Joint Issues and the Plus Size Client
Joint Issues and the Plus Size Client – Training Progressions
Many individuals who are overweight have knee issues. Those issues are often the result of being overweight and will become worse if they don’t lose weight. As fitness professionals, we know what exercise programs will produce the quickest results, yet we must choose wisely. The exercise program we choose will either help to decrease or increase the knee problems. Additionally, many of these individuals have back problems also related to excessive weight. Again, the exercise program will help or further increase the back issues.
Now before we go further it’s certainly important to point out that most overweight clients need to change their diet and this will bring about the greatest change in weight. We can give general guidelines and even point them to specific books or recommend a dietitian/nutritionist. It’s just important that your client is fully informed. If a client believes they will achieve their perfect body with a poor diet and your workouts, they may end up discouraged when that doesn’t happen and likely quit training. Our clients need to recognize that exercise is not a quick fix, and it’s not simply about weight loss. Exercise is a lifestyle that will facilitate a strong well-balanced life. We know as professionals all the physiological and psychological benefits that exercise provides and some clients may benefit from seeing that list. I recommend giving it to your client that may struggle with exercise adherence.
I believe the fitness industry has oversold the idea that exercise is the cure-all for weight issues, thus many believe it’s the only reason to exercise. This is why we have such a revolving door when it comes to clients that start and stop exercise programs. They don’t get the quick result, or they think I will just lose some weight then I’m good. They don’t fully understand it’s a lifetime commitment. Just the simple fact that everyone is aging and losing muscle is enough of a reason to never stop exercising in my opinion. Ask them, “do you want to be the 80 year old with a walker, or the one who has that independent strength to go and do as they please?” Everyone needs strength, bottom line. The feeling of physical strength adds a level of mental strength to most individuals as well. We have muscles and joints that were made to move and when that is neglected the body will deteriorate. Strong muscles are able to support the joints, as weak muscles cause greater stress and strain on the joints. Thus building strength is a must with the overweight client.
First, the most important thing to consider is communication. It is absolutely imperative that your client feels comfortable expressing how they feel while performing exercises (this should be true for all clients no matter their condition). Help them understand the difference between the pain of challenging your muscles and pain that can cause further injuries. Generally, any pain that is sharp or stabbing is in the danger zone, stop the exercise. Also a sudden tightening of the muscle could mean you’ve pulled a muscle or will pull it if you continue the exercise. This one would generally be common sense, but we must say it, if anything pops in a muscle or joint, stop exercising. If a joint feels achy or tight, it’s time to back off. Finally, pain that increases and is not related to muscle fatigue means it’s time to stop.
Now, if you are a trainer or group instructor that judges a successful workout session based on bringing the pain, that’s your choice, just be attentive to any issue your client expresses to you. I have fussy clients and I use that as a guide to indicate they are working hard. Yet, they know if something feels bad they let me know immediately. I have a client who had a previous trainer that didn’t listen to her and pushed her to keep working through the pain. As a result she has a chronic shoulder injury that we have to try to work around. I always ask my clients how they are feeling and stay informed of any muscle or joint issues they have. For example; I have one female client that has wrist issues and actually likes doing pushups (she is rare). So we use the smith machine (clearly we could use dumbbells or other devises) and do pushups with her wrist aligned as straight as possible to reduce the pressure. If on any particular day that hurts we will stop and do different exercises. One of the greatest indicators of a superior fitness professional is one who knows how to modify and change what needs to be changed to continue offering a safe and effective workout. If you believe the only way to provide an intense workout for your clients’ means running on the treadmill, stairs or jumping exercises then the overweight/knee injured client is not for you. Consider the facts you will find in the special populations chapter of your NFPA manual. Jumping multiplies the joint pressure to 9X their body weight, running is 6X and climbing is 3X their body weight on the knee joints. This is why you need to understand how to elevate the heart rate/burn calories without multiplying joint pressure.
Differences which affect training and sport
My clients don’t wimp out on me and I think many fitness professionals are overly concerned about that issue. Most clients don’t pay a trainer to wimp out, I’m sure some do, but that’s not the norm. Bottom line, your client needs to know that you are there to help, not hurt them. That assurance will only come when they feel confident that you truly care and want to see them succeed and reach their goals safely. You can be a hard-core trainer; you just need to be willing and able to recognize when to back off. Fitness professionals should NEVER injure their clients because they didn’t listen to them or refused to recognize when it was time to stop. Communication is key to the clients’ success as well as yours if you want referrals. Let me also say that if you find it hard to empathize with an overweight client then it’s not in their best interest or your best interest to take them on as your client. This client needs understanding and encouragement as all clients do, but they need a little extra.
Now we will look at the recommended exercises for specific issues.
First we will discuss knee issues. A gradual warm-up prior to resistance training is imperative. The recumbent bike is generally the most knee friendly option. The severity of the injury will dictate the exercises your client is able to perform. Generally the hardest client to work with is one who has osteoarthritis. That is a bone on bone issue and it can be minimal to extreme. I have two clients with osteoarthritis and one is more severe than the other. I have both of these clients in the water. I previously worked with them on resistance equipment as well, but the water is our safest option at this stage. If you don’t have the option to put your client in the water, then the following exercises are what you will implement in your exercise program.
Side note: If the doctor has given your client specific instructions regarding exercise then stick with those exercises and move on to others when the doctor allows.
First and most important is proper alignment; knees line up with ankle and hips. I’ve found with my clients who have knee issues that ROM is also an issue. I let them determine the ROM that feels right. Often our first leg exercise is a body weight squat, but is that always your best choice? In my experience it’s not the best to start with. I believe a leg press machine is a better choice and here is why. Consider the weight of your client, if they weigh 300 lbs. for example, that’s a significant amount of weight you can’t adjust. Yes squats are functional and they are needed if they can be done without joint pain. Just don’t get hung up on a “functional squat”. I have a client that simply can’t do them without joint pain. She cannot do squats holding onto the smith machine, ball squats or even wall sits at a simple 30-degree angle. All of those exercises cause her pain. She was able to use the leg press, yet we determined water would offer her even better results. The bottom line is I want to increase her strength and not cause more damage…that’s the name of this game! We do what is right for our clients, not what is common or popular or what everyone else says to do. You put wisdom and common sense into your exercise choices. If it hurts them it’s simply the wrong exercise! Now I must say most individuals that have arthritis will experience some discomfort while exercising, but they generally know how much is too much. It’s been my experience that clients want to please their trainer and work hard while exercising, so avoid that “kill them” mentally. It’s your job to make the client feel comfortable enough to expressing how they feel while exercising to avoid further injury. They know you want them to work hard, but you don’t want them pushing through the pain that could cause further damage simply to please you.
The absolute basic leg exercise that can be performed or may need to be the starting point of your client is a seated leg extension is a chair or on a bench without weight. This exercise would be performed with a slight bend in the knee followed by full extension of the leg to engage the quad muscles. The ROM of this exercise will also be to the degree that the client is able to perform without pain. The key is the quad muscles are contracting. Perform 10 reps each leg with control, no jerking motion or quick movements, slow and controlled at least 2 sets, up to 4 when first starting out. As this exercise is performed without pain, increase the reps up to 15 then add more sets.
After this you can move on to leg press, ball squats, smith machine squats, and wall sits when they are able to do so without pain (certainly not all of those in one session). Keep in mind as you are working to strengthen the quad muscles it is equally important to strengthen the hamstrings, as this will add stability to the knee. When opposing muscles are not equally strengthened it causes more pressure and instability in the joint (this applies to all muscles and joints).
It may be challenging to work the hamstrings as well. Some individuals will have a hard time with the leg curl machine and others will not. If flexing the knee with resistance is painful, then try stiff leg dead lift, if that is a problem, use a band around the ankle while standing and hyperextend the leg straight back (you may also use a machine that has an ankle attachment where weight is loaded). This exercise can be performed without resistance if it is painful to use weight or resistance bands when they are starting. Keep in mind the volume of exercise performed for the quads needs to be performed on the hamstrings as well.
If you have a client who has a significant imbalance of strength from one leg to the other you will need to work on correcting that issue. I have one client with this issue who has osteoarthritis in both knees and has one leg a bit longer then the other. As a result, when she performs leg press (she can’t do squats without pain) we do single leg with weight that is challenging, but not causing pain. You will need to work on finding the proper angle; foot straight or toes turned slightly out, hip, knee, ankle alignment will be placed where the client feels and shows stability without pain. ROM will also be performed to the degree that the client is stable and without pain. Some individuals with knee problems will lack stability, thus affecting their alignment. If you find the client is unable to maintain alignment while performing a single leg leg-press/squat or even a double leg leg-press/squat use a resistance band or even a ball at the knees to maintain alignment. Generally that inability to maintain alignment is a result of weakness in the glutes. Thus you will need to work on strengthening the glutes as well.
We know that cardio offers the best opportunity to burn maximum calories in the shortest period of time. Thus we need to find options for these clients that will produce results without causing further joint damage. First, calculate the target heart rate for your client or have the client discuss with their doctor the desired range (this is most important for individuals with medical conditions). The recumbent bike and the elliptical machine are typically the best choice as they offer low impact cardio training. Side note; be sure to fit client properly on bike if that is what you use. An improper seat setting can cause more issues. The pool is an option (if available to you and your client) that is clearly the most joint friendly choice. It can be a seriously intense workout depending on how hard you work. If I want my client to work hard without impact I have them use a float belt, and or pool noodle, go in the deep end and perform running motions and various kicking motions to get their heart rate up. The options for exercise in the pool are vast, but the important thing to remember is if the client experiences pain doing a specific exercise, change that movement and find what works. When designing the cardio program keep in mind that cardio needs to be performed after the resistance training is complete, not prior to resistance training.
The client with back issues can be a challenge to train as well. The excess weight causes back pressure in addition to the weak abdominal muscles. Thus it’s important to strengthen the abdominal muscles to aid in stability. Most of our options for training abs on an individual with excess weight in the midsection simply won’t work. The following are possible ways to work around those issues.
First, it’s important to teach the client how to properly engage their abdominals. The abdominal contraction of a client with excess fat in that area will be a challenge, but it’s important to train. Have them lie supine on a bench with knees bent (if the bench is too narrow, put two of them together) or use a yoga table (they could do this seated in a chair if lying down isn’t an option) and place their hands on their abs. Teach them to breath through their diaphragm. As they experience that, have them inhale through the nose, exhale through the mouth and press their abs toward their spine (as the diaphragm lifts on the exhale the abdominals are able to contract deeper). Let them practice that and as it becomes more familiar ask them to hold that contraction while breathing. This will take some practice before they feel they’ve mastered it. This is commonly a challenge for most individuals regardless of their size. The important thing is that all abdominal exercises are preformed with abdominals contracted toward the spin and not pushed out. Let your client know that pushing out while performing abdominal exercises increases a pouch and causes pressure on the spine.
First exercise, seated on a bench have the client hold a resistance band while you hold the other end or anchor it to something at the appropriate height. Have the client contract their abs and hinge back on an inhale, lift back to start position on exhale. The ROM should only be as far as the client is able to maintain the abdominal contraction without pushing abs out. A small degree of ROM is fine; it will increase as strength is gained. A rotational movement should be added also if the client can do this without pain, doctor permitted, and with proper abdominal contraction. Start seated straight up with elbows bent at a 90 degree angle, have the client rotate back (shoulder and elbow rotating) while leaning back to the degree they are able to maintain the proper abdominal contraction (rotate from right to left). Start with 10 reps straight back and up and 10 reps on the rotation movement. Add more reps and sets, as they are able. Abdominal machines can work also if they are able to maintain the proper abdominal contraction. If they have the strength and stability to use the stability ball this is a great option as well. Remind the client to press the abs toward the ball and encourage a ROM that enables them to do that. If the client is not able to get down and up from the floor easily then don’t put them their to perform exercises. If they are fine to do that or even better if you have a yoga table available have them do a forearm plank on their knees. They must be able to keep their shoulders retracted and depressed as well as maintain the proper abdominal contraction without pushing out. The illustrations in this CEC will show proper progression of this exercise.
Things to consider
The client who has a hard time getting up and down will benefit from a program design that minimizes moving from machine to machine. For example if you have them on the leg press machine, finish the number of planned sets, then move on to the next exercise. I don’t train my other clients like this, but the client with severe knee issues will only receive more wear and tear on the joint and there will not be any significant gains to calorie burning that would make it worth the joint strain. Certainly you can have them do various exercises standing if they are able. It’s always important to approach your programming with joint protection as first priority. If the client needs extra recovery time after your training session (was too stressful) that simply increases the time it will take them to reach their goal and reduces your profits. They need a solid 3 to 4 training sessions a week to achieve the expected weight loss and need to understand that consistency is imperative. Remind your client that significant weight loss reducing joint pressure is gained from proper eating habits as well as cardio training and resistance training that is consistent and joint friendly.
Furthermore, we do not recommend the client with knee problems getting on the floor. It’s just too hard to get down and up, so keep that in mind as you are designing their exercise program. As functional as we might argue that it is to get off the floor, it simply invites a series of possible further damage as well as the humiliation of struggling to get up. We must always consider how we are making the client look in public and give them exercises that will help them feel empowered, not a failure. A great majority of overweight clients will have psychological reasons for their condition, thus we need to give them as much encouragement as we can. Every positive gain they have while training with you will encourage them to keep going.
Flexibility is import as well. We know that if the hips, quads, glutes, and hamstrings are tight it can cause greater pressure on the knees. Additionally it can pull the pelvis out of proper alignment causing back pain and pressure. You will find in this cec examples of simple ways to stretch without getting on the floor.
It ‘s such a great privilege to help our clients achieve the change they need to live a healthier life and your client should know you feel that way. Pointing out progression is a great way to encourage your client. They need to understand that proper progression is a process that produces results consistently over time. Trying to do too much too fast puts the client in danger of further injury, help them understand there’s no quick fix and exercise must be a way of life. They need to realize you don’t have to love it to do it, just recognize it’s an absolute necessity in their life (it’s not optional just like paying bills isn’t optional).