NASM Chapter 16 Chronic Health Conditions and Physical or Functional Limitations

Age Considerations

  • youth refers to children and adolescents between the ages of 6 and 20
  • Current recommendations state that children and adolescents should get 60 minutes (1 hour) or more of physical activity daily.
  • Children and adolescents should engage in aerobic, muscle-strengthening, and bone-strengthening activities daily to improve their health and reduce their risk of developing chronic disease.


  • Personal trainers should be aware of important physiologic differences between children and adults that impact their response and adaptation to exercise. These include:
  • ■ Peak oxygen uptake: Because children do not typically exhibit a plateau in oxygen
    uptake at maximal exercise, the term “peak oxygen uptake” is a more appropriate term than V˙O2 max or maximal oxygen uptake. Adjusted for body weight, peak oxygen consumption is similar for young and mature males, and slightly higher for young females (compared with mature females). A similar relationship also exists for force production, or strength.
  • ■ Submaximal oxygen demand (or economy of movement): Children are less efficient
    and tend to exercise at a higher percentage of their peak oxygen uptake during submaximal exercise compared with adults.
    ■ Children do not produce sufficient levels of glycolytic enzymes to be able to sustain bouts of high-intensity exercise.
    ■ Children have immature thermoregulatory systems, including both a delayed response
    and limited ability to sweat in response to hot, humid environments.
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Resistance Training for Youth

  • Resistance training for health and fitness conditioning in youth also results in a lower risk of injury when compared with many popular sports (including soccer, football, and basketball)
  • The most common injuries associated with resistance training in youth are sprains (injury to ligament) and strains (injury to tendon or muscle), which are usually attributable to a lack of qualified supervision,
    poor technique, and improper progression.
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  • A recent review of the literature suggests that untrained children can improve their strength by an average of 30 to 40% after 8 weeks of progressive resistance training
  • Information from the movement assessments will help the fitness
    professional design an individualized phase 1 Stabilization Endurance program. Progression into phases 2 through 5 should be decided on the basis of maturity level, dynamic postural control (flexibility and stability), and how they have responded to training up to this point


  • Arteriosclerosis
    A general term that refers to hardening (and loss of elasticity) of arteries
  • Atherosclerosis
     which is caused largely by poor lifestyle choices (smoking, obesity, sedentary lifestyle, etc.), restricts blood flow as the result of plaque buildup within the walls of arteries and thus leads to increased resistance and blood pressure
  • Peripheral Vascular Disease
    A group of diseases in which blood vessels become restricted or blocked, typically as a result of
  • Individuals with blood pressure levels between 120/80 mm Hg and 139/89 mm Hg are considered prehypertensive and should be carefully monitored and referred to a physician if their blood pressure continues to rise or if they have other risk factors for heart disease.
  • All individuals regardless of their age who have a blood pressure reading of 140/90 mm Hg or higher should be referred to a physician for further evaluation.
  • Some of the normal physiological and functional changes associated with aging include reductions
    in the following:
  • ■ Maximal attainable heart rate
  • ■ Cardiac output
  • ■ Muscle mass
  • ■ Balance
  • ■ Coordination (neuromuscular efficiency)
  • ■ Connective tissue elasticity
  • ■ Bone mineral density
  • Stages I and II will be appropriate levels of cardiorespiratory training for this population. However, older adults taking certain prescribed medications and those with other chronic health conditions must be carefully monitored and progressed slowly.
  • For adults taking prescription medication- Phase 1 of the OPT model will be applicable for this population and should be progressed slowly, with an emphasis on stabilization training (core, balance, and progression to standing resistance exercises) before moving on to phases 2 through 5.
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  • Obesity The condition of subcutaneous fat exceeding the amount of lean body mass.
  • Body mass index (BMI) is used to estimate healthy body weight ranges based on a
    person’s height.
  • BMI is defined as total body weight in kilograms divided by the height in meters squared. For example, a client with a body weight of 200 pounds (91 kg) and height of 70 inches (178 cm, or 3.16 m2) would have a BMI of 28.79 (91 kg/3.16 m2).
  • Because BMI does not actually measure body composition, other techniques such as skin-fold or circumference measurements may be performed to assist in developing realistic weight loss goals and to help provide feedback to clients.
  • A BMI of 18.5 to 24.9 is considered within normal limits, 25 to 29.9 is considered overweight, and a BMI of 30 or greater is obese.
  • For effective weight loss, obese clients should expend 200 to 300 kcal (calories) per exercise session, with a minimum weekly goal of 1,250 kcal of energy expenditure from combined physical activity and exercise. The initial exercise energy expenditure goal should be progressively increased to 2,000 kcal per week.
  • When Training for obesity- weight loss proprioceptively enriched environments are the best exercises to choose.
  • Core and balance training is also important for this population because they lack balance and walking speed
  • Phases 1 and 2 of the OPT model will be appropriate for the obese population. Personal trainers should ensure that the client is breathing correctly during resistance training exercises and avoids straining during exercise or squeezing exercise bars too tightly, which can cause an increase in blood pressure

Psychosocial Aspects of Working with Obese Clients

  • Proper exercise selections and positions are very important to the client’s sense of well-being. For example, machines are often not designed for obese individuals and may require a significant amount of mobility to get in and out. Dumbbells, cables, or exercise tubing exercises work quite well instead of machines.
  • it is recommended that obese clients engage in weight-supported exercise (such as cycling or swimming) to decrease orthopedic stress.
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  • Diabetes
    Chronic metabolic disorder, caused by insulin deficiency, which impairs carbohydrate usage and enhances usage of fat and protein.
  • Diabetes is a metabolic disorder in which the body does not produce enough insulin (type 1) or the body cannot respond normally to the insulin that is made (type 2).
  • There are two primary forms of diabetes:
  • type 1 (insulin-dependent diabetes) and type 2 (non–insulin-dependent diabetes). Although type 2 is referred to as non– insulin dependent diabetes, some individuals with type 2 diabetes cannot manage their blood glucose levels and do require additional insulin. Type 2 diabetes is strongly associated
    with an increase in childhood and adult-onset obesity.
  • Refer to table 16.7 and 16.8 for the best approaches on how to work with individual’s with diabetes
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  • Hypertension
    Consistently elevated arterial blood pressure, which, if sustained at a high enough level, is likely to induce cardiovascular or end-organ damage
  • Hypertension, or high blood pressure, is a common medical disorder in which arterial blood pressure remains abnormally high (resting systolic ≥140 or diastolic ≥90 mm Hg).
  • Some of the most common causes of hypertension include smoking, a diet high in fat (particularly saturated fat), and excess weight
  • Research has shown that exercise can have a modest impact on lowering elevated blood pressure by an average of 10 mm Hg for both systolic and diastolic blood pressure
  • It is important to monitor the body position of clients with hypertension at all times throughout an exercise training session. (because different positions affect blood pressure differently)
  • Supine or prone positions (especially when the head is lower in elevation than the heart) can often increase blood pressure, and, as such, these positions may be contraindicated.
  • Clients may use the full flexibility continuum; however, static and active stretching may be the easiest and safest.
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  • Resistance training should be performed in a seated or standing position as well. Phases 1 and 2 of the OPT model will be appropriate for this population, but should be progressed slowly.
  • The programs should be performed in a circuit-style or Peripheral Heart Action (PHA) training system
  • Valsalva Maneuver
    A maneuver in which a person tries to exhale forcibly with a closed glottis (windpipe) so that no air exits through the mouth or nose as, for example, in lifting a heavy weight. The Valsalva maneuver impedes the return of venous blood to the heart.

Coronary Heart Disease


  • Clients must be able to find and monitor their own pulse rate or use an accurate monitor to stay below their safe upper limit of exercise
  • Avoid heavy lifting and Valsalva maneuvers
  • Do not let client overgrip weights
  • Perform exercises in standing or seated position
  • Resistance training should be performed in a seated or standing position, as well. Phases 1 and 2 of the OPT model will be appropriate for this population.
  • The programs should be performed in a circuit-style or PHA training system
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  • Osteopenia
    A decrease in the calcification or density of bone as well as reduced bone mass.
  • Osteoporosis 
    Condition in which there is a decrease in bone mass and density as well as an increase in the space between bones, resulting in porosity and fragility.
  • Exercises should be progressed if possible toward free sitting(no support) or standing
  • Focus exercises on hips, thighs, back, and arms
  • Avoid excessive spinal loading on squat and leg press




  • Arthritis
    Chronic inflammation of the joints.
  • Osteoarthritis
    Arthritis in which cartilage becomes soft, frayed, or thins out, as a result of trauma or other conditions.
  • Rheumatoid Arthritis
    Arthritis primarily affecting connective tissues, in which there is a thickening of articular soft tissue,
    and extension of synovial tissue over articular cartilage
  • Personal trainers should also monitor the progress of clients with arthritis to assess the effects of the exercise program on joint pain.
  • Pain persisting for more than 1 hour after exercise is an indication that the exercise should be modifi ed or eliminated from the routine
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  • Cancer
    Any of various types of malignant neoplasms, most of which invade surrounding tissues, may metastasize to several sites, and are likely to recur after attempted removal and to cause death of the patient unless
    adequately treated
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  • Self- myofascial release is not recommended for clients receiving chemotherapy or radiation treatments.
  • Core and balance exercises will be essential for this population.

Exercise and Pregnancy

  • Avoid exercises in prone or supine position after 12 weeks
  • twisting motions of the torso, is not advised.
  • certain resistance exercises such as hip abduction and hip adduction machines are not advised
  • Avoid SMR on varicose veins and areas of swelling
  • Plyometric training not advised in second and third trimesters
  • The gradual growth of the fetus can alter the posture of pregnant women, making flexibility and core training important, particularly core-stabilization exercises to improve strength of the pelvic floor musculature.
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  •  Cardiorespiratory training should consist primarily of stage I and only enter stage II on a physician’s advice
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Chronic Lung Disease

  • Restrictive Lung Disease
    The condition of a fibrous lung tissue, which results in a decreased ability to expand the lungs.
  • Chronic Obstructive Lung Disease:
    The condition of altered airflow through the lungs, generally caused by airway obstruction as a result of mucus production
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Intermittent Claudication/Peripheral Arterial Disease

  • Intermittent claudication
    the name for the manifestation of the symptoms caused by peripheral arterial disease (PAD). (The term peripheral vascular disease is also commonly used to describe the activity-induced symptoms that characterize this disease.)
  • intermittent claudication is characterized by limping,
    lameness, or pain in the lower leg during mild exercise resulting from a decrease in blood supply (oxygen) to the lower extremities.
  • Peripheral arterial disease
    characterized by narrowing of the major arteries that are responsible for supplying blood to the lower extremities.
  • The primary limiting factor for exercise in the client with PAD is leg pain.
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