Adaptive fitness

1. Adaptive fitness Join the movement towards inclusion

2. Objectives • Learn about your presenter • Recognize American disability statistics and adaptive terminology • Identify the most common types of impairments- how they could impair a person’s function and how to best handle these issues • Realize your opportunity in the inclusion movement • Empower trainers to feel confident in their ability to coach an adaptive or injured person in a safe manner • Acquire tools for better communication and what questions to ask this population

3. Presenter: Tina hurley • Lifelong athlete and gym goer • Completed a personal trainer certification 16 years ago • Bachelor’s degree in Exercise Science; externship in cardiac and pulmonary rehabilitation • Master’s degree in Physician Assistant Studies; 8 years of clinical practice in acute care medicine, vascular surgery and wound care • Below knee amputee since 7/2016; popliteal artery entrapment syndrome • NH TX in April for the Adaptive Training Foundation; participated in their 9 week ReDefine program then became a personal trainer for them serving person’s with disabilities

4. Adaptive Athlete

5. My story… • Dx 6 years ago,13 surgeries on left leg including 3 amputations, socioeconomic change • Identity? Purpose? • Difficulty finding knowledgeable trainers locally; secondary consequences- overuse injuries, underutilization, muscular imbalances and rhabdo • 2018 paradigm shift • The move, ATF, Less Leg More Heart, peer advocacy/mentorship, adaptive training and education

6. Americans with disabilitiesEveryday we are further recognizing the tremendous need for adaptive fitness education • Based on the 2017 Disabilities Statistics Annual Report: • “The American Community Survey (ACS) estimates the overall rate of people with disabilities in the US population in 2016 was 12.8%.” • 12.8% of 323M = 41M Americans • The most common types of disability involve difficulties with walking or independent living. 

7. Persons with disabilities are more likely than the general population to suffer from: • Depression • Anxiety • Polypharmacy • Interpersonal struggles • Self care neglect • Comorbidities leading to shortened life span • Isolation • Fear • Anger • Unemployment • Earn less and more likely to be in poverty • Metabolic syndrome

8. The journey of a person with a disability This is where we will help! …Or they have a congenital issues- then It’s straight to ???

9. an exercise prescription for the disabled population improves: • Cognitive, emotional and social difficulties (depression, anxiety, fear, isolation…) • Stress and pain • Ability to do ADLs- promotes confidence through enhanced independence • Global functionality- possible engagement in employment sooner + enhanced productivity at work • Medication utilization • Social contact- improving negative sterotypes • Mood • Obesity and all related pathologic sequalae • Hospital readmissions due to improved health thus improving the state of healthcare spending

10. why aren’t many of the 41M people with disabilities going to the gym… • They’re unsure of what to do and where to go • They’re intimidated by negative stereotypes • There are negligible gym advertisements showing adaptive participants • There is a deficit of fitness professionals who have worked with or have been educated on different disabilities (both physical needs and communication styles that work); an adaptive athlete may not be easily retained for this reason even if they come through the doors • Many gyms lack accessible equipment for autonomous use

11. This is where you come in!

12. Lifetime has progressive thinking: that’s why we’re here today Problem solving involves: • Creating inclusive advertisements • Initiating community outreach projects • Improving gym equipment accessibility • Trainer education

13. Let’s tackle some content! A few good tackles to transition into talking about injured folks...

14. A culture, set of practices and policies designed to identify and remove barriers such as physical, communication, and attitudinal, that hamper individuals' ability to have full participation in society, the same as people without disabilities. Inclusion: Terminology ✔ Able-Bodied: persons without a permanent physical impairment (AVOID “normal”) ✔ Impairment: to refer to an athlete’s condition/injury ✔ Disabled: a person with a permanent impairment (congenital vs acquired) that restricts their ability to function physically, mentally or socially. (visible vs invisible) AVOID: handicapped, invalid, cripple, deformity, abnormal, defect, disorder, deranged, wheelchair confined Unnecessary creativity: handicapable, diversibility, differently-abled, adaptively-abled ✔ Limb impairment: “Sound/Unsound side” ✔Amputee: “residual limb”, prosthetic Use language that describes the person first… “Our disabled client Susan” Vs “Susan, our client with a disability”

15. we will cover the following categories of impairment

16. Spinal cord injuries • No two are alike; the level of injury determines the extent of paralysis or sensory impairment. • Complete vs incomplete • Spinal circuits are capable of significant reorganization induced by both activity-dependent and injury-induced plasticity* • They have hyperdominant push muscles and an underdeveloped posterior chain/ rotator cuffs from wheelchair use; if higher than mid thoracic may have truncal instability • Topics of consideration: Bowel/ bladder, management thermoregulation (they often don’t sweat), spasms, sacral ulcers (!!), autonomic dysreflexia/ orthostatic hypotension (>T6), wheelchair accessibility • Brief examples of solutions for training: Anterior stretching/posterior strengthening focus, pad all surfaces when out of chair to avoid integument trouble, repetitive training sessions for reorganization of neuronal circuits and targeting neuronal plasticity* • Pro-tips: transferring into/out of chair is time consuming so group exercises accordingly, also consider couplets etc where you can keep a circuit in close proximity to decrease transition time, if any truncal instability is present- work this out of the chair to improve ADLs/QOL, they may need to be strapped/weighted down on equipment (i.e. hips/legs in a traditional bench press)

17. Neuromuscular disorders • Disorders of the motor unit- mainly affects voluntary muscles • Many different types (congenital, genetic, acquired): • CP, Muscular dystrophy, GBS, Myasthenia Gravis, Parkinson’s, ALS/ Lou Gerhig’s, Hunington’s… • Causes rigidity, muscle pain, spasms and weakness/ muscle wasting, neural fatigue • Most are incurable but exercise in NMD is known to improve: QOL, reduce degradation of muscle, improve movement, improve symptoms or comorbidities of the disease, prolong independence, reduce risk of falls and injury, and prevent or limit disability* • Not to mention the CV and respiratory benefits which are usually the route of mortality in these people • Things to keep in mind: FALL RISK, pain receptors may be altered so start low and go slow, consider resistance and flexibility couplets, as well as balance and/or fall drills, may need foot/hand straps and accessory tools for training • Pro-tips: QOD recommended for neural recovery, lower weight/ crescendo higher rep is ideal

18. Limb impairment • Etiologies: • Congenital condition vs acquired impairment (hemiplegia- stroke, JRA, nerve palsies, venous or arterial insufficiencies, spastic syndromes, etc) and limb loss • Though training is helpful for most impairments, it can be dangerous and/or contraindicated in some • i.e. PAES- recurrent calf activation can expedite arterial occlusion and limb loss • Moral of the story- know the diagnosis and tread cautiously (use collective knowledge) • Longer the functional piece of the limb, the easier adaptation movements and prosthetics are • Compensatory movement patterns are often necessary for people to live their lives • They may not always move in a symmetric fashion or in ergonomic alignment for a functional reason • So when adding exercise, look at the upstream/downstream effects as well as the impact it will have on their functionality outside of the gym when weighing risks/benefits of proceeding with “fixing” malalignments

19. Each year >130K Americans undergo the amputation of a limb

20. Upper extremity Loss • Many different levels and types of prosthetics- often they don’t use prosthetics • 70% are caused by traumatic injuries and 30% from birth defects or disease • Physical challenges for training: • More difficult the higher the amputations, unable to grip on one side, favor non-impaired side • Some solutions: Bands are your friend! Strapping systems for symmetric deadlifts, farmer’s carry and oly work (we can discuss specifics in future lecture series) • Pro tips: trial and error, get creative, be aware of sensory impairments when strapping/banding to avoid skin breakdown

21. Lower extremity Loss • Many different levels and types of prosthetics • 30% increase in TEE for BKA, 60% in AKA • Imagine the requirements if bilateral • Leads to geriatric FTT due to decreased cardiopulmonary reserves to support this demand • Physical challenges for training: • Fixed ankle and/or loss of knee joint, lack of proprioception, balance difficulty, limited limb rotation, issue getting to depth • Secondary compensation issues due to the above such as exaggerated forward torso lean i.e. squats/thrusters etc • Some solutions: heel elevation, band distraction, unilateral movements to avoid cheating with unaffected side, possibly removing prosthetic for some activities, bail box, staggering stance, wide stance/toe out • Pro tips: skin checks, manage perspiration • We want to improve their fitness but also help them build confidence with prosthetic (in addition to PT) to improve QOL FYI: ACSM has specific recommendations re: aerobic training for amputees (we will cover specifics in the future)

22. Sensory impairments: hearing and visual • Visual deficits • Requires unique cueing • Auditory/ tactile- the latter is sensitive due to industry regulations but hands on coach for demonstration is very effective • Highly descriptive and detailed • When I say “X” it means you should do/feel “Y” • Equipment set up should be consistent and set up ahead of time • Hearing deficits • Requires unique cueing • Eye contact • Lip reading/ body language • Cue facing the person • Whiteboard, ASL, visual (I-go-you-go) • Hearing aids, cochlear implants etc • Some may fall off during dynamic moves • Potential common issues like balance disorders- i.e. fall risk

23. Communication is key • Treat them like any other human that walks through the door • Athletes may or may not know their limitations; or the limitations may be perceived but inaccurate • Despite what medical providers say, no one truly knows what is possible • Experiment/ explore but ensure the client is comfortable engaging with you and post-reporting to tailor program accordingly • Ask many questions and ask to speak with providers/family if client is a poor historian (do not feel like you’re prying/ offending/ intruding- digging into details with your client will build trust and promote safety which is especially important with the adaptive person)

24. Adaptive Client Interview example: The Human Experience of Disability 1)  Can you tell me about yourself? Where are you from? Who do you live with? What do you enjoy doing? 2)  Tell me about your disability? How did you come to find out about it or when/how was it acquired? 3)  How does living with your disability affect your daily life? 4)  Does your disability affect your ability to live independently in any way? 5)  How do you overcome obstacles/challenges that you encounter because of your disability? 6)  Can you describe how fitness/rehab professionals (or doctors and nurses) interact with you when you receive their services? Describe positive and negative experiences. 7)  Do you ever feel like people avoid you because of your disability? Do you feel like people avoid discussing it or don’t know how to discuss it with you? 8)  What is the best thing that has happened because of your disability? 9)  What is the biggest challenge that you’ve encountered because of your disability? 10)Are you provided with the resources you need when you need them in the training environment (i.e. educational materials, assistive devices)? 11)Do you feel you have enough support (i.e. community groups, caregivers, family/friends)? 12)If there is something that our staff could do differently that’d help you, what would it be? 13)How do you want to be treated by coaches/staff when you receive training/instruction?

25. Examples of impairment related questions • [SCI] “Do you need help cooling down during a workout?” “How would you like to handle bowel/bladder issues?” “When a spasm occurs, how do you like to handle it?” (wait, stretch, keep going) • [Limb impairments] “Are there activities you prefer to sit/stand for and why?” ”What kinds of movements cause you pain? (Is it in limb, proximal joint or CL side?) • [Hearing/ visual impairments] “How is it best for me to cue you?”

26. Time for Q&A THANK YOU FOR YOUR TIME

27. Resources • https://disabilitycompendium.org/sites/default/files/user-uploads/2017_AnnualReport_2017_FINAL.pdf • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949033/ • http://exerciseright.com.au/neuromuscular-disease/ • https://cascadeorthoblog.wordpress.com/2018/04/16/april-limb-loss-awareness-month/ • https://www.nchpad.org/827/4217/Ex~Rx~Tips~for~Trainers~Working~with~Amputees • https://www.nmd-journal.com/article/S0960-8966(15)00187-X/abstract • https://www.cdc.gov/ncbddd/disabilityandhealth/disability-barriers.html