Exercise for Disabled Clients - Sample Manual by HealthFitnessEducation

Exercise for Disability Level 3 Student Manual

Contents

Table of Contents Section

Page

Understanding Disability 2

Working with Clients who have Disabilities 15

Screening and Assessing Clients with Disabilities 28

Programme Design for Clients with Disabilities 51

Exercise Prescription for Specific Disabilities 58

Preparing and Teaching Exercise to Clients with Disabilities 82

Helping Clients with Disabilities to Adopt and Maintain a 88 Physically Active Lifestyle

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Section 01

Understanding Disability

Level 3 Exercise For Disabled Clients

Section 01

Understanding Disability Working with clients with disabilities can be both a challenging and an extremely rewarding experience for exercise professionals. While many of the same skills are required to work with

level of knowledge, skill and professionalism.

Disability should not therefore not be viewed primarily as a health problem, but rather a complex interaction between the individual with an impairment or disabling condition and the personal and environmental factors he or she is faced with, such as negative attitudes, limited social support, inaccessible transportation and public buildings etc. (WHO, 2016).

Defining Disability

Models of Disability

There are a number of definitions of ‘disability’, historically, these have tended to be somewhat narrow, as they focus on the physical restrictions a condition may impose on an individual. For example, the Oxford Dictionary (Ions and Marshall,1994) defines disability as ‘something which disables or disqualifies a person, a physical incapacity caused by injury or disease’. Such narrow definitions provide little insight into what is in fact a more complex issue that reaches far beyond a person with a disability’s physical impairments. This definition also fails to acknowledge the diversity of disabling conditions that exist and their range in severity.

A number of models of disability have been developed to offer a clearer understanding of what disability is. These models are also useful to guide strategies and policies to better meet the needs of people with disabilities. They also help to shape public opinion, guide the allocation of resources and influence the training of professionals working with clients with disabilities (Smart, 2014).

those without a disability, the range of disabling conditions and the extent to which an individual is impaired by them, requires the exercise professional working with this group of clients to have considerable empathy and a very specific

The Equality Act (2010) provides a much more comprehensive definition because it recognises a disabled individual as someone who has a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on their ability to perform normal daily activities or tasks. According to the International Classification of Functioning, Disability and Health (ICF), disability should be considered as an umbrella term, encompassing impairments, activity limitations, and participation restrictions. It defines impairment as a problem in body function or structure; an activity limitation as a difficulty encountered by an individual when executing a task or action; and a participation restriction as a problem experienced by an individual in involvement in life situations (WHO, 2017).

Throughout this manual, the terms disability, impairment and disabling condition (for example, Multiple Sclerosis, Arthritis or Myalgic Encephalomyelitis, sometimes known as chronic fatigue syndrome) are used interchangeably.

Such models are not without criticism and are often described as being overly simplistic and onedimensional, especially when in reality, disability is a highly complex issue that is multidimensional in the way that it impacts the disabled individual. These models also tend to reflect the values and beliefs of their developers; with the exception of the social model, none of these were developed by people with disabilities themselves. Given that these models help to shape attitudes towards disability and affect the way people think about and behave towards people who have disabilities, they also indirectly affect outcomes for people with disabilities, how they are treated and how they participate in society. All of these issues can give rise to prejudice and discrimination. The four most commonly cited models of disability include: •

Charity

•

Functional

•

Medical

•

Social

Section 01

Level 3 Exercise For Disabled Clients

Understanding Disability

Charity Model of Disability (Tragedy Model)

Functional Model of Disability (Economic Model)

The charity model depicts people as victims of circumstance who deserve pity. It is often used by charities when fund-raising (MDRC, 2016). For example, the televised Children in Need appeals tend to show disabled children alongside children suffering famine, poverty or child abuse. This model has been heavily criticised by disabled individuals and those working for the rights and welfare of people with disabilities for being disempowering, contrary to principles of enablement and a leading cause of discrimination. Its depiction of people as tragic victims in need of help implies that they are not capable of looking after themselves or managing their own affairs, and that they need others to make decisions on their behalf, to look after and protect them (Smart, 2014). This, and the medical model, are probably the most influential of all models of disability on the public’s perception of and attitudes towards people with disabilities. It stigmatises and excludes people who have disabilities from ‘normal society’ as opposed to promoting inclusivity.

As the name suggests, the functional model views disability from a functional perspective with a particular emphasis on the ability of the person with the disability to perform physical tasks that relate to daily living. Similar to the medical model, it conceptualises disability as an impairment or deficit that is caused by physical, medical or cognitive deficits. The disability itself limits a person’s functioning or the ability to perform functional activities. The functional model is used primarily by policy makers to assess the distribution of social/welfare benefits to those who are unable to work. It is criticised for its judgement of individuals based on perceived costeffectiveness, which can lead to people with disabilities being considered a burden or a drain on social resources (MDRC, 2016). A positive aspect of viewing disability from a functional perspective is that it carefully considers the impact the disability has on the individual’s functional ability. By assessing individually how each person functions, it is possible to identify and assess the barriers that prevent functional independence, so that the disabled individual is capable of performing without assistance common activities of daily living (ADLs), including work. This may be a particularly useful model for exercise professionals in assessing an individual’s functional ability to engage in and benefit from a structured programme of exercise. However, an over-emphasis on disability from a purely functional perspective can have a dehumanising effect (treating someone as ‘less than’ a full human being) with regards to the person with the disability and their abilities instead of focusing on the individual’s opinions and experiences of living with an impairment.

Section 01

Understanding Disability

Medical Model of Disability (Biomedical) The medical model depicts disability as a defect or biomedical abnormality which renders a disabled individual functionally limited. The source of the problem and the potential solution are considered to lie within the individual while ignoring the influence of the individual’s physical and social environments (MDRC, 2016). It reinforces the view that health care professionals are the best people to make key decisions affecting the person with the disability and it is the role of the person to accept these decisions on the basis that the health care professionals are the experts. This can lead to a tendency to treat people with a disability in terms of their diagnoses and disability category e.g. ‘the deaf’, ‘the blind’, ‘the physically disabled’, rather than treating them as individuals (Smart, 2014).

Level 3 Exercise For Disabled Clients

The UK government encourages the use of the social model in all statutory services for people who have a disability and in 2009, ratified the UN Convention on the Rights of People with Disabilities (www.gov.uk). While the social model highlights the important role that society and the environment play in the experience of people with disabilities, its critics suggest that it tends to dismiss or diminish the considerable role a health condition may have on the life of a person with a disability (Smeltzer, 2007), for example, on an emotional and psychological level through the experience of stigma and social exclusion, and on the physical level through the experience of fatigue, pain and problems with physiological function.

The medical model of disability has been rejected by many people with disabilities and disability advocacy groups because it fails to address the full spectrum of issues relating to the life of a person living with a disability. It also places less value on the knowledge that a person with a disability has about their own condition which has been gained from real life experience. Instead however, it privileges the medical knowledge of ‘so called experts’ over that of the impaired individual’s opinions. Furthermore, it fails to acknowledge the ability of many people with a disability to live full, happy and independent lives (Smeltzer, 2007).

Social Model (Barriers Model) The social model views disability as a result of environmental, social and attitudinal barriers which prevent people with a disability from fully participating in society, rather than the presence of a medical condition. Society is depicted as the cause of disability, which is considered a consequence of an environment created for non-disabled people (MDRC, 2014). This model emphasises society’s lack of awareness and concern about those who may require some modifications to live full, productive lives. By placing the onus upon society and not the individual, the social model is effectively in direct opposition with the medical model.

Level 3 Exercise For Disabled Clients

Programme Design for Clients with Disabilities

Section 04

Programme Design for Clients with Disabilities A well designed exercise programme can

•

Moderate intensity (40-59% heart rate reserve (HRR)) to vigorous 60-89% HRR is recommended for most adults. Light intensity (30 -39% HRR) to moderate intensity exercise can be beneficial for deconditioned individuals.

•

Progression can be achieved by gradually increasing exercise time and or frequency or intensity.

enhance the health, physical function and ability to live independently of people with disabilities. Specific exercise guidelines have been developed for certain medical conditions and disabilities and more recently, general guidelines for clients with chronic diseases and disabilities have also been issued (Painter and Moore, 2016). Since 1975, the American College of Sports Medicine (ACSM) has issued guidelines for the prescription of health-related exercise, which have continually evolved in-line with advances in sport and exercise science. These guidelines have become the standard for exercise prescription. These guidelines provide a framework to develop safe and effective exercise programmes for apparently healthy individuals, which will also be appropriate for some clients with disabilities, particularly those with a higher level of physical function. However they will need to be applied with care by the exercise professional and adapted to accommodate the ability and needs of the individual.

Muscular Fitness •

Adults should train each major muscle group two or three days each week, using a variety of exercises and equipment.

•

Very light or light intensity is best for older persons or previously sedentary adults starting exercise.

•

Two to four sets of each exercise will help adults improve strength and power. One set can be effective, particularly for novice exercisers and the elderly.

•

8-12 repetitions should be performed to improve strength and power, 10-15 repetitions to improve strength in middle-age and older persons starting exercise, and 15-20 repetitions to improve muscular endurance.

•

48 hours recovery is recommended between resistance training sessions for the same muscle group.

•

Overload can be achieved by increasing the resistance, and/or number of repetitions and/or sets and/or frequency.

A summary of the key points from the 2017 guidelines is provided below:

Aerobic Exercise •

Select rhythmical aerobic activities that involve the large muscle groups and which can be maintained continuously. Suitable examples include cycling, walking, running, rowing, swimming, etc.

•

Moderate intensity aerobic exercise should be performed at least 5 days per week or vigorous intensity done at least 3 days per week, or a weekly combination of 3-5 days per week of moderate and vigorous exercise is recommended.

•

Most adults should accumulate 30-60 minutes per day of moderate intensity exercise, 20-60 minutes of vigorous intensity, or a combination of moderate and vigorous intensity exercise daily. This can be achieved in one continuous session or accumulated throughout the day in bouts of 10 minutes or more. Durations of less than those recommended can be beneficial for very de-conditioned individuals.

Section 04

Programme Design for Clients with Disabilities

Level 3 Exercise For Disabled Clients

Flexibility

General Exercise Guidelines for Disability

•

Adults should perform flexibility exercises at least two or three days each week to improve range of motion, with daily being most effective.

•

Each stretch should be held for 10-30 seconds to the point of tightness or slight discomfort. For older adults, 30-60 seconds may be more beneficial.

•

Repeat each stretch two to four times, accumulating 60 seconds per stretch.

•

Static, dynamic, and PNF stretches are all effective.

•

Flexibility exercise is most effective when the muscle is warm. Light aerobic activity or a hot bath prior to stretching will help to prepare the muscles.

The ACSM’s CDD4 guidelines provide a ‘general’ overview of what exercisers with a disability should be working towards. These are intended for individuals whose condition or disability dramatically diminishes their exercise capacity. Their goal is to ensure that everyone is sufficiently active to maintain independent living. This requires a minimum ability to perform activities that involve light intensity aerobic exercise combined with strength, flexibility, balance and coordination (Gordon et al, 2016).

•

Optimal methods for progression are unknown at the current time.

Neuromotor Exercise •

Neuromotor exercise is recommended for two or three days per week.

•

This should involve motor skills (balance, agility, coordination and gait), proprioceptive exercise training and multifaceted activities (e.g., tai chi and yoga) to improve physical function and prevent falls in older adults.

•

20-30 minutes per day is appropriate for neuromotor exercise.

•

Optimal methods for progression are unknown at the current time.

For a more comprehensive explanation of the guidelines for exercise prescription, readers are advised to consult the latest edition of The ACSM’s Guidelines for Exercising Testing and Prescription.

As a general guide, every person with a chronic condition should be physically active, accumulating a minimum weekly total of 150 minutes of preferably moderate-intensity physical activity or, if that is too difficult, 150 minutes of light-intensity physical activity may be substituted.

Aerobic Exercise •

Frequency: 4-5 times per week

•

Intensity: Start at a self-selected intensity that meets the talk test. Gradually increase to an RPE of 3-5/10

•

Time: Start at any duration as tolerated. Goal of 40 minute sessions or 20 minutes if combined with strength training

•

Type: Large muscle group easily accessible activities, such as walking, cycling etc. Aquatic exercise is recommended for individuals who experience musculoskeletal problems during weight-bearing activity

•

Progression: At self-selected pace, over 4 weeks gradually increase time to 40 minutes, increasing intensity as tolerated.

Strength

•

Frequency: 2-3 times per week.

•

Intensity: 50-70% 1RM 1 set of 8-12 reps to fatigue.

•

Type: Functional gravity-based exercises are recommended as the basic programme. More conventional weight training is recommended for clients motivated to do it.

•

Example programme: Sit-to-stands 8 reps, at least 10 stair steps leading with each foot, arms curls 8 reps with a minimum of 2 kg, preferably 4 kg weight.

•

Progression: Build to as many sets as tolerated. For curls and other resistance exercise, progress to 2 sets over 8 weeks.

Section 04

Level 3 Exercise For Disabled Clients

Programme Design for Clients with Disabilities

Flexibility

Exercise Intensity and Monitoring

•

Frequency: 2-3 times per week.

•

Duration: 20 seconds.

•

Intensity: maintain stretch below point of discomfort.

Prescribing the right intensity and monitoring it are crucial to the safety and effectiveness of an exercise programme.

•

Target muscle groups: hips, knees, shoulders and neck.

•

Progression: Discomfort should occur at a ROM that does not cause instability. This point will vary between individuals and between joints within individuals.

•

A warm up and cool down of 10-15 minutes should be performed at an intensity of RPE <3/10.

Adapting the Guidelines to the Specific Client Needs The above guidelines are generally relevant for people with a variety of different conditions, impairments and disabilities because the vast majority of recommendations are more similar than dissimilar. However, exercise professionals will need to evaluate their appropriateness on an individual basis and adapt them accordingly. Section 05 of this training manual provides more specific information about the exercise guidelines for different types of disability and impairments.

When working with apparently healthy adults, exercise intensity tends to be prescribed and monitored using heart rate, which is the most objective measure. However, it is recommended that when working with disabled individuals or people with chronic diseases, that rate of perceived exertion and the talk test are used instead. This is because certain conditions and medications can alter the heart rate response to exercise (ACSM, 2017). RPE is the preferred measure and is calibrated by each individual’s ventilatory abilities as established via the talk test (Painter and Moore, 2016).

Ratings of Perceived Exertion Ratings of perceived exertion is assessed using a scale that provides a way of quantifying subjective feelings of exercise intensity, including factors such as breathlessness and feelings of muscular fatigue. An individual is asked to state how hard they feel they are working. A given numerical rating then corresponds to the perceived relative intensity of the exercise. For example, an individual may say they are working ‘somewhat hard’, which has a numerical rating of 4 of the 0-10 category ratio scale. There are numerous types of RPE scale, available with the 2 most common being: •

the borg scale (6-20)

•

the category ratio scale (0-10)

Either of these scales can be used however it is important that exercise professionals and clients alike understand that they are quite different in their meaning. The 6-20 scale is based on the linear relationship between exertion and heart rate, while 0-10 is based on the non-linear relationship between exertion and ventilation. The 0-10 scale was originally developed for individuals with chronic pulmonary conditions and tends to have a more intuitive range. It is however have a nonlinear at higher levels of exertion. For clients who a have normal cardiopulmonary response to exercise, the 6-20 scale is normally recommended as it is easier to make fine adjustments at the higher end of the scale (Gordon et 2016). Each of these RPE scales are presented on the following page.

Section 04

Programme Design for Clients with Disabilities

The Borg Ratings of Perceived Exertion (RPE) 6-20 Scale 6

No Exertion At All

Extremely Light

8 9

Very Light

10 11

Level 3 Exercise For Disabled Clients

For clients without medical issues that preclude the use of heart rate to monitor exercise, rating of perceived exertion can also provide an accurate method of monitoring and prescribing exercise intensity because it is highly related to exercise heart rates and VO2. Buckley et al (1999) provide the following guidelines to help standardise the procedure and improve the accuracy of RPE: •

Define RPE for each client: ‘It is the measure of your exertion/effort during this exercise. There are no right or wrong answers; it’s how hard you are finding it’.

•

Anchor the ratings to sensations the client has experienced; for example, 6 ‘no exertion at all’ (or 0), is how much physical exertion one would experience sitting on the sofa watching television.

•

Remove preconceptions of exertion and specific activities. People perceive different activities as requiring different levels of effort. For example, running is often perceived as requiring a lot of effort whereas walking is perceived as requiring little effort. However, it is possible to have an ‘easy’ run. On the other hand, it is possible to have a ‘hard’ walk, such as that experienced during a graded exercise test. Remember that it is how hard a client is finding an activity at the time they are doing it.

•

Keep the RPE scale in full view of the client whilst they are exercising.

•

Use the scale when clients are exercising, not between or after exercise.

•

Use RPE throughout the session including the warm up and cool-down.

•

Encourage clients to use the scale outside of the exercise environment.

•

Beware of factors, which may influence RPE, such as anxiety, depression, activity mode, mood and distractions, such as loud music, a lot of activity or loud conversation around the client.

•

Ensure clients can reliably estimate ratings of perceived exertion before allowing them the responsibility of self-regulating their exercise intensity.

Light

12 13

Somewhat Hard

14 15

Hard(Heavy)

16 17

Very Hard

18 19

Extremely Hard

Maximal Exertion

0-10 Category Ratio RPE Scale 0

No exertion at all

0.5

Extremely Light

Very Light

Light

Moderate

Somewhat Hard

Hard

6 7

Very Hard

Extremely Hard

Maximal

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Exercise for Disability Level 3 Student Manual