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Stress Management Exercise Programming

As fitness professionals, we know that exercise helps our clients to cope with stress. We are told that any type of exercise will help them to reduce stress levels. The problem with this way of thinking is that we do not look at stress from the same point of view as a chronic illness. In turn, you could be putting your clients at risk of developing illness’s. We know that stress can wreak havoc on the body but what can we do as fitness professionals?

When we have clients diagnosed with diabetes, cancer and heart disease, for example, we follow a certain protocol or guideline. Not everyone is the same so you may have to deviate and think outside the box. Why should there be a difference with stress management exercise programming? There are specific guidelines that you should be following.

Many fitness professionals take into consideration the mental piece of stress but not what is actually going on inside the body as a direct correlation. Or fitness professionals may think that the client is better because they feel less stressed mentally after their session. When we do any type of exercise, endorphins will be released throughout the body. This will make you feel better mentally but it is a quick fix for what is really going on inside.

If a client is highly stressed and you have them do an intense workout they may become physically worse. Exercise is a stressor on the body itself and will increase cortisol levels. This  in turn, can make blood sugars and blood pressure higher. If someone does not have either of these conditions it could become their new norm over time. When pushed to hard, a client may develop conditions like Alzheimer’s Disease earlier due to high cortisol levels.

We need to look at stress management from a physiological standpoint when prescribing exercise. Many fitness professionals do not make this important connection during their sessions. We may advise clients to do meditation, yoga and exercise as a “one size fits all approach” Our clients’ bodies are different and therefore need a customized exercise and health education plan. If you have a client who cannot lose weight when exercising and eating properly have them see their doctor. The Physician may want their patient to take a cortisol level test to make sure their body is functioning normally.

Fitness professionals should follow the FITT Principle for stress when working with this population. Knowing the appropriate frequency, intensity, time and type of exercise is very important. You must assess your client and know their stress levels before you can customize a program. It is also important to look at their health history and what medications they are taking.

One way of effectively training clients is by using the Aria Method™. Open and flowing movements are important for training individuals who are stressed. Posture and stress play an integral part of movement and should be taken into consideration. For instance, Stress can make people hunch over or adapt to a kyphotic posture. By opening the chest and strengthening the muscles you are correcting this motion. Take a moment and really look at your clients before deciding how to train them.

Educating clients about stress and healthy coping techniques is also important and can make a big difference. It may be hard for some individuals to make positive lifestyle changes. Remember to praise clients for any changes they make no matter how small.

Robyn Caruso is the Founder of The Stress Management Institute for Health and Fitness Professionals. She has 18 years of experience in medical based fitness.


Elder woman training with physiotherapist

Resistance Training: Programming and Execution

In my previous article I made a case for a comprehensive resistance training program as a way to “cut the odds” in our favor as  we “grow older and not old”. I  also strongly believe in developing a strong cardiovascular system since it is responsible for keeping the life giving oxygen and nutrients moving into the body’s tissues and organs in order to sustain our lives. These two beliefs are driven by my desire to keep my body as strong and adaptable (and flexible) as I can in order to “prevent” challenges of all kinds from entering my experience in the future.

I would like to examine programming and execution in this article in order to enable and empower you to “take up the challenge” of becoming more than you ever thought possible through a well planned resistance training program that enhances your life through an acquired discipline, focus and commitment to your own health and well being. This process – (and it is a process) – continues throughout our lifetimes and rests on the foundation of a desire to consistently learn new things about ourselves. It is a process of expanding not only our own consciousness, skill and knowledge of our potential health and fitness futures – but also includes our developing ability to maintain such a process over time.


I find the key to my success over the past 55 years has been my desire and commitment to retain my program of running and resistance training by tracking all of my workouts – both running and weightlifting – allowing me to know “where I am” at any point in time. These records keep me up to date on the factors influencing my growth and reflect my effort to attain my goals of improving strength. power, endurance, speed, quickness, flexibility and balance.

The reality is that today “tracking devices” are available through technological advances and now can serve us in ways that I never dreamed possible before. I still record my results in logs and journals and appreciate the way in which this form of tracking has enabled and inspired me to keep going and improve my results. The gym where I train is filled with people “wandering” through their time there and never really getting focused while staring at their electronic devices or “smart” phones. NO ONE ever is tracking their work and consequently they will never know when – or how – to improve.


Resistance training is the progressive stimulation of muscle fibers in order to create a more adaptable and powerful muscle. The “loads” we place on particular muscle “groups” are in alignment with the capability, experience and knowledge of the individual executing the program. There are type I and type II fibers. Each type responds differently to the multiple “stimuli” applied.

Type I fibers handle loads “over time” and respond well to longer periods of stress thereby classifying them more as “endurance” fibers. Type II fibers do not become engaged until the load reaches a high enough level where they get “recruited” to assist in handling the applied load. They are power fibers and help with explosive movements such as sprinting from danger. They normally are not required in the day to day activities most people engage in and only when we need them will they enter the equation. If they never get trained to respond however, the odds of being able to engage them when needed becomes remote.


BASE SET (8-12 reps): This set warms the muscle and allows it to perform under a minimal load preparing it for more work in subsequent sets. A set is a prescribed number of repetitions that puts the muscle through a complete range of motion and allows the muscle to “respond” to the load. This stimulus enhances the neuromuscular system to become more capable and ready to help our bodies move effectively throughout the day or when doing other activities requiring a response such as cycling, swimming or hiking.

STRENGTH SET (4-8 reps): This set increases the load and allows for a greater stimulus and response to the activity of moving a “heavier load” through a full range of motion. This set is a “building set” since its intention is to take the muscle to “fatigue” allowing for growth during recovery and down time. One can induce additional growth in this phase by adding sets and continuing the process – depending on your experience and readiness to train in this more advanced manner.

BASE SET (8-12 reps): The final part of the pyramid is to return to a lighter load – not necessarily the original load – and allow the muscle to “work through” the waste that accumulates in the fibers as a result of the prior stimulation.

SETS: Sets are the “pieces” – the individual components – to the puzzle of resistance training. “Putting it all together” in a cohesive program is very important in determining your success. Generally, it is advisable to seek professional guidance when assembling a resistance training program since determining proper training technique, loads and the types of exercises can become quite daunting if you are inexperienced and lack the proper knowledge to do it yourself.

I think of this issue in the following manner: If I am attempting an activity such as snow skiing that I have limited or no experience or skill in doing, I will hire an instructor to teach me the basics and allow me to LEARN how be safe while I learn and begin to enjoy this new activity SAFELY.


(Include free weights, machine assisted and body weight exercises in planning)

Chest: Push ups (regular and modified), bench press (free weights), or machine press.

Shoulders: Overhead press (dumbbells), lateral raise (machine), rubber tubing with handles.

Back: Lat pull (cable), seated row – tubing, machine, wall press (body).

Arms: Curl (free weights), tubing, machine curl.

Abdominals: Basic crunch (knees bent, upper body life), resistance balls (destabilized crunch), wall crunches with back flat on wall.

Legs: Squats (wall) and lunges (static or moving), leg press (machine) calf extension (stairs and machine).


Resistance training is the “pay check” and cardio is the “bonus”. My former fitness manager said these words to me over twenty years ago and I cannot disagree with him today. You will not get an argument from me on the benefits and power of a well planned resistance training program – especially after the age of 40! The idea that we can maintain our muscular strength and endurance over time WITHOUT training is ludicrous.

Every day that passes without proper stimulation of our major muscle groups is a day that we will never recover. The outcome could become catastrophic if we break a hip or suffer some other major injury that could eventually end our lives. I schedule my own resistance training sessions on Monday and Thursday so as to maximize my training and recovery times. Each program is varied by the number of sets I do, the resistance I engage and the time I take to execute the program. Each session is designed with this thought in mind: MAINTAIN my current lean muscle mass and strength for the years to come.

Your programming efforts are waiting for your decision to begin this new phase of your life and it is MOST definitely a “life affirming” decision. Take the time today to evaluate your needs and make the decision to begin TODAY! If you need help to get started – as I would with my skiing example – then get it! Don’t be afraid to learn new skills that could possibly save your life “down the road” because you – and your body – will be grateful you took a positive step that will NEVER let you down. I embrace this message myself everyday – and KNOW you will too! Travel well.

Reprinted with permission from Nicholas Prukop.

Nicholas Prukop is an ACE Certified Personal Trainer & a Health Coach, a fitness professional with over 25 years of experience whose passion for health and fitness comes from his boyhood in Hawaii where he grew up a swimmer on Maui. He found his calling in writing his first book “Healthy Aging & You: Your Journey to Becoming Happy, Healthy & Fit” and since then he has dedicated himself to empowering, inspiring and enabling people of all ages to reach for the best that is within them and become who they are meant to be – happy, healthy and fit – and be a part of a world where each person can contribute their own unique gifts to life.

If you need help in designing a fitness plan, you can contact Nicholas Prukop via email at runningnick@sbcglobal.net or read his inspiring book Healthy Aging & YOU.

top view of Healthcare costs and fees concept.Hand of smart doct

​​Looking at the Use of CPT Coding for the Wellness Profession. A Revised Look at Integration of Health Promotion within Healthcare.

It has been over 24 years since I wrote my first book on Medical Insurance Billing for the Health and Fitness Profession.  The book was based on my years as an exercise therapist who used CPT coding for sessions with diabetic patients.  Our use of proper billing, follow up letters, and reasonable pricing allowed our physician practice to bill out for some exercise sessions for over two years.

I have been asked recently to discuss the issue of reimbursement in our current system.  Over the past 50 years the system has worked for physicians, and some allied health professionals, who have developed procedures that they will get paid for – and they usually perform specific types of services within their practice that allow them maximum reimbursement.

The times are changing, though.  As they have since the mid 1990s when managed care tried to curb the amount of fee for service payments for specific services.  If you talk with physical therapists, you would see that they have been concerned over a decade that they are unable to bill for the same amounts per service that they once did.  A sign of the times?  Perhaps – but in the wellness profession we need to dig a bit deeper to see how the system (that is not built for us) can work for us.

Billing for a Fee For Service Method

All healthcare agencies that use CPT coding to some degree.  How they use them is a different situation.  Some medical practices will submit bills to CMS or health plans and wait for payment.  It is based on where they live, and what these agencies pay on an average for the particular service.  Medical professionals will “bundle” a number of different procedures together for each payment in hopes of getting a higher payout. However – using CPT codes are also valuable for health promotion professionals to understand the “language” of health care.  Let’s look at some examples of how these codes may work well for wellness programs.

Success Stories in Contracting

Perhaps one of the biggest success stories of working with healthcare is the Silver Sneakers program.  They don’t bill directly for FFS – they have used specific CPT codes to negotiate for contracts for their wellness programs.  Another example is Wellquest – the east coast company that competed in the senior wellness space with Silver Sneakers.  They were also successful in negotiating contracts with regional health plan.  They didn’t use CPT codes – but specific types of programming to convince health plans to buy into their model.  There are a few companies that use versions of coding to help injured athletes come back to work.  One is the Industrial Athlete in Detroit, MI.  This company has been delivering preventive and therapy services to companies since 1989.  Companies look to specific CPT codes to detail the particular type of program they are delivering.  Of course – they may want to know what type of reimbursement is being delivered in their area, but many in the health club setting look to costs of personal training, which may range from $30-150 per session depending on the location.  Let’s look at the types of codes that have been historically been used for exercise-related services.  There are other worker’s compensation programs that are billing directly for personal training with staff that have been to the Occupational Medicine doctors, and now want to get back to work.  With chronic exercise, many of them reduce their risk for future back injuries by almost 100%.

What are the Codes?

When I started investigating CPT billing codes, I uncovered what I thought was the Holy Grail for many allied healthcare personnel.  They thought that because they studied an allied healthcare curriculum in school, and passed a state board licensure exam – they were entitled to receive reimbursement based on these skills.  However – when I spoke with the American Medical Association (the national body that owns the © the CPT codes used by all healthcare professionals), I received a different story.  The codes are merely descriptors of services. They are copyright of the AMA, and they are licensed to others to use them directly. For our purposes, we will be discussing CPT codes that have to do with exercise therapy, and some health education procedures.

Exercise therapy falls under the physical medicine section of the CPT coding book. They may be used for exercise prescription if an MD or other licensed professional wishes to incorporate these services in their practice. Specific codes for these services are as follows:

*Physician or therapist is required to have direct patient contact.

97110 – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility.  This code is used for limited visits, such as exercise training for rotator cuff therapy, or general use of aerobic machines.  This type of training may encompass a one or two-week period, and be billed out ≈ 3-5 times.

97112 – Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, & proprioception.  This code is used primarily by Physical Therapists and Massage Therapists for patients with neuromuscular deficits that require movement along with physical manipulation of body parts (along with pressure point work, etc.).  This code would not be used for therapeutic exercise procedures, but specific movement programs such as shoulder or hip movement post stroke, or shoulder movements post breast cancer surgery.

97113 – Aquatic therapy with therapeutic exercises is used for any therapeutic activity involving water.  Aquatic therapist and inventor of the Hydro-Tone equipment Dan Solloway of Oklahoma used this code for all of his work with patients referred to him for aquatic exercise therapy for over two decades.

97116 – Gait training is again used for persons who have orthopedic limitations with movement.  It is used infrequently (or not at all) by most exercise therapists, but could be used in the expanding market of senior gait and balance prevention exercises.

97150 – Therapeutic procedure(s), group (2 or more individuals). This code is used for classroom programs, such as T’ai Chi, yoga, chair aerobics, therapeutic step classes, etc.  This is designed for practitioners who teach in the group setting – especially with special population classes.  One of the top codes that could be used in wellness.

97530 – Therapeutic activities, direct (1 on 1) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes.   It replaces the old Kinetic Activities code that was used primarily for exercise therapy procedures.  This code should still be used most by exercise therapists for 2-4 segments of 15 minutes each

97535 – Self care/home management training (e.g., activities for daily living [ADL] and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct 1 on 1 contact by provider, each 15 minutes.  This code is used primarily in the PT/OT settings, where patients need to regain day-to-day skills, as opposed to general strength and aerobic capabilities. Community Training (97537) is an extension of the self-care coding used primarily by PT and OT.  However – now that more trainers and coaches are training in the home, this code may have a benefit relating to home care fitness and wellness programs.

97537 – Community/work reintegration training (i.e.: shopping, transportation, money management, vocational activities and/or work environment/modification analysis, work task analysis), direct 1 on 1 contact by provider, each 15 minutes.

97545 – Work hardening/conditioning; initial 2 hours.  It is used for applying exercise to rehabilitate a person after an injury or accident, allowing return to competitive employment.  The role of the exercise specialist would be to provide specific work-related exercises, and education principles to patients in these rehab settings (low back, carpel tunnel syndrome, lifting techniques, etc.).

97546 – Work hardening/conditioning; each additional 1-hour

97750 – Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.  It is used to measure strength and aerobic performance, and should be used for all testing procedures that do not require physician supervision or monitoring equipment (such as ECG).  This is a good code to use for pre and post testing.

90900 – Biofeedback training; by electromyogram application (e.g., in tension headache, muscle spasm) is used by persons applying low intensity exercise and breathing techniques (Ayurvedic medicine, Hatha yoga, etc.) using EMG applications in the clinical setting.  It is used by some exercise physiologists who perform relaxation exercises with patients.

90904 – Blood pressure regulation (e.g., essential hypertension) may be used for programs that offer stress reduction for hypertensive patients.  Does not have to include monitoring equipment, but would necessitate improvements in BP control over time independent of pharmacological agents.

93015 – Cardiovascular stress test using maximal or sub-maximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report.  It is used for cardiac and pulmonary testing, using ECG and monitoring equipment, physician supervised.  This code should be used in the clinical exercise setting when performing testing services on patients who are involved in cardiopulmonary rehab services.

96150 – Health behavior assessment (e.g. – health focused clinical interview, behavioral observations, health-orientated questionnaires), each 15 minutes, face-to-face – initial assessment.  Mostly for counselors, but could be used with health coaching programs.

Where is the Future?

Since reimbursement is harder to obtain for most licensed health care practitioners – it certainly won’t be something that anyone in the exercise community will be able to obtain simply by becoming licensed or accredited.   The system is in a transformation mode.  Most of the methods for obtaining reimbursement or contracting dollars will come from outcomes-based programming.  Companies such as Optum are moving into this realm by their executive summaries relating to data analytics, outcomes, and ROI.  Health and fitness professionals should do well to read the recent report by Marshall et. al. on outcomes in the health club setting.  It has set the stage relating to the opportunities to work with clinical populations, and sets the stage for developing relationships with third party payors through a contract mechanism that will satisfy the needs of both parties.

CPT codes are the language of health care procedures, and they were made for physicians.  However – that language can help health and wellness professionals to negotiate contracts that will help pay for memberships, personal or group training, nutrition, and mind/body health programs through the health club industry.  After 25 years – I think that the disruption in the health care industry is big enough that smart health club companies and training programs will be able to offer comprehensive wellness services that will be reimbursed at some level.  We see it as the next logical step in the progression of the industry.

Reprinted with permission from Eric Durak.

Eric Durak is President of Medical Health and Fitness, and has been involved with exercise and health care since the 1980s.  He has worked with the insurance billing system with both physicians and physical therapists.  He is the author of over 20 books on health and wellness, one being the Fitness and Healthcare Reimbursement Guide.


  1. http://karenallenhomeopathy.com/wp-content/uploads/2013/06/c_abc-coding-structure1.pdf
  2. Durak, EP, Shapiro, AA.  The Fitness and Healthcare Reimbursement Guide.  7th edition, 2016.  Medical Health and Fitness Publishers, Santa Barbara, CA
  3. Towards Better Outcomes.  Optum Executive Summary Report.  Optum.com/frostreport.  2016.
  4. Marshall, TF, Groves, JR, Holan, GP, Lacamera, J, Coudhary, S, Pietrucha, RJ, and Tjokro, M.  Feasibility of Community-based Supervised Exercise Programs to Engage and Monitor Patients in a Post-Rehabilitation Setting.  2018.  Am. J. Lifestyle Med.  13(1):DOI: 10.1177/1559827617750385
  5. Nieves, PN. How a synchronized approach addresses key drivers of change in the industry.  Optum.com report, 2016.

Disclaimer:  Medical Health and Fitness and the American Medical Association are not responsible for any claims filed by individuals or group practices using the five-digit numeric Physician’s Current Procedural Terminology, 6th Edition codes, service descriptions, instructions and/or guidelines are copyright as part of the publications of CPT as defined in the Federal Copyright Law, American Medical Association.  All rights reserved. CPT (current procedural terminology) is a listing of descriptive terms and five-digit numeric identifying codes and modifiers or reporting medical services performed by and for physicians.

This representation includes only CPT descriptive terms, identifying modifiers for reporting medical services and procedures selected by Medical Health and Fitness for inclusion in this publication. The most current edition is available from the American Medical Association.  No fee schedules, conversion factors, or scales or components are therefore found in CPT.

Medical Health and Fitness has selected certain CPT codes and service procedures descriptions and assigned them to various specialty groups of a CPT service or procedure descriptions and its code number in this publication not restrict its use to a particular specialty group.

Any procedure in this publication may be used by designated the services by a qualified health professional.  “The American Medical Association assumes no responsibility for the consequences attributable to or related to an use of or the interpretation of any information contained or not contained in this publication”.

Instructor Showing Health Results On Clipboard To Senior Couple

Respiratory Disease and Exercise: How to help your clients not suck at exercise!

According to the World Health Organization (WHO), hundreds of millions of people suffer every day from chronic respiratory diseases (CRD).  Currently in the United States, 24.6 million people have asthma1, 15.7 million people have chronic obstructive pulmonary disease (COPD)2 while greater than 50 million people have allergic rhinitis3 and other often-underdiagnosed chronic respiratory diseases.  Respiratory diseases do not discriminate and affect people of every race, sex, and age.  While most chronic respiratory diseases are manageable and some even preventable, this is what is known about the nature of chronic respiratory diseases4:

  • Chronic disease epidemics take decades to become fully established.
  • Chronic diseases often begin in childhood.
  • Because of their slow evolution and chronic nature, chronic diseases present opportunities for prevention.
  • Many different chronic diseases may occur in the same patient (e.g. chronic respiratory diseases, cardiovascular disease and cancer).
  • The treatment of chronic diseases demands a long-term and systematic approach.
  • Care for patients with chronic diseases should be an integral part of the activities of health services, alongside care for patients with acute and infectious diseases.

Exercise and CRD

If you are a health and fitness professional, some of your clients may be suffering from a chronic respiratory disease and you may be an important source for relief.  Moderate exercise is known to improve use of oxygen, energy levels, anxiety, stress and depression, sleep, self-esteem, cardiovascular fitness, muscle strength, and shortness of breath. While it might seem odd that exercise improves breathing when one is short of breath, exercising really does help one with respiratory disease.  Exercise helps the blood circulate and helps the heart send oxygen to the rest of the body.  Exercise also strengthens the respiratory muscles which can make it easier to breathe.

Beneficial Types of Exercise

There are several challenges to exercise prescription and physical activity participation in this population, but a large body of evidence demonstrates important health benefits from aerobic exercise.  Resistance training has also been shown to increase muscle mass and strength, enhancing individuals’ ability to perform tasks of daily living and improving health-related quality of life.5

Aerobic exercise is good for the heart and lungs and allows one to use oxygen more efficiently. Walking, biking, and swimming are great examples of aerobic exercise. The guidelines are approximately the same as generally healthy individuals.  One should attempt to train the cardiorespiratory system 3-5 days a week for 30 minutes per session.  One should exercise at an intensity level of 3-4 on the Rating of Perceived Exertion Scale (Scale Rating from 0 Nothing at All-10 Very, Very, Heavy).

Resistance exercise increases muscular strength including the respiratory muscles that assist in breathing.  Resistance training usually involves weights or resistance bands but using one’s own body weight works just as well depending on the severity of the symptoms.  It is recommended that one should perform high repetitions with low weight to fatigue the muscles.  This type of resistance training also improves muscular endurance important for those with CRD.  Resistance training should be performed 2-3 days a week working all major muscle groups.

Stretching exercises relax and improve one’s flexibility.  When stretching, one should practice slow and controlled breathing.  Not only does proper breathing help to deepen the stretch, but it also helps one to increase lung capacity.  One should gently stretch all major muscles to the point of mild discomfort while holding the stretch for 15 to 30 seconds, slowly breathing in and out. Repeat each stretch 2-3 times.  Stretching is an effective method to warming up and cooling down before and after workout sessions.

When exercising, it is important to remember to inhale in preparation of the movement and exhale on the exertion phase of the movement.  An individual should take slow deep breaths and pace him/herself.  It is recommended to purse the lips while exhaling.

Use of Medication

If an individual uses medication for the treatment of respiratory disease, he/she should continue to take the medication based on his/her doctor’s advice.  His/her doctor may adjust the dosage according to the physical activity demands.  For example, the doctor may adjust the flow rate of oxygen during exercise if one is using an oxygen tank.  In addition, one should have his/her inhaler on hand in case of a need due to the increase of oxygen demand during exercise.

Fitness professionals can effectively work with those who have a chronic respiratory disease providing them with a better quality of life through movement.  You as their health and fitness coach can provide a positive experience to facilitate an effective path to better health and wellness.

You can join CarolAnn at the Medical Fitness Tour Chicago, October 25-26; she’ll present a session on Respiratory Disease and Exercise at the conference.

CarolAnn is also the author of a course with PTA Global on Respiratory Disease and Exercise. More info at ptonthenet.com/mfef

Known as the trainers’ trainer, CarolAnn has become one of the country’s leading fitness educators, authors, and national presenters. Combining a Master’s degree in Exercise Science/Health Promotion with several fitness certifications/memberships such as FiTOUR, ACSM, ACE, AFAA, and LMI, she has been actively involved in the fitness industry for over 25 years. She is currently the Founder and Director of Education for Chiseled Faith, a Faith Based Health and Fitness Program for churches. Visit her website, www.CarolAnn.Fitness


  1. 2015. NHIS Data; Table 3-1. www.cdc.gov/asthma/nhis/2015/table3-1.htm
  2. Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey 1988-1994. Arch Intern Med. 2000;160:1683–1689.
  3. CDC, Gateway to Health Communication and Social Marketing Practice. Allergies. https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/Allergies.html
  4. World Health Organization http://www.who.int/gard/publications/chronic_respiratory_diseases.pdf
  5. Eves ND, Davidson WJ. Evidence-based risk assessment and recommendations for physical activity clearance: respiratory disease. Applied Physiology Nutrition and Metabolism. 2011;36(Suppl 1):S80–100. [PubMed]

The Importance of Stretching

I remember the first time I figured out what my piriformis was, and how having a tight piriformis and IT band affected my movements. I had just started running hard core. As a former dancer, we stretched our hamstrings, inner thighs, the “dancer muscles”. But a piriformis or IT band was not something a DANCER experienced as this was not a muscle that was targeted in ballet, or other forms of dance.

The PAIN, was a knot in the right side of my hip/tush. It began to radiate all the way down the side of my right leg. It even affected my lever length so that the right leg felt “shorter”. I eventually learned how to do stretches such as “parvritta trikonasana”, and a bastardized version of pigeon on my back to target this muscle group (the external rotators).

Also, as a swimmer, and runner, my calf muscles will get super tight. This eventually pulls on my achilles tendon. Having torn my right achilles tendon in a freak accident in 2002, I can tell you keeping the achilles tendon happy can make the difference between being able to walk or not. Hand to foot calf stretches both standing and supine, as well as forward bend, and parvritta trikonasana, will take care of the problem. I also flex my foot against a wall before starting my run.

If my knees ache, it is usually because my quads are tight. I start with alternating kick ups from down dog into lunges to warm up. I also do natarajasana, which provides me an open angled quad stretch.

My students will often have problems targeting their abdominals. Tight hamstrings and hip flexors are usually the problem. I will do a “half lunge” where they press through the psoas to release it, then stretch the ham/calf in a forward bend while flexing the front foot, and keeping the standing knee right under the hip.

For other hard to read groups, such as under the shoulder blades, nothing beats a foam roller. I body surf along the foam roller, and hold until the knot dissipates. I have a chapter in “Healthy Things You Can Do In Front of the TV” complete with photos to describe how to target key muscles.

Stretching is often a forgotten, and yet necessary part of fitness. It makes the difference between proper kinesthetic alignment and gait, or movement that is off-balance, which can cause injuries. Not to mention, it just feels good before or after an intense workout. It also aids in recovery, so that you can be ready for your next challenge. Even die-hard couch potatoes need to stretch. And many stretches can be done at work or at home. See my lovely book for more examples of how to keep your body functioning at its best.

Kama Linden has been teaching fitness for over 2 decades. She has taught strength, step, pilates, vinyasa yoga, senior fitness, and has worked with clients and students of all ages and fitness levels. She is certified by AFAA Group Exercise and NASM CPT, as well as 200 hour Yoga. She has a BFA in Dance from University of the ARTS.  Her new book, “Healthy Things You Can Do In Front of the TV” is now on sale on Amazon, Barnes & Noble, and Kindle.

Adam Presses

Life as we Grow It: Fitness as a Life Skill for Special Needs Populations

“Kettlebell and the sandbag,” Nico states as I’m preparing for him to do squats.

“You want to do farmers carries?”

“Yes,” he says in a soft voice but with an assurance that tells me he’s not just randomly calling out an object in the room.

“Awesome. Yes, you can definitely do farmers carries right after this set of squats, okay?”

“Yes,” he says, in the same low but definitive tone. I’m thrilled. Farmers carries involve roughly 3 steps; Pick something(s) heavy up, carry them while maintaining an upright, healthy posture, and put them down with control, sometimes with less control than other times. Farmers carries have fantastic generalization to other life skills, yes, carrying things of course, in addition to maintaining trunk stability and gait pattern (think climbing two or three flights of steps).

When we consider fitness as a life skill rather than something individuals with ASD and related special needs either “like” or “don’t like” the focus becomes less on “if/should” and more on “how/what.” We’re not just talking about young populations either. Fitness over the lifetime has immense benefits for both short- and long-term development, both proactive and reactive qualities.

That fitness and physical activity are only for young populations disregards the true value of progressive movement programs. As we age, the importance of strength, stability, and motor planning increases, as these are skills that degenerate with age and dis- or non-use. The result is costly, both in quality of life and financially. Consider the healthcare costs for a 55 year old individual with pervasive Autism Spectrum Disorder (ASD), diabetes, and compromised mobility. Two out of these three complications are entirely avoidable. They are also, with the proper fitness and nutritional interventions, reversible.

Quality of life can be a general, not-certain-what-we-mean-by-this-but-sounds-good term unless we consider it with respect to what those in our care can do and what skills will allow them to be more independent, healthier (physically and emotionally), and enable them to connect with others (building community) in meaningful ways. We also want to consider stress levels and longevity. What does life look like and feel like for a non-verbal individual in his/her 20’s? 30’s? 60’s? How can we ensure the best possible present and future for them?

Let’s take away “Doesn’t like to exercise.” Let’s get rid of that. In fact, I don’t even know what that means. Our definitions and perspectives on exercise programs may a “little” different. I get this interaction a lot;

“Kevin hates exercise.”

“What do you mean by exercise?”

“Oh, well we had him run on the treadmill for five minutes and he hated it and doesn’t want to do it again.”  

The fault isn’t in the trying. There is no fault. There is, however, a lack of information about the components of an appropriate fitness program. So here are the rules;

  • We use exercises that will have the greatest benefit/generalization to life skills. These include squatting, pushing, pulling, carrying, and locomotion.
  • We get a baseline understanding of what an individual can currently do.
  • We progress exercises and movements once an individual demonstrates mastery.

What do we do? What do we doooooooooooooo? What exercises do our athletes need? What’s age appropriate? Are there super special special needs exercise?

The thing about fitness is that we’re doing it with human beings (goat yoga being a hideous exception). Since we’re doing it with human beings, we’re looking at human movement patterns and our individuals with ASD and related special needs are no exception.

The key is learning to what degree an exercise or movement needs to be simplified (regressed) or made more challenging (progressed). This is where baseline comes into play. If where know where our athlete is starting with an overhead Sandbell press, we can decide on an appropriate course of progression, maybe increasing the weight by 4lbs once they can complete 10 repetitions independently.

Understanding how each movement relates to quality of life is helpful. So let’s review that.


  • Maintaining healthy posture when sitting/standing
  • Increasing low body strength for walking/climbing (stairs, etc.)
  • Sustaining healthy posture
  • Prevention of low back pain
  • Increased trunk/core stability


  • Shoulder stability when reaching/placing items overhead
  • Trunk stability and postural control when holding weighted objects
  • Increasing general upper body stability for fine motor movements


  • Development of upper back muscles to decrease forward posture
  • Increased range of motion for shoulders
  • Trunk stability when opening doors, dragging laundry bags
  • Increased control when grabbing objects from above or below


  • Being able to move objects from one place to another independently
  • Increasing postural control and strength endurance (the ability to do a task for a longer period of time)
  • Gait patterning
  • Groceries/laundry/boxes/etc.


  • Getting from point A to point B with minimal discomfort
  • Establishing coordination and motor planning for multi-step activities and ADLs (cooking, taking out the garbage, showering)
  • Decreasing latency (catching the bus, getting to the car in less time)

The reasons why our Autism Fitness programming focuses primarily on developing strength, stability, and motor planning in these movement patterns is because these are the most common deficits and will have the greatest short- and long-term benefit for our athletes. We want to build a physical ability and progress as the athlete demonstrates their improved capabilities.

Programming, for individuals and groups, should include each of these exercises at a level of challenge where the athlete can perform the movement safely and with good technical form. We don’t just have our athletes move a lot, but coach healthy movement. This is why regressions in exercises are so critical and why we spend so much time with them in the Autism Fitness Level I Certification seminars.

As professionals working with and enhancing the lives of individuals with ASD and other developmental disabilities, there is a responsibility to provide life-enriching skills and opportunities. So much of this can be found in effective fitness programming. In both reducing the instances of health complications and increasing independent life skills, we can used the development of strength, stability, and motor planning to help build our athlete’s futures.

Photos provided by Eric Chessen.

Eric Chessen, M.S., is an Exercise Physiologist with an extensive background in Applied Behavior Analysis. Eric provides on-site and distance consulting worldwide. He is the founder of Autism Fitness®, offering courses, tools, resources and a community network to empower support professionals to deliver adaptive fitness programming to anyone with developmental deficits to create powerful daily living outcomes that last a lifetime.


Neuroplasticity and the Aging Brain

One of the greatest concerns for the aging population is cognitive decline which leads to loss of independence as well as an extreme burden on the caretakers.  Individuals worldwide are fearful of being diagnosed with any of the various cognitive issues: Dementia, Parkinson’s, Alzheimer’s, and other forms of cognitive debilities.  In 2015 there was an estimated 47 million people living with dementia and this number is expected to triple by 2050.  In 2014, the Alzheimer’s Association reported that they believe there is sufficient evidence to support the link between several modifiable risk factors and a reduced risk for cognitive decline and sufficient evidence to suggest that some modifiable risk factors may be associated with reduced risk of dementia. Specifically, that regular physical activity and management of cardiovascular risk factors (diabetes, obesity, smoking, and hypertension) reduce the risk of cognitive decline and may reduce the risk of dementia. The Association also believes there is sufficiently strong evidence to conclude that a healthy diet and lifelong learning/cognitive training may also reduce the risk of cognitive decline.

Positive association between aerobic exercise or CV fitness and executive functions is highly consistent but cannot determine causality.  Aerobic exercise (AE) has shown moderate to medium sized effects on executive function and memory. Resistance Training (RT) has improved executive function and memory. Combined AE and RT has the biggest (potentially synergistic) effect. It has been proposed that the physical and cognitive exercise might interact to induce larger functional benefits.  Larger benefits on cognitive test performance were noted for combined physical and cognitive activity than for each activity alone.  “Claims promoting brain games are frequently exaggerated and at times misleading. … To date, there is little evidence that playing brain games improves underlying broad cognitive abilities, or that it enables one to better navigate a complex realm of everyday life (Consensus statement, 2014).

Neuroplasticity is the brain’s ability to reorganize and rebuild itself by forming new neural connections. The more neural pathways you have, the more resilient your brain is. Neurogenesis is the process of creating new neurons (brain cells).

Contrary to popular belief, neurogenesis continuously occurs in the adult brain under the right conditions such as with exercise.  Substantial benefits on cognitive test performance were noted for combined physical and cognitive activity than for each activity alone. It was also noted that the physical and cognitive exercise together might interact to induce larger functional benefits.  “We assume, that physical exercise increases the potential for neurogenesis and synaptogenesis while cognitive exercise guides it to induce positive plastic change” (Bamidis, 2014).  To maximize cognitive improvement, combine physical exercise with cognitive challenges in a rich sensorimotor environment that includes social interaction and a heaping dose of fun.

Brain health is becoming extremely important as individuals live longer.  Today there is much more information available on how to train the aging brain.  Three great resources are:

Dianne McCaughey Ph.D. is an award winning fitness specialist with more than 35 years experience in personal training, group exercise, coaching, and post-rehabilitation. She is a master trainer for multiple companies and practices and teaches optimal wellness emphasizing the mind, body and spirit. She works with special populations and focuses on posture, gait, balance and corrective exercise programs for better function and health.

Cody Sipe, PhD, has an extensive background in the fitness industry with 20 years of experience as a personal trainer, fitness instructor, program director, exercise physiologist and club owner. He is currently an Associate Professor and Director of Clinical Research in the physical therapy program at Harding University. He is the co-founder and vice president of the Functional Aging Institute (FAI).


Resistance Training: Principles and Planning

As I have grown in my own understanding of strength training over the years, I have  come to realize that many people are aware of the need to develop strength but appear to miss the point when applying their efforts to the actual process. I have observed over the years that men tend to want to “load up” their exercises and do minimal repetitions (maximizing the resistance) while women tend to work with very light weight and do greater numbers of repetitions.

Both approaches are not wrong but in applying their effort in this way they will both get minimal results. Men tend to get fatter in the abdominal cavity and women tend to gain fat mass in the hips and thighs – and eventually arms. Both approaches will not solve the “fat storage” problem and I suspect the frustration both groups feel grows ever time as each attempts to change the outcome by going with what they “think” will work.

I feel that if I can highlight the PRINCIPLES of resistance training while identifying the underlying benefits of a successful resistance training program I will hopefully “shed light” on the mystery of getting a “lean body” which we all seem to want.  Lean and strong beats fat and weak any day -doesn’t it? I know it does because I am able to say that after 30 years of weight training I AM lean and strong! Would you want that too? Of course!


RESISTANCE: Applying a predetermined  “load” to a particular muscle group in order to create a deficit of stored energy and allow the muscle to respond to the “stimulus” by “adapting to the load presented” – and getting stronger over time. The muscle grows in size and strength by responding to increased loads and gives the joint more stability while creating a more flexible and adaptable joint.

REPETITIONS: The number of movements around the joint that create the result. The lower the number of repetitions – the greater the load. The higher the number of repetitions – the lower the load. Repetitions can range anywhere from (6 for “power sets” to 15 for “endurance sets”. The number of sets one can do will determine how quickly – or slowly – the muscle will respond to the stimulus. When it can no longer perform the movement (1-3 sets for beginners to 4-6 – or more – sets for experienced individuals) it has reached a “failure point”.

EXERCISES: The number of exercises is determined by the condition of the individual and the outcome desired. The form (body weight, machine, free weights) the exercises take is determined by the experience, knowledge and acquired skill of the individual. The process is always dictated by the conditioning and “readiness” of the person to train and MUST always include the safety and effectiveness of the exercises selected. Examples of exercises are: Leg extension, calf extension (seated or standing), shoulder press, chest press, back – rowing or pulldown, arm curls, lunges, and squats.

SPEED/TIMING: Timing refers to the speed with which we do the movements needed. The 2/4 count is a common tool used to either “speed up” or “slow down” the movements. (2 is for raising the weight and 4 for is for lowering the weight slowing the movement). Each has value but the faster we do the movements the more likely we are to increase the risk of injury. The heavier the load the more speed will have to be employed to “move the weight”. The lighter the load the slower the movement can done increasing fatigue and allowing the muscle to respond over time to the stimulus. Do a movement that is comfortable for you and remain in control of both the positive and negative resistance.

RANGE OF MOTION: The principle of range of motion comes into play when we attempt to move a heavier “load” through a “full range of motion” when our muscle is unable to do it without assistance from another joint. A classic example would be a standing arm curl where we are applying a weight against our bicep and attempting to raise the weight to our shoulders without using our back or lifting with our shoulders. I see this all the time. If you can’t “curl the weight” slowly – at the elbow for example – without assistance the weight is too heavy.

PROGRAMMING: Programming applies to the overall effort – and the result one is attempting to achieve. Starting with lower weight and doing more repetitions correctly is always preferable since safety must come first. The muscle develops over time and then additional “reps” can be applied with higher resistance since the muscle “adapts to the loads” over time. Patience is important and “going slowly” at first is always advisable. Weight training can show results in as little as 30 days so keep going!

THE PRINCIPLE OF ADAPTATION: This principle is the most important to keep in mind. All muscles get stronger over time if consistent effort is made and the issue of safety is always kept foremost in mind. My own training is now focusing on high numbers of repetitions while maintaining the weight I have been using to this date. The endurance and power issues are  being addressed in this manner since I am older now and my goal is to “maintain” my existing lean muscle mass”. We should ALL want to maintain our lean muscle mass since it is the most active tissue in our bodies – and burns lots of calories! The aging process WILL have a long term – and negative – effect if we do nothing!


Do “something” every week for the rest of your life when it comes to building – and maintaining – your existing lean muscle mass. Strength and endurance decline with the years – especially after the age of 40. The process actually begins in our 30’s but accelerates in our 40’s and beyond. I am fighting for a lean and strong body every time I train with weights.

I am building ENDURANCE through massive numbers of sets and reps. I am creating more POWER and STRENGTH through increased loads. I am increasing my CAPACITY when I keep the time between sets down to 30 seconds or less. I don’t waste time sitting or talking with people. I don’t allow myself to be distracted (no PHONE). I work toward the completion of my weight training workout in under an hour and fifteen minutes twice a week.

Scheduling time to work on building muscular strength and endurance is critical to a healthy and fit body. Your commitment to creating and maintaining your existing lean mass is VITAL so start with 2-3 days and build your program to suit your needs. Consider all your options (machines, free weights, body weight exercises etc.). Seek guidance from a fitness professional to assist you in planning your training especially if you lack proper training and experience – better “safe than sorry”!

Set a firm schedule for yourself and stick to it! I strength train on Mondays and Thursdays – and train HARD each time. I want to keep what I have as long as I can – and enjoy every minute at the same time! You should too! Find a way and commit yourself to your purpose and NEVER QUIT!


Strength training is vital to a healthy and fit body as we age. Without our muscles we WILL become frail and weak – and our spine will collapse along with our ability to take care of ourselves – which I never want to experience. I see this outcome every day and walkers are becoming more commonplace for the “elderly”. I NEVER want to be called “ELDERLY”. That to me is the kiss of death. Remember after the age of 40 “all bets are off”. If you haven’t been active and developing your body before that age then get started and don’t waste a minute – or even ONE DAY.

Once the time is gone it can never be recovered. I am off to do my weight training for the start of my week and I can’t wait to “get to it”. My energy levels will go up and my attitude will be positive – and happy. I will accept the challenges of my day and start my week off on the “right foot”. Will you do the same? Only you can answer this question. I am guessing that if you do all you can today to get stronger – your body – and your mind – will be forever grateful that you charted a course that will forever keep you young and vital – and that is priceless!

Nicholas Prukop is an ACE Certified Personal Trainer & a Health Coach, a fitness professional with over 25 years of experience whose passion for health and fitness comes from his boyhood in Hawaii where he grew up a swimmer on Maui. He found his calling in writing his first book “Healthy Aging & You: Your Journey to Becoming Happy, Healthy & Fit” and since then he has dedicated himself to empowering, inspiring and enabling people of all ages to reach for the best that is within them and become who they are meant to be – happy, healthy and fit – and be a part of a world where each person can contribute their own unique gifts to life.

If you need help in designing a fitness plan, you can contact Nicholas Prukop via email at runningnick@sbcglobal.net or read his inspiring book Healthy Aging & YOU.

team hands

Collaborative Thinking in Health & Wellness

Over the past 18 months, I have seen my primary M.D. three times, enjoyed the services of my favorite massage therapist six times, visited my chiropractor nine times, chatted with a local R.D. twice and seen my personal trainer regularly. And not one of them even asked if I was seeing any of the others, much less inquiring what their treatments or approaches to treatments might be. To me, that is like trying to achieve success with a baseball team where the 1st base coach, 2nd base coach, 3rd base coach and pitching coach never communicate with each other.

Success cannot occur in a vacuum, neither can true individual health & wellness, yet for decades these medical, fitness & wellness providers have proffered their services in distinct and distinctly separate spaces.

Even as the internet has made access to information easier and facilitated the sharing of knowledge, including private, HIPAA compliant information, these providers continue to operate in “informational silos.”

It is true that in the past some of these providers may have held less than favorable opinions of some of the other providers, but that is, and certainly should be, a thing of the past. No longer will M.D.’s consider Chiropractors “quacks”, R.D.’s claim nutritionists “just don’t know enough”, and Physical Therapists think of Personal Trainers as ”wanna-be P.T.’s who couldn’t hack the education.” Science, knowledge and time have evolved all these disciplines into valuable, useful and incredibly beneficial specialties, each offering specific training and specific methods to apply to their patients/clients. And all those patients/clients typically can benefit from their combined expertise and knowledge.

No longer is it sufficient to simply treat the symptoms. Real wellness needs to encompass the patient/client holistically… address the symptoms, understand the cause, strengthen the mind, examine the diet, resolve the issue and prevent future occurrences. And isn’t that best accomplished by viewing patient/client wellness as a Team Sport?

Over the years I have had the pleasure of knowing and speaking at length with many of these medical, fitness & wellness providers, and not one of them indicated there is anything in their training that says “Thou Shalt Not Collaborate.”

We are not talking about “asking for help.” Rather we are simply saying to include those other practitioners in the conversation. Instead of the M.D. telling the patient to “walk more to improve cardio health”, why not conference call with the Personal Trainer and discuss the walking program that is most appropriate. Let the Physical Therapist inform the Personal Trainer of any specific issues to address or avoid. Allow the Massage Therapist to work with the Chiropractor to ensure optimum results from both. In other words, (and the simplicity of all this may surprise you), just TALK TO EACH OTHER.

So, let’s start to make that happen. For more than 20 years my company has helped health clubs and fitness centers create mutually beneficial relationships with Physical Therapy practices, Chiropractic offices, Registered Dietitians, Nutritionists and Massage Therapists. Now is the time to extend the conversation, and, to return to my baseball metaphor, get ALL the coaches working together to create truly Championship results.

Cosmo Wollan is the Senior Executive at Synergy Cubed, a premiere consulting firm providing customized solutions to the health & fitness, parks & recreation, medical fitness and corporate wellness industries since 1994. His Fitness Industry clients have engaged him as an expert problem-solver in profit center development, retention strategies, customer engagement, sales training, programming design, operational streamlining and health club management.