PT on the Net Research

Programming for Special Populations - Case Study

Exercise programming for special populations can often be a very basic affair. I've had students become either very amused or very frustrated when they saw that all special populations have the same basic exercise guidelines (extended warm up and cool down, high repetitions, form failure, circuit format and so on). However, the exercise professional has a pivotal role to play not just in guiding special population-based clients towards their exercise goals, but often in the actual treatment and management of the condition as well.

Fitness instructor courses often only teach the broadest view of exercise programming for the most common special populations and then often for the most able of that group. For example, some asthmatics require hospital treatment on a daily basis because their particular condition is so severe, but how to treat that person is unlikely to appear in an exercise course. Although disappointing, this is nevertheless reasonable because the exercise professional should be treating clients (or patients, in some cases) on an individual basis and programming each person on their own abilities. There are so many diseases and disabilities that the pharmaceutical companies and gene therapy departments do not have sufficient funding to research, so it is not reasonable to expect that exercise scientists or training providers can sufficiently research each one either.

I recall quite clearly the emotions that I went through when writing a paper on Duchenne’s muscular dystrophy (DMD) for my biochemistry class at university. During the research, I looked into a number of different types of muscular dystrophies and became very depressed during the weeks that I wrote the paper because the conditions were so rare that hardly any funding went into researching treatments. Not only that but these were conditions for which any muscle damage lead to bone formation within the muscles, meaning that young people were living out their final years in wheelchairs, unable to move and dying before reaching their 20s. When we consider our very raison d’etre is to promote exercise, with many of us always wanting to push people to their limits, this sort of understanding becomes quite a wake-up call for us.

When I used to teach exercise professionals about special populations, I would tell them about a former client of mine named Brian who had Parkinson’s disease. Brian was a wonderful, positive man, but he had given up on living. He resorted to spending almost his entire day in his armchair in front of the television. He was interested in the idea that exercise could help him become mobile again, and the notion was put to him by a friend of mine that had been doing massage treatments on his back (while Brian sat in his armchair, of course).

Brian had been a semi-professional footballer and cricketer when he was younger, and I promised him that if he worked for it, during the summer I would play football with him. At this stage, Brian could barely get out of a chair without assistance. Not only did he have Parkinson’s disease, but he also had significant circulatory and postural problems, muscle weakness and atrophy and various musculoskeletal issues (including fractures) caused by the many falls he'd had when trying to walk. He would occasionally black out while walking and then be unable to protect himself as he hit the ground, and quite often, he would be found lying there several hours later. His resting heart rate was over 100 bpm, and he had just been diagnosed with diabetes mellitus, but it bore such little consequence on what we were doing that it had no impact on his exercise selection (simply ensuring that his diet was manipulated accordingly).

For the first couple of months, almost all of the sessions took place with Brian in his armchair. I would begin by massaging the larger muscles around the joints in his leg and then start working through mobility exercises (using my hands to manipulate the ankles, knees and hips). Then I would work on the wrists, elbows and shoulder joints. As we progressed, I introduced strengthening exercises using manual resistance as he attempted to move the joints himself. Frequently, during those first few months, he would drift off to sleep, and I would have to wake him when I wanted him to do something. From doing the manual resistance work, I could feel that his muscles were working and a large proportion of the muscle fibres were able to fire when required. That was the reassurance I needed to show me there was progress.

After those first couple of months, the sessions continued in a similar manner. There was always the massage to begin with, then the mobility and strengthening work. How he felt on the day dictated how quickly we could get through everything. On days when he was feeling strong, I would help lift Brian out of his chair and hold him while we both did squats together. I would then get him to practice the Ministry of Silly Walks around his living room, manoeuvring around various obstacles - including the dog - while overstretching his strides and turning his body as he went. Over time, I would stand a little further away from him. When finished, I would pull the armchair over, have him rest his hands on the back and then go through some split squats and balance exercises including functional mobility work for his ankles, knees and hips.

Progress was not always continuous from one week to the next. Sometimes he would be too tired to manage more than a couple of sets of squats, while at other times he would have the strength and energy to walk me to the door after the session. On the whole, when viewing his progress across a number of weeks rather than from one to the next, his progress was tremendous. He had certainly stopped falling asleep during the sessions. Sometimes he would black out when he was on his own, but the black outs were becoming less frequent, and he was often able to break his fall and even get back up again afterwards. His sleep pattern was also improving. Often, it would seem that we would take three steps forward and two steps back. Something would happen to initiate the regression, but each time, I would use manual resistance on his legs and I could feel that those pathways we were building up were still there.

On a warm summer day, we walked out into his garden and played some football. He suddenly became that young man again, striding out to reach the ball and flick it over his head, all sorts of silly things that he knew better than to try. But he tried anyway, with a cheeky grin on his face from ear to ear and put me to shame. If it were not for the couple of hard tackles on my part, he probably would have won.

I went away for a couple of months, and when I came back, I heard that Brian had had another accident. We started the sessions again, but they were infrequent because his recovery was so slow. He passed away within a couple of months. I had phoned his house to speak with him, as I always did before the next session to check that everything was going well, and it was his daughter-in-law that answered the phone and gave me the news. I remember vividly his eldest son shaking my hand at the funeral and thanking me so much for everything that I had done. When something like that happens, you always think about what you could have done better. He had been so frail and then become so strong, only to lose it again. With so many older people, it really came down to confidence. If he had a bad fall, then he would need reassurance to know that he could get better again. This last time, it had been a really bad fall, and although he started to recover, he eventually died of a heart attack a few weeks later. It was his second, and he never let anybody know about his first (not even his sons), such was his pride and wish that nobody treated him any differently.

When I first met Brian, he was so frail that we both thought he would only be with us for a few months at the most. Through his own perseverance, he lived two more years, and he lived those two years much better than he could have imagined. He had been receiving other treatments for a while, but he found that they were ineffective, primarily because they were only mobility-based with no functional or strength-based approach. The health care industry as a whole has yet to see that despite all other treatments that were offered, it was an aggressive, functional exercise-based program that proved the best course of treatment. The reason for the lack of recognition was that hospital-based care is too often about pharmaceuticals and mobility at best. Despite many health care professionals recognizing that exercise should be promoted for everyone, there is still a widespread reluctance to accept that exercise professionals are the real missing link between the basic clinical treatments and individuals being able to live out their lives independently.

I used to think that simply being able to treat someone like this meant that afterward, you would be able to treat anyone. But this is not true. Not only must the exercise professional completely understand the merits of training people on a truly individual basis, but he or she must also make every attempt to fully understand the conditions each client has and actively seek guidance and information via other health care professionals that treat and assess that individual as well. Finally, the exercise professional must accept the reality that if working with someone who is in the later years of their life, they will die and this might even happen during a session. You must seek to understand the condition and what is realistic from any work you do, obtaining consent and so forth from the appropriate health care professionals, and you must be open with the person’s family members about their expectations.

Whatever the condition, in the majority of cases, exercise can be used as a treatment in some form. There are certainly some conditions for which exercise can neither help nor hinder and a few for which exercise would make the condition dramatically worse, but in most cases, it is the reverse that is true. The decision to take on a client is always up to you. If you do not feel qualified to take on a particular client, then have the sense of mind to recommend that individual to someone more appropriate or ask for time to research the condition. Our biggest obstacle to health care-wide recognition and acceptance is the exercise "professional" that does not take into consideration the conditions of an individual who comes to them for help. Our greatest asset, therefore, is the exercise professional that does.