Module 1: Musculoskeletal Screening

Why?

Primary Aim: To reduce the likelihood of injury

• Identifying individuals at risk, who are attempting to maintain or increase activity level.
• Assisting in program design by systematically using corrective exercise to normalize or improve fundamental movement patterns.
• Providing a systematic tool to monitor progress and movement pattern development in the presence of changing injury status or fitness levels.
• Creating a functional movement baseline, which will allow rating and ranking movement for statistical observation.

Common assessment batteries:

• Postural assessment
• ROM testing (e.g. Ely’s test)
• Muscle activation tests (e.g. prone hip extension)
• Beighton scoring system for hypermobility

Functional movement screening (FMS™)

The FMS™ is a screening tool that allows practitioners to assess the fundamental movement patterns of individuals. It is comprised of seven tests that involve a combination of stability and mobility:

1. The Deep Squat
2. Hurdle Step
3. In-Line Lunge
4. Shoulder Mobility
5. Active Straight Leg Raise
6. Trunk stability Push Up
7. Rotary Stability

Scoring of the FMS: The scores range from zero to three, with three being the best possible score and then scores are added together giving a total score out of 21.

Athlete Movement Index (AMI)

The AMI is an example of a screening tool that uses a range of tests from different evidence-based batteries that is designed to asses the fundamental movements of athletes, which involves some of the core FMS movements, as well as some balance and dynamic stability assessments. The purpose of the AMI is to be able to provide information on an athlete specific to the way they move, so that you can get an understanding as to how problems in movement patterns may lead to injury. Further details of the AMI will be provided during the practicals. Athlete Movement Index (PDF Link)

The AFL Musculoskeletal Screening Process

Through the AFL Research Board, the AFL has developed a standardised MSK Screening Protocol which is relevant to the game, applicable across different ages and skill levels, suitable for evaluation of injury outcomes in a cohort study and simple and easy to apply.

Module 2: Injury Prevention & Musculoskeletal Rehabilitation

Injury prevention should not be considered as separate sessions or drills, rather it needs to be considered as integral part of the overall training program and as such it needs to be formally integrated into all facets of the program. Integrating suitable strength & conditioning sessions with appropriate skill session loads during the pre season can prevent overtraining whilst also adequately preparing the athlete for the demands of in season competition (Burgess, 2014).

A common injury prevention technique that should be used during the preseason is regular prehabilitation sessions which consist of a variety of proprioception, balance, activation, dynamic and strength exercises (Burgess, 2014).

High Training Loads Alone Don’t Cause Injuries

Historically high training loads have been considered as a primary cause of sport injuries, however recent research has refuted this belief and shown that how you get to a high training load (ie how quickly you increase your training load)  is more important than the training load (Gabbett, 2016).

The Acute:Chronic Workload Ratio

The acute:chronic workload ratio is a recent concept introduced when discussing the positive and negative effects of training. This ratio compares the acute training workload (the past week’s training load) to the chronic workload (rolling average of most recent 4 weeks training) (Gabbett, Hulin, Blanch & Whiteley, 2016). If the chronic workload is high (ie, the athlete has developed ‘fitness’) and the acute workload is low (ie, the athlete is experiencing minimal ‘fatigue’), then the athlete is considered well prepared. Conversely, if acute workload exceeds the chronic workload (ie, the athlete has performed inadequate training to develop ‘fitness’ or workloads have been rapidly increased resulting in ‘fatigue’), then the athlete is considered underprepared and likely at an increased risk of injury (Gabbett, Hulin, Blanch & Whiteley, 2016). Refer to the figure below:

0.85 – 1.35 acute:chronic workload ratio ranges was shown to make players more resistant to injury

In studies of rugby league4 players, high chronic workloads were associated with a reduced risk of injury, while large ‘spikes’ in acute workloads relative to chronic workloads were associated with increased risk of injury. A consistent theme throughout this paper was the importance of progressively and systematically increasing workloads to minimise the risk of injury. Importantly, the predictive ability of this approach is very high; we reported a positive likelihood as high as 70 times.5

According to Gabbett, 2015, in his paper (The training-injury prevention paradox: should athletes be training harder or smarter?), the training-injury paradox refer to Athletes accustomed to high training loads have fewer injuries than athletes training at lower workloads

An extended de-load or break from training = a lower chronic workload which means you can’t theoretically tolerate as much volume acutely for the next training block. Which is why you begin W1 of new programs lower volume and intensity and taper up accordingly IF they’re coming off the back of a de-load of moderate – long time of no training. #Post (Chris Duffin)

Figure 1: Acute/Chronic Workload Ratio (Gabbett, 2016).

Injury Prevention Programming

When designing an injury prevention programme, the strength and conditioning coach can either target a specific injury or control injury risk factors (Drew et al, 2016). Injury prevention based on a specific injury considers:

• Primary prevention – removal or reduction of causal factors, eg pre season screening
• Secondary prevention – injury detection early to prevent progression or worsening of the injury
• Tertiary prevention – reduction of complications and long-term burden of injury

On the other hand, injury prevention based on injury risk factors considers:

• Universal prevention – common risk factors to all (or most) sports (e.g., sleep, nutrition, mental health and training loads)
• Selective prevention – risk modifiers displayed by asymptomatic individuals (e.g., age, sex, sport and training age)
• Indicated prevention – selective and universal risk factors for athletes at higher risk of injury (e.g., previous injury history)

Training load management needs to be an important component of all programmes for the prevention and treatment of all sports injuries; however athlete load monitoring alone, without concurrent management of training loads, is not sports injury prevention (Drew et al, 2016).

Module 3: Women In Sport

Exercise Programming Considerations

Before the onset of puberty, there are essentially minimal differences between males and female physiology; however, as puberty begins to progress, the production of oestrogen in girls increases leading to increases in fat deposits, whereas in males the increased production of testosterone leads to increases in protein synthesis. As a result, adult women tend to have more body fat and less muscle mass on average compared with adult males (Faigenbaum, 2008). These sex-related differences means that in terms of absolute strength, women tend to have about two-thirds the strength of men because of lower quantity of muscle (women tend to have less muscle mass above the waist) (Faigenbaum, 2008).

Research that compared the hormonal responses of strength training in men and women has shown that after completing heavy resistance training, a significant increase in growth hormone (GH) was observed in both males and females, however the increase was greater than men, whilst testosterone increase was only observed in males. As growth hormone and testosterone are anabolic hormones that play an important role in increases in hypertrophy and maximal strength, young females will need to be exposed to resistance training more regularly than males to maximise their genetic potential in strength and power during adulthood (Linnamo et al, 2005).

When participating in a resistance training program, women can increase their relative strength at the same rate as men, although absolute strength gains are often greater for men. As such, there is no reason of justification why resistance training programs for women should be different from those of men. Regardless of the sex of the athlete, resistance training programs should be designed to improve the sports performance of the athlete (Faigenbaum, 2008).

Exercise During Pregnancy

Exercise during pregnancy presents a number of challenges that must be considered by both the individual and health professional. As such, the health and safety of the expecting mother and unborn child is paramount. Given the physiological changes during pregnancy, there are several guidelines that suggest relative and absolute contraindications to exercise during pregnancy including Sports Medicine Australia (SMA Position Stand).

Summary:

Contraindications:

• Women exercising when they have a high grade placenta (low lying placenta) after 32~ weeks of gestation.
• Rupture of membranes should rest more during pregnancy
• Calf swelling (increased risk of thrombosis –
  A blood clot in a deep vein, usually in the legs).
• Diving because the fetus cant adjust to decompression
• Supine exercise should be avoided later during pregnancy

Info:

• From late first tri (13~ week) of pregnancy a women require about an extra 100 cal per day.
• Hormones become lax due to progesterone and relaxin. Musculoskletal injuries are more prevalent.
• Posture also changes (5-6 month) you get a lumbar lordosis of the spine which tilts the pelvis forward which contributes to common low back pain during pregnancy.
• Temperature control is very important especially in the first trimester. The fetal temp is about 0.5 a degree more than the mothers temp. An increase in temp above 39 degrees especially in the first trimester can cause teratogenic (disturb development of fetus) and neural tube defects if the fetus is exposed to high temps so its very important for a women to control her temp while exercising.
• Post partum: General guidelines is to exercise after breast feeding so that when you exercise you don’t have the discomfort of breast engorgement and there is a theoretical risk of lactate being transferred from the breast milk to the baby.

Pelvic Floor:

According to the SMA Position Stand, recommended pelvic floor exercises for a female who is physically active and in the first trimester of pregnancy is to perform at least 8-12 contractions, three times per day

Key Considerations and Recommendations for Exercise Programming for Pregnant Women (ACSM’s Resources for the Health Fitness Specialist, 2014):

• Women with a normal pregnancy can start exercising or continue exercising without fear of harm to herself or her foetus
• Exercise is encouraged during pregnancy due to the same benefits all people reap from doing exercise
• 30 minutes of moderate-intensity exercise (12-14 out of 20 on a Borg scale) on all or most days of the week
• Activities should be dynamic and involve large movements of the whole body such as cycling and walking

In conclusion, while exercise is highly beneficial for the expectant mother and her unborn child, exercise professionals must also consider the type of exercise being conducted to ensure safety. Although several exercise modalities (e.g., resistance training and aerobic exercise) have shown positive benefits during pregnancy, including reduced weight gain, minimising the risk of gestational diabetes etc., some types of physical activity should be avoided. Generally these activities include those with increased risk of falls (e.g., horse riding), physical contact (e.g., football and rugby).  Also, activities such as scuba diving should be avoided due to increased risk of fetal malformations (Dammon et al, 2016).

The Female Athlete Triad – the interrelationship between energy availability, menstrual function and bone mineral density

Sport can be an enjoyable experience for most girls; however, for some who participate in sports that emphasize aesthetics or leanness (such as gymnastics, ballet or athletics), this can lead to the development of a syndrome known as the Female Athlete Triad.

The Female Athlete Triad is a health risk for female athletes who train for prolong periods of time with insufficient dietary caloric intake to support training load (and hence the energy expenditure required). This can lead to bone fractures, hormonal changes (endocrine complications), and can negatively impact on menstrual cycles (later onset of menarch) and sporting performance. The Female Athlete Triad is a syndrome that includes 3 clinical entities:

1. Eating disorder/energy deficiency (e.g., Anorexia or Bulimia Nervosa)
2. Amenorrhea (i.e., menstrual dysfunction)
3. Osteoporosis (i.e., low bone mineral density)

Figure 1. Female Athlete Triad

Anorexia athletica is a term used by some researchers to describe a disordered eating pattern seen in female athletes who have an intense fear of gaining weight, even though they are underweight. Female athletes are at increased risk of developing eating disorders due to pressure to maintain a low body weight, along with poor guidance about nutrition and weight loss from the athletic community (Nazeem & Ackerman, 2012).

Amenorrhea is the absence of at least three consecutive menstrual cycles in females This may be due to overtraining, and can be the first sign of the Triad (Sherman & Thompson, 2004).

Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissue, resulting in bone fragility and increased risk of fractures (Sherman & Thompson, 2004).

Prevalence of the Triad

Although the triad affects female athletes in all sports, women in sports that emphasize a thin or small body size or shape appear to be at the most risk. In these sports (e.g.,gymnastics, diving) the prevalence of amenorrhea can be as high as 69%, compared with 2% to 5% in the general population (Nazeem and Ackerman, 2012). The prevalence of clinical eating disorders among female elite athletes ranges from 16% to 47% compared to the 0.5% and 10% prevalence among nonathletic men and women in the general population. The prevalence of osteoporosis among female elite athletes can be as high as 13%, compared to 2.3% prevalence in the general population (Nazeem and Ackerman, 2012).

Complications of the Triad

Aspects of the Female Athlete Triad have broad implications for the health of female athletes. Menstrual dysfunction may lead to infertility, and Amenorrheic athletes that also have low bone density have a 2-to-4 times greater risk for stress fractures. Eating disorders lead to decreased energy availability, which can be detrimental to the body’s ability to synthesis new tissues and can limit the development, maintenance and repair of bone, muscle mass, connective tissues, and can compromise recovery from injury. Eating disorders can also has serious psychological ramifications, including depression, low self-esteem, and various anxiety disorders (Nazeem and Ackerman, 2012).

The LEAF Questionnaire

The Low Energy Availability in Females Questionnaire (LEAF-Q) was designed to identify female athletes at risk for the Triad. The LEAF-Q focuses only on self-reported physiological symptoms linked to persistent energy deficiency, with or without the presence of an eating disorder, which can be routinely used to identify individuals at risk of the Triad.

The LEAF-Q is a brief questionnaire that could be considered for use to identify female athletes at risk of the Triad, in order to facilitate early detection and treatment (Melin et al, 2014).

Risks of Early Sport Specialisation for Females

Early sport specialisation has been defined as the presence of three important components: year-round training for >8 months, focusing on a single main sport, and quitting all other sports to pursue a single sport (Jananthi & Dugas, 2017). Recently, there has been growing concern that many young female athletes are focusing on single-sport participation at a young age which can involve intensive training and suboptimal dietary intake potentially causing several serious health issues, including the female athlete triad, overuse injury, and burnout (Blagrove et al, 2017). As a result of this study there are now recommendations to minimise the risks associated with early specialisation for female athletes (see the below infographic for a summary of these recommendations).

So basically if you’re going to specialise early make sure you’re child is adequately recovering through smart sustaining nutrition and optimal sleep and social requirement. 

Module 4: Group Training

Some of the wider benefits of group training (Bailey, 2013) are that it:

• Encourages co-operation
• Enables participants to learn from one another
• Encourages the involvement of everyone
• Removes the stigma of failure from participants
• Enables participants to respect others’ strengths and weaknesses
• Focuses on processes required to complete exercises and drills
• Is particularly effective for problem-solving activities
• Encourages participants to engage in the problem solving, especially when incorporating small-sided games into the session

Considerations:

• In particular, the practitioner needs to be mindful there is likely a large degree of variability across individuals in a group, in terms of levels of fitness, motor control, and motivation levels.
• It is therefore possible that some individuals in a given group are highly competent at performing certain skills/exercises, whereas others may need extra attention when conducting the same tasks.

According to the Australian Strength and Conditioning Association (ASCA), there are 3 stages of learning a skill (ASCA, 2017):

Stage 1 – the Early or Cognitive stage: the athlete has to think about how to perform the skill – this stage may last a few sets (rare) up to a number of weeks.

As a general plan, when introducing a new skill, the following 5 step approach should be adopted:

1. 1. Name the skill to be learnt
   2. Demonstrate the skill two or three times
   3. Identify two or three points for the athlete to focus on
   4. Demonstrate the skill a number of times again so the athlete can look for key points stressed by the coach
   5. Get the athlete/client to practice the skill

Stage 2 – the Intermediate or Associative stage:  the athlete/client has some control over the skill, but it is not reflex-based yet – this stage may last a few sets to a number of weeks.

• The athlete uses internal (kinaesthetic) control mechanisms together with their visual processes

Stage 3 – is the Advanced, Final or Autonomous stage: the skill is reflex based within the athlete’s neural circuitry such that the skill becomes automatic – it may be weeks or months before this stage is reached by a novice.

Importantly, the level of athlete/client you are working with can influence the types of instruction and feedback you should use.

When coaching novice athletes, the coach should (ASCA, 2017):

• Not give lengthy verbal descriptions of the minor details of technique
• Realise that at this stage novice athletes are mainly using the visual depiction of the exercise and 2-3 keys/cues (verbal) to attempt to replicate the “master” performance
• Try not to overload the “thinking” processes with lots of “bits of information”
• Allow plenty of practice in low-stress situations (e.g., very light loads for strength, slow movement speeds for speed drills etc.) – this helps the athlete/client grasp the kinesthetic feel of the exercise
• Realise that in terms of immediate feedback, Knowledge of Results (i.e., the result from performing the skill/exercise) is more important than Knowledge of Performance (i.e., the specifics of how their performance led to the result) for novice athletes

When teaching new exercises to advanced athletes (ASCA, 2017):

• Because advanced athletes should have already been taught (and mastered) the fundamental exercises, it is not necessary to use the 5-step approach when teaching these athletes new exercises
• Most new exercises that an advanced athlete learns are merely variations or extensions of previously-acquired motor skills
• Therefore, teaching new exercises to these athletes is often a matter of “chaining” and “shaping”:
  • A complex exercise is merely a collection of less-complicated parts that have been learnt previously and then “chained” together and “shaped” into the final complex skill
  • The part-whole method of teaching involves the “parts” of a complex exercise somewhat separately and then “chained” back together to form the whole complex skill.

Communication strategies including feedback and coaching cues

To reinforce good technique and appropriate skill execution irrespective of the stage of learning of the athlete/client, the following 3-step procedure is recommended:

1. 1. Provide simple, positive praise (e.g., “good rep”, “well done” “excellent” etc.).
   2. Positive reinforcer (e.g., “good chest position”, “great knee lift” etc.)
   3. Corrective reinforcer if needed (e.g., “keep your chest up more”, “need to lift knee higher” etc.)

It is therefore important that any feedback provided to athletes or clients should be (ASCA, 2017):

• Specific – Should relate to the athlete/client’s performance relative to the components of the task the athlete has been asked to perform
• Constructive – If used to identify an error, it should provide reasons for the error and possible solutions
• Immediate – An athlete retains memory information about the performance for a brief time afterwards, so quick feedback is important
• Clear – Athletes/clients must understand exactly what is required
• Positive – Should be positive and encouraging

Another important consideration is WHEN feedback should be provided when a client/athlete is performing an exercise or skill. In this case, the timing of feedback should consider the stage of learning (ASCA, 2017).

In this regard, a coach should provide feedback:

1. Only at the completion of the skill (or set) in the early stages of learning (TERMINAL FEEDBACK)
2. Between repetitions (during a set) for intermediate learners (if necessary).
3. During a repetition (if necessary) for advanced/final stage learners

When providing feedback to reinforce appropriate technique, coaches commonly use key words or phrases (known as “cues”). These are typically used prior to an exercise to reinforce key technical points. The use of 2-3 single-word “cues” is typically sufficient to remind the athlete of important technical points leading to appropriate execution of the particular exercise or skill.

So what are the recommendations for appropriate group sizes? The Australian Strength and Conditioning Association (ASCA, 2017) recommends that:

• The coach-to-athlete/client ratio be 1:15 or less, where possible, for the most effective coaching to occur
• The use of sub-groups of 2-4 athletes/clients of similar capabilities can help the organisation of training
• Precise programming (exact work:rest periods/start times etc.) also goes a long way towards the effective organization of a training session

Some examples of methods of organising training sessions with large number of athletes, where there might be issues with space and/or access to equipment, include (ASCA, 2017):

• Split training with skill/specialist coach – E.g. in soccer, a skill coach takes eight players for 4 v 4 small-sided game, while the fitness coach takes another eight players for speed or conditioning training for 15 minutes, after which the two groups swap
• Stagger start times of training sessions – E.g. one group starts in the gym at 4:00 PM before the next begins at 4.30 PM
• Stagger the exercise order in the gym – E.g. half of the group start with lower body exercises and the other half start with upper body exercises – this order can be switched for the next session

The importance of reflection to enhance group training practices

Reflective practice is an important tool to enable us to improve our exercise programming and training practices by reflecting on what worked well, and what could be done better next time.

1. Description: What has happened?
2. Feeling: What were you thinking and feeling?
3. Evaluation: What was good and bad about the experience?
4. Analysis: What sense can you make out of the situation?
5. Conclusion: What else could you have done?

Module 5: Children and Adolescents

With regards to resistance training prescription, the ASCA recommends the following depending on age group:

1. Children 6-9 years: > 15 repetitions or 45 second hold.
2. Children 9-12 years: > 10 repetitions or 30 second hold.
3. Youth 12-15 years: > 8 repetitions or 20 second hold.
4. Youth 15-18 years: > 6 repetitions or 15 second hold.

Long Term Athlete Development (LTAD)

In today’s society, children and adolescents face many challenges related to health and fitness, including high rates of obesity and record numbers of children being pushed into early sport specialisation (Bayli et al, 2013). In recognition of these challenges, the Long Term Athlete Development (LTAD) model was created.

The LTAD model is a planned, systematic and progressive developmental model of young athletes, designed to deliver effective long-term athlete development that focuses not on short-term gains and early success, but on what is best for the sport participant throughout life (Bayli et al, 2013). The LTAD model was introduced to improve the quality of sport programs for all participants to reach their potential. The LTAD model consists of seven stages (see Figure 1) from infancy through to adulthood (Bayli et al, 2013).

• Review the LTAD Model by clicking on this link.

Active for Life

Individuals who have a desire to be physically active are in the Active for Life stage. A participant may choose to be Competitive for Life or Fit for Life and,…

Figure 1. Long Term Athletic Development Framework Part 1 (Canadian Sport for Life).

Figure 2.  Long Term Athletic Development Framework Part 2 (Canadian Sport for Life).

Module 6: Collaborative Prescription

Whether you are an Accredited Exercise Scientist (AES), Exercise Physiologist (AEP), Strength & Conditioning Coach, or another allied health practitioner, it is important that you understand your scope of practice: “an AES can design and deliver exercise programs and assessments based on scientific evidence with the intent to improve health and fitness, wellbeing or performance but not for the treatment and/or management of a clinical condition or injury” (ESSA, AES Scope of Practice). We’re not physios – stay inside your scope.

ASCA Scope of Practice

According to the Australian Strength & Conditioning Association (ASCA), “A strength and conditioning coach in Australia is an accredited ASCA coach who develops the physical capabilities of competitive athlete populations.”

As part of this scope of practice, it is recognised that fitness training credentials are not a substitute for ASCA qualifications and that fitness training for the general population is not in the scope of practice of strength and conditioning coaches (according to asca). In turn, physical preparation of athletic populations in Australia is not in the scope of practice of individuals who are not credentialed by the ASCA (e.g. Personal Trainers) through the National Coach Accreditation Scheme.

It is out of the scope of practice for an AES to design exercise programs to treat and/or manage a clinical condition or injury. However, an AES can deliver and supervise exercise programs for patients with pathology or injury that have been prescribed by an appropriately qualified health professional, such as an AEP or physiotherapist.

Which of the following is outside of the scope of a Strength and Conditioning Coach (unless they possess other qualifications): Recommending specific supplements to enhance recovery and/or performance. What’s the repercussions? 

S&C Coaches MUST: 

• Refer to Nutrition specialists for more advanced and individualised information on dietary intervention;
• Refer to Sports medicine practitioners to diagnose and treat injuries and illnesses.

S&C Coaches DO NOT: 

• Diagnose injury or illness;
• Prescribe medications;
• Treat injuries through manual therapy or manual corrective joint manipulation; (can be a fine line with some of the techniques I use)
• Rehabilitate injury, or oversee (directly) the rehabilitation of injury (contradicted by what we do at WSSC?)
• Provide diets or recommend specific supplements;
• Work with the general population (e.g. Personal Fitness Training), or clients with health concerns including cardiac dysfunction, diabetes, or other conditions 

IMPORTANT: Some Exercise and Sport Science graduates may end up being qualified for both AES and S&C coach roles. In this case, these individuals can work with general and athletic populations and prescribe exercise for general purposes and conditioning for people with some chronic diseases, provided it is not an attempt to directly treat these conditionss.

Hypertension:

When supervising an exercise session of a client with hypertension, when is it recommended that the session be postponed and the client be referred to their general practitioner as a matter of priority? If resting blood pressure is poorly controlled (e.g., SBP ≥180mmHg or DBP ≥110 mmHg)

The minimum exercise prescription recommendations for patients with hypertension, predicted to result in a lowering of blood pressure? A combination of moderate or vigorous intensity aerobic exercise (3-4 days per week) and resistance exercise (2+ days per week)

Figure 1. The process of care for an athlete who is returning to play, with different providers and roles (Kraemer et al, 2009).

Module 7: Older Adults

Older adults are defined as healthy individuals ≥ 65 years of age, or individuals aged 50-64 years with disabilities, chronic disease, and/or functional impairments (ACSM, 2014)

A hallmark of the aging process tends to be inactivity, or a decrease in activity, resulting in a loss of lean muscle mass (known as sarcopenia) and a redistribution of fat mass from subcutaneous (under the skin) to visceral (surrounding internal organs), which is associated with cardiovascular disease and Type 2 diabetes.

Exercise may slow down the brain’s aging by 10 years

• The study, published today in the online issue of Neurology, the medical journal of the American Academy of Neurology, found that older adults who reported either light or no exercise at all experienced a cognitive decline equal to 10 more years of aging when compared to people who were moderate to intense exercisers.
• In all, 90 percent of the group reported light exercise, such as walking and yoga, or no exercise at all. The remaining 10 percent were categorized as high intensity exercisers and reported participating in activities like running, aerobics, and calisthenics.
• After reviewing the data, the researchers found that of the people who had no signs of memory and thinking problems after the first set of cognitive tests, those who reported low activity levels showed a greater decline over five years than their high activity counterparts
• “We found that people who exercise moderately or heavily had a reduced risk of memory loss and what we call executive function, equivalent to about 10 years,” study co-author Dr. Mitchell Elkind, professor of neurology and epidemiology at New York Presbyterian/Columbia University, told CBS News
• The authors note important limitations to the study, including the fact that that they did not collect lifetime patterns of exercise and relied only self-reported information from the participants.

Osteoarthritis: degenerative joint disease involving the cartilage and many of its surrounding tissues.

In general, exercise is safe and well-tolerated by most people with lower-limb OA, including those with severe disease. It is, however, not uncommon for patients to experience some discomfort in the affected joint during exercise, and patients should be advised this is normal and does not indicate a worsening of their OA disease. Exercise practitioners should therefore not adopt a pain-contingent approach to exercise prescription in this patient group. However, substantial increases in pain and/or swelling during or following exercise (lasting more than several hours) can suggest  modifications to the exercise program are needed (Bennell & Hinman, 2011) .

Evidence supports the role of regular physical activity and enhanced fitness capacity (ACSM, 2014) in:

• Slowing physiological changes of aging that impair exercise and functional capacity
• Optimising age-related changes in body composition
• Promoting psychological and cognitive well-being
• Managing chronic diseases
• Reducing the risks of physical impairment and disability
• Increasing quality of life years
• Decreasing the risk of Type 2 diabetes and osteoporosis
• Reducing medical costs and prescription medication dependence, and
• Improvements in sleep duration and quality

Regular aerobic and resistance training exercise in older adults has been demonstrated to:

• Increase cardiorespiratory and muscle fitness
• Improve health and function activity
• Improve insulin sensitivity and glucose tolerance
• Decrease body fat mass and increase lean muscle mass (i.e., improve body composition)
• Increase energy metabolism
• Decrease sarcopenia
• Improve hormone regulation, and
• Improve bone mineral density

Falls Prevention in Older Adults (ESSA Position Statement on falls prevention)

• It has been reported that over one-third of Australians aged 65 years or older fall one or more times per year, which can often result in disability, loss of mobility, reduced quality of life and fear of falling (Tiedemann et al, 2011).
• falls accounts for 14% of emergency admissions and are the leading cause of injury-related deaths, with the medical cost of treating a single fall averaging between $1600 and $5688 (Tiedemann et al, 2011). Qualified exercise professionals are well-placed to implement and supervise evidenced-based exercise programs aimed at preventing falls in healthy older adults.
• It is now clear that a structured exercise program can help prevent falls in older adults, and exercise interventions can reduce the risk and rate of falls in older people by between 17% and 34%. An important component of an exercise program aimed at reducing the risk of falls is balance-focused exercises, which may include activities such as: standing exercises where individuals aim to (a) stand with their feet closer together, or on one leg, (b) minimise use of their hands to assist balance and (c) practice controlled movements of the body’s centre of mass (Tiedemann et al, 2011).

Module 8: People With a Disability

Defined: A disability or a long-term health condition is defined as a limitation, restriction, impairment, disease or disorder that has lasted, or is likely to last, for at least six months and restricted everyday activities. 

The degree of limitation can be recorded at four levels:

• Mild;
• Moderate;
• Severe;
• Profound.

The nature of a disability can classified into five categories:

• Physical;
• Intellectual;
• Sight, hearing; speech;
• Psychological;
• Type not specified.

According to the Australian Bureau of Statistics, just under one in five Australians (18.5% or 4.0 million persons) reported having a disability in 2009. Of those with a disability, 87% had a specific limitation or restriction; meaning an impairment that restricted their ability to communicate, affected their mobility, their ability to complete self-care activities, or affected their schooling or employment.

The disability rates differ between sexes and age groups. For example, the rate of profound or severe core-activity limitation for 5-14 year old males (6.6%) was approximately double that of females of the same age (3.0%). In contrast, women aged 90 years and over had a higher rate of profound or severe core-activity limitations (75%) than men of the same age (58%).

Spinal Cord Injury (SCI)

• Refers to damage to neural elements of the spinal canal (spinal cord, cauda equina and spinal nerves), frequently resulting in permanent impairments of motor, sensory and/or autonomic function.
• Traumatic SCI may result in tetraplegia (motor and/or sensory nervous system impairment of the arms, trunk and legs) or paraplegia (motor and/or sensory impairment of the trunk and/or legs only) (Tweedy et al, 2017).
• The global incident rate of SCI is estimated at 23 cases per million (179,312 cases per annum), although in Australia it is estimated to be lower (15 per million), with the incidence of SCI being highest among males aged 18–32 years (Tweedy et al, 2017). As such, evidence-based interventions which assist people with SCI to optimise their health, fitness and functioning are critical. Accredited Exercise Scientists (AES), in close collaboration with Accredited Exercise Physiologists AEP), therefore play a pivotal role in exercise programming for people with a SCI.

Benefits of Exercise

People with SCI are profoundly inactive and this inactivity is causally linked to an increased risk of preventable diseases that compound the primary effects of SCI. Exercise interventions are an effective means of increasing physical activity and reducing preventable disease risk in people with SCI with the primary benefits including an increase in cardiorespiratory fitness and improved muscular strength (Tweedy et al, 2017). (these are two fitness components to have strong and consistent evidence to support individuals with SCI)  Other benefits include:

• Resistance training leads to improvements in muscular strength of non-paralysed muscles;
• Aerobic exercise can lead to improvements in BMI and lower percentage fat mass, higher total daily energy expenditure and improvements in lipid profile and glucose homeostasis;
• Sufficiently intense aerobic exercise training (≥ 70% maximum heart rate) may improve elements of respiratory function. Specific training techniques for inspiratory and expiratory muscles can improve respiratory function and may improve peak exercise response;
• Decreased rates of depression, enhanced functional independence and improvements in activities of daily living including cleaning and wheeling;
• Regular exercise can maintain bone health, reducing the risk of fractures.

Exercise Prescription for Spinal Cord Injuries

Many people with SCI are unable to engage in lower-limb exercise and must use upper-limb modes such as wheelchair pushing or upper-limb ergometers (e.g., arm-crank or wheelchair). This constraint is important because, compared to lower limb exercise, upper limb exercise elicits a considerably reduced cardiovascular response (Tweedy et al, 2017).

The guidelines for exercise prescription for individuals with SCI are:

Aerobic Exercise:

• ≥ 5 days/week for moderate intensity; ≥ 30 min per session at 40 – 59% HRR; OR
• 3 days/week for vigorous intensity; 20 – 30 min per session at 60 – 89% HRR; OR
• A combination of moderate and vigorous exercise on ≥ 3–5 days/week.

Resistance Exercise:

• ≥ 2 days/week at moderate-vigorous intensity, 60 – 70% 1-RM;
• 4-5 exercises upper limb exercises involving major muscle groups;
• 3 sets of 8 – 12 repetitions.

Flexibility:

• ≥ 2 days/week;
• Hold each static stretch for 10–30 s, with a total duration of 60 s for each flexibility exercise (e.g., 2 × 30 s or 4 × 15 s);
• Address the major muscle groups, including those of the neck, upper limbs, trunk and lower limbs;
• Focus areas: stretching internal and external shoulder rotators, chest, and anterior shoulders.

Special Considerations for Exercise Prescription in individuals with SCI

The following special considerations must be taken into account to maximise the safe and effective development of an exercise program for people with a SCI (Tweedy et al, 2017):

• SCI Aetiology: traumatic (e.g. motor vehicle accident or a fall) or non-traumatic (spinal stenosis or a tumour) SCI have significant exercise implications;
• Time since injury: A longer time is associated with a significant decrease in physical functioning;
• Muscular Paralysis: reduces the range of exercises that are possible;
• Autonomic dysreflexia (AD): AD affects individuals with SCI at spinal level T6 or above, and results from a noxious (harmful) afferent stimulus below the level of the lesion (e.g., over-distended bladder);
• An increased risk of orthostatic hypotension (OH): A decrease of ≥ 20 mmHg in systolic BP, or 10 mmHg in diastolic BP upon sitting up from a supine position associated with light-headedness, dizziness, and syncope (fainting
• Thermoregulatory function may be impaired, especially in hot conditions;
• Sensory impairment: increases the risk of pressure sores and falls (through decreased proprioception) and can delay detection/ diagnosis of serious injury (e.g., bony fractures) following collisions or falls;
• Spasticity: defined as a velocity dependent increase in muscle tone and hyper-excitability of the stretch reflex which can result in involuntary muscle activation.

Sport and Physical Recreation Participation among Persons with a Disability

• According to the Australian Bureau of Statistics (ABS) in 2002, 3.1 million persons with a disability or Long Term Health Condition (LTC) participated in sport and physical recreation. The sport participation rate amongst those with a disability or LTC in 2002 is at lower levels (54.6%) than those who did not have a disability or LTC (70.2%)
• Overall, 57.3% of males with a disability or LTC participated in sports and physical recreation, compared with 52% of females. Walking for exercise ranked as the number one activity for both genders. Activities with high male participation were golf, cycling and fishing. Females were more likely to participate in swimming, aerobics/fitness and tennis. This information can assist AEP’s and AES’s when designing, modifying and/or instructing exercise programs for people with a disability.

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Recovery in Sport

Functional Overreaching: short-term decrement of performance without signs of maladaptation as a consequence of intensive training

Cold water immersion (CWI) has shown to limit improvements (and improve) in strength and muscle mass with resistance training is.