, no hip internal rotation,
high impact, resisted hip flexion, full sit-up. Do ½ squats, elliptical, and improve
gait.

ARTHRITIS: OA�mechanical stresses leading to microfractures, deterioration

of weight-bearing cartilage, proliferation of new bone at margins of joints like
spurs or osteophytes, and sclerotic changes in subchondral bone. In majority of
people age 55 and older. Chondroitin sulfate and glucosamine. Biking, elliptical,
swimming, weight management. Open chain upper body, no push-ups, and lower
body except full ROM with patellofemoral syndrome. Light weight closed kinetic
chain for lower body.

RA- inflammatory, autoimmune, proliferation of joint's synovial lining, pannus,

edema, inhibition. Exacerbation, remission, then progression. Unstable joints.
Disuse atrophy. Can include osteoporosis, periarticularnodules, deformity,
ankylosis. Neck, shoulders, wrists, and hands. Don't do high impact, neck
exercises (particularly resisted) or movements outside the safe zone, upper trap
stretch, behind the neck shoulder press. (Could rupture ligaments of neck,
rotator cuff tears in 30% to 40% of RA, loss of grip strength.) Exercise at 60%-
80% on bike, (vigorous non-impact aerobics may reduce inflammation),
elliptical, stepper, ROM but don't overstretch, isometrics, stationary bike, water
aerobics. May have to build up dumbbell's diameter to facilitate grip. During
acute flare-ups, rest.

Spinal Cord Injury: Between T-1 and C-1�quadriplegia or tetraplegia, complete

paralysis. T-2-T-12�paraplegia of trunk, legs and or pelvic organs.
Thromboembolic events and dysrhythmias, reduced vascular tone, and
unbalanced hyperactivity of the vagal system. High lesions are prone to
bradycardia, primary cardiac arrest, and cardiac conduction disturbances.
Chronic CVA could has atherosclerosis, angina, heart failure and other serious
cardiovascular manifestations, particularly AD or autonomic dysreflexia, which
is a disruption in normal neural regulation of arterial blood pressure, esp above
T6 where there is hypertension (20-40mmHg or boosting) due to distended
bladder, menses, sores, sex, scrotal compression, restricted clothing,
infections�can die. Look out for pounding headache, sweating, goose bumps,
blurred vision with spots, congestion, anxiety and dysrhythmias. Track
wheelchair and swimming athletes with SCI sometimes strive for AD to boost
their circulation and get this reflex response. Overuse injuries are at shoulders,
wrists, and elbows�57% of NWAA. So stretch anterior and strengthen posterior
compartment. Higher HR and lower BP compared to others. Above T-6 clients
cannot regulate through sweating or shivering. Compensate or work only in
temp controlled environments. Risk of dehydration and poor venous return as
well. Train in supine position, be alert to fainting. Also at risk for CVD, diabetes,
dyslipidemia etc. They may not know they are having a heart attack. Limited by
extensive paralysis and or sympathetic autonomic nervous impairment.

Multiple Sclerosis: Autoimmune disorder, related to Epstein-Barr virus, sensory

disturbances, fatigue, weakness, ipsilateral optical neuritis, gait ataxia,
neurogenic bowel and bladder, trunk and limb parestheisa. 80% have
relapsing/remitting and 20% have progressive MS. Benign (10-15%) Minimal or
no disability, Classical relapsing-remitting (25-30%) , Chronic relapsing-
remitting (25-30%), often permanent motor and sensory deficits, chronic
progressive (15-20%) insidious onset, gradual but steady worsening of
symptoms, quadriparesis, cognitive decline, visual loss, loss of bowel, bladder,
and sexual function. Manage dystonic spasms, spasticity, ataxia, incordination,
depression, dysfunction, pain etc. Could have foot drop, memory problems. Meds
manage inflammation and try to modify disease process. Although sedentary,
aerobic exercise could increase fitness 30%. 40-70% of VO2max or HRR,
progressing over 3-6 months to 50-70% as tolerated. Yoga, tai chi, resistance
with modifications. Prone to heat intolerance, but could do aquatics if it isn't too
hot. 8-12 exercises, 40-60% of 1RM load , 1-3 sets or 8-12 reps. Progression at
50% of normal rate.

Epilepsy: Two or more unprovoked, recurring seizures�involuntary alteration

in movement, sensation, perception, cognitive behavior, and or loss of
consciousness. Status epilepticus is a seizure lasting more than 30 minutes or so
frequently that consciousness is not restored. Recognize precipitants�exercise
could do it in 10% of the cases, emotional stress, hyperventilation, menses, sleep
deprivation, fever, lights/TV, alcohol, then modify intensity or avoid exercise.
Partial seizures can be: Simple with no LOC, Complex (35-40%) partial or
complete LOC, often preceded by aura, evolving to generalized (40-45%)
including both hemispheres, complete LOC. Generalized seizures can be petit
mal (staring or eye flickering), no convulsions, myoclonic, clonic, tonic, tonic-
clonic (or grand mal, which is rigidity followed by flexion with labored
breathing, tongue biting, cyanosis, incontinence, post-ictal confusion, fatigue,
stupor) or atonic, loss of postural tone. A weight loss of ten pounds can increase
the bioavailablity of antiseizure medication, and risk of side effects. First aid:
Keep client prone. Remove glasses, loosen clothing, do not restrain, keep objects
out of path, do not place anything in mouth, after seizure, turn client into CPR
recovery position, observe until awake, alert doctor and family.

Cerebral Palsy: Impaired body movement and coordination (apraxia, ataxia

from cerebellum, athetosis from midbrain, chorea, dyskinesis from basal ganglia,
dystonia, myoclonus, spasticity from motor cortex of cerebrum) with possible
difficulty swallowing, speaking, or seizures (60%) etc due to brain damage at
birthing or infancy, but it isn't progressive. CP1-8 from severe spastic tetraplegia
to minimally affected diplegia. Excellent responses to exercise. After medical
clearance, can do arm and/or leg ergometer, rarely treadmill can be used if they
have balance. Wear gloves or strap feet to pedals. 6-12 minute walk or
wheelchair push. Skinfold measurements can be taken at uninvolved sites. 50-
85% VO2 or HRR, 30 minutes, 4 or more days of the week. Begin with 5-10
minutes twice a day. May not be able to use free weights�just machines. Warm-
up, cooldown, and stretching. Cognitive, visual, hearing, and speech difficulties.
Supervise on machines like treadmill, ski, elliptical.

Facility organization can be by body part, or by equipment type.

•  Equipment that requires spotters should be located away from windows,

mirrors, and doors.

•  Tallest machines or power racks should be placed along walls, and may need to
be bolted. Dumbell racks also on walls and shorter, smaller pieces in the middle.

•  Resistance training machines are placed in an order so that large muscles are
trained first, smaller ones last.

•  Stretching is a separate area, with a minimum of a five foot user length and
width for a home gym.

•  Aerobic machines that require clients to be upright (treadmills, elliptical)

should be placed behind the rowing machines and bikes so that the taller
machines are close to the wall.

•  All equipment should be placed at least 6 inches (15 centimeters) from mirrors,
which should be 20 inches above the floor.
•  Separate room for group exercise.

•  Bench press, lying triceps extension: 156 square feet

Standing exercises like biceps curl and upright row: 100 square feet

Back squat and shoulder press: 100 square feet

Olympic lifting platform with 4-foot safety space cushion and lunge and step-
ups: 256 square feet, 36 inches between the ends of the Olympic bars

Stretching and warm-up: 49 square feet, larger if PNF is needed

Treadmill: 117 square feet

Machine seated chest press: 110 square feet

Aerobic dance videotape: 36 square feet

Traffic flow should be around perimeter of machines. There should be at least

one walkway that bisects the room, three feet wide maintained clear at all times.
Ceiling should be free of low-hanging apparatus and high enough for
jumping�minimum of 12 feet. All resistance training machines should be placed
at least two feet, preferably three feet apart. If a free weight exercise is
performed, a three-foot safety space cushion is needed between the ends of the
barbell and adjacent stations, as well as between multi- and single stations. The
ends of all Olympic bars should be spaced three feet apart. A free weight station
should be able to accommodate three to four people. Racks holding the fixed-
weight barbells should have a minimum of three feet between the ends of the
bars. Weight trees should be placed close to plate-loaded equipment, but not
closer than three feet. The walkway around Olympic platform should be three to
four feet wide. Three feet is a good cushion around everything although a small
home gym may only have 18 inches, with 25-49 square feet for aerobics.

Ground electrical equipment and outlets, keep facility free of children and pets,
machines should not exceed home circuitry. Lighting, circulation, flooring,
(rubberized, wood, tile, padded, short-pile, or aerobic platforms) mirrors 20
inches off the floor. Plyometric boxes and jumping equipment must have padded
flooring, nonslip surfaces.
PTs must inspect, clean, and maintain equipment. Guide rods on selectorized
machines should be cleaned and lubricated twice a week.

Be able to calculate the total needed area in square feet if client is performing
seated shoulder press, upright row with a 5-foot long bar, a 5-foot long weight
bend for the lying triceps extension with a 4-foot EZ-curl bar, a step-up on an 8-
foot Olympic platform with a 3-foot safety space chsion, a front squat in a41/2
square power rack using an Olympic bar, a stair machine, and a seated toe
touch.

LAW

Understand contracts and torts resulting from negligence�a failure to act, or

substandard care. Many PTs do not have appropriate education, training, and
certifications, and there is no licensure as there is for massage and physical
therapy. It is crucial to keep records of comprehensive assessments, appropriate
fitness tests, thorough evaluations, suitable program design, attentive
supervision, emergency prep. Only NSCA and ACSM have credible certifications
for personal training and formal education in the exercise sciences is crucial.
Know the difference between common or case law based on past cases, and
statutory law, enacted and authorized by statutes, ordinances, and codes. Usually
PTs are sued in a civil suit, but criminal action could occur with the
unauthorized practice of an allied health profession, even with the attempt to
prescribe rehab or dietary recommendations. Contractual requirements are
established when it is documented that a written agreement existed, consensual
words were articulated, or that implied conduct was expressed, as well as
releases, waivers, assumptions of risk, informed consents, or any exculpatory
agreement. Contracts are also between business partners�any fiduciary
relationship. A tort necessitates the establishment of a legal duty coupled with
the fact that breach of that duty resulted in proximate cause of a verified insult,
injury, or death to which compensation can be awarded, which can be intentional
or negligent or strict liability regardless of fault such as defective equipment
produced by the manufacturer. If a primary settlement cannot be achieved, then
the plaintiff and defendant go through the discovery process where all
paperwork is inspected and analyzed such as contract, medical history, lifestyle
questionnaire, physical exam reports, physician clearance forms, informed
consents, waivers, releases, assumption of risk forms, fitness profiles, program
design, workout logs, personal notes, as interrogatories and depositions are taken
of all involved, especially PT's education and credentials. An incident report
must be filed immediately, especially if it happens at home. Someone other than
trainer should have witnessed client's signature, and all forms must be updated
every year, and stored for at least four years.

First a summary judgment is sought to dismiss the case. An arbitration hearing

is held in hopes of again settling out of court; if it doesn't work, a jury trial
begins for adjudication. Employers can be found vicariously liable for negligent
acts of PTs (even as independent contractors) in respondeat superior. You can be
sued for negligence, (protect with a waiver�exculpatory clause) inherent
injuries (no one's fault so protect with an informed consent or agreement to
participate), and extreme forms of negligence. If an exculpatory clause is added
to an agreement to participate for adults then it becomes a waiver. Negligence
can be as simple as not completely a PAR-Q form or perceived sexual
harassment. But the plaintiff must prove duty (standard of care), subsequent
breach of duty, causation, and damages, which can be compensatory (and
comparative or contributory depending on whose fault it was) or punitive.
Expert witnesses are usually other trainers or health professionals.

Memorize the following liability exposures:1)Preparticipation screening and

clearance

2) Personnel qualifications

3)Program supervision and instruction

4)Facility and equipment setup, inspection, maintenance, repair, and signage

5)Emergency planning and response

6)Records and record keeping

7)Equal opportunity and access

8)Participation in strength and conditioning activities by children

9)Supplements, ergogenic aids, and drugs

Code of ethics cements the standard of care with confidentiality, respect,

continuing education, a safe and effective environment, and reporting other
people who violate this, avoiding words diagnose, or treat, in favor of assess,
motivate, educate, train, and refer unless they have other licenses that permit
this. Exercise program, not prescription. Must monitor signs and symptoms of
overexertion, intensity levels, and proper form and execution of movement.
Fitness owners are business invitees who must maintain safe premises. Clients
injured on equipment can sue PT, manufacturer, facility or all three. Even at
home, what is the emergency plan? Kits must be inspected once a month and
rehearsals quarterly. Need AED as well�over 95% of CVA die without it,
because once blood stops circulating, every minute without defibrillation
decreases the chances of survival 10%.

With a mild to moderate MI, activate EMS , and administer emergency oxygen.

Arm stroke accounts for 80% of power in freestyle.

17% body fat is lean for a 46 year old male.

Don't grasp the patellar tendon insertion in a knee to chest stretch.

A common technique in back hyperextension on the stability ball is allowing the

navel to move off of the ball.

Rowing machines is the cardio machine that works the most muscles.

On free weight bench press keep wrists rigid below elbows, and don't extend bar
upward and slightly away from the face.

Depth jump is the highest intensity plyo.

Incorrect technique can help perform more repetitions more easily but hurt the
body and not achieve results.