Despite calls for higher levels of physical activity from the Centers for Disease Control and Prevention, National Institutes of Health, Surgeon General, the American Heart Association and the American College of Sports Medicine (Pate, et al., 1995), the majority of people with disabilities do not get the recommended amount of physical activity needed to confer health benefits and prevent secondary conditions associated with a sedentary lifestyle, such as heart disease, obesity and osteoporosis (Rimmer & Braddock, 1997; Rimmer et al., 1999). Joining a fitness center is an excellent way for persons with disabilities and health limitations to maintain their physical function after rehabilitation or to improve their overall health in a supervised setting where they can benefit from the assistance of a qualified fitness professional.

A recent study, however, showed that the majority of subjects with mobility limitations felt that fitness centers typically do not have the type of equipment or professional staff needed to assist them properly (Rimmer et al., 1999). Fitness professionals have a tremendous opportunity to become more knowledgeable about disabilities and tailor programs to this population.

People with disabilities generally fall into four categories as shown in Table 1. Also note that people with disabilities often face a higher incidence of secondary conditions, including obesity, pressure sores, infections and osteoporosis, that can cause further disability, and in many cases, a loss of physical independence.

As persons with physical disabilities age, the interaction between the natural aging process and the disability can create a more demanding physical environment. Tasks that could be accomplished when someone was young, such as climbing stairs, walking with a cane or walker, carrying packages and transferring from a wheelchair to a bed or car, can become difficult or virtually impossible with aging.

Fitness professionals first need to understand the terminology used to define movement limitations. A few of these terms are defined in Table 2.

Because of the various kinds of disabilities, describing specific components of an exercise prescription for each condition can be difficult. Following are medical conditions associated with physical disabilities and exercise guidelines fitness professionals should follow when working with people with physical disabilities.

1. Some physical disabilities are classified as progressive, which means that the condition will worsen over time. Some forms of multiple sclerosis and postpolio syndrome are considered progressive disorders, while other conditions, including cerebral palsy and spinal cord injury, are considered non?progressive. Progressive disorders require careful monitoring to assure that the exercise program is not causing the condition to worsen, which is referred to as an exacerbation.

2. Persons with physical disabilities often exhibit asymmetrical weakness. Many individuals with cerebral palsy or stroke have hemiplegia (weakness or paralysis on the right or left side of the body), which results in significant differences in strength between the stronger and weaker sides of the body. The fitness professional must improve the affected side as much as possible without neglecting the non?affected side.

When the nerves controlling the affected side have been partially or completely damaged, the magnitude of improvement in the affected muscle groups will be greatly reduced. If some nerve innervation is present on the weakened side, however, a resistance training program may result in a measurable improvement in strength. Someone with hemiplegia may require active?assistive resistance exercise (instructor helps client perform the movement) on the affected side while using standard exercises on the non?affected side.

3. Spasticity describes various types of rigid or hypertonic muscle tone, and can be classified as mild, moderate or severe. It results in an exaggerated contractile response to stretch, and often is seen in persons who have damage to their central nervous system (CNS) such as with cerebral palsy, stroke, multiple sclerosis and spinal cord injury. The condition occurs due t (a) loss of control from the damaged portion of the brain or spinal cord, (b) hypersensitivity of nerve receptors that are no longer being supplied with control after the injury or © growth of new nerve pathways (Lockette & Keys, 1994, p. 95).

Spastic muscles are very tight or rigid. Severe spasticity usually results from the muscle groups being in a fixed position for a significant period of time - resulting in a contracture. Contractures can be stretched except in severe cases where the muscle group is permanently shortened.

Since many individuals with physical disabilities will have some degree of spasticity, flexibility training is critical. The fitness professional needs to identify the spastic muscle groups and develop a long?range plan to increase range of motion. The instructor should consult with a physical therapist, physician or appropriate medical professional to determine how to stretch a spastic muscle without causing injury.

4. Those with neurological conditions, including multiple sclerosis, postpolio syndrome, amyotrophic lateral sclerosis and muscular dystrophy, can become progressively weaker as a result of the decline in CNS functioning. Therefore, fitness professionals should continue working with clients to try to offset this decline by improving their fitness levels. Consult with the client's physician or physical therapist if you notice a rapid or spontaneous decline in function for more guidance about appropriate activities at this stage.

5. Exacerbations may necessitate a temporary break in training. Exacerbations occur most often in persons with multiple sclerosis. After an exacerbation, starting out at a much lower resistance is typically necessary because of the new complications. The fitness professional should contact the client's physician to determine the appropriate training progression. Although the person may be unable to reach the level of fitness achieved before the exacerbation, fitness professionals should reassure clients that fitness still can be improved. Clients who have exacerbations should understand that they begin with a "new slate" and that the goal is to attain the highest level of fitness possible from this new starting point.

6. Damage to sensory nerves occurs with many types of physical disabilities. This results in the inability to detect pressure against the skin, which, if left untreated, can result in a pressure sore. Since people with physical disabilities who wear braces or use wheelchairs have a high risk of developing a pressure sore, frequently checking all body parts for skin irritations that may result from a new exercise routine or from using a new piece of equipment is very important. These injuries start with a small area of redness and gradually get larger if untreated.

7. Depending on the disability, muscle groups may be functional, partially functional (paresis), or nonfunctional (paralysis). The fitness professional should consult with the client's physician to identify which muscle groups fall into each category. Also, fitness professionals should consider joint irregularity in the exercise prescription. For example, individuals with cerebral palsy often have hip dislocations due to the strong pull of the adductor muscles. If the client has a history of hip displacement, the instructor should check with the client's physician to determine any necessary modifications for the training program.

8. Keep detailed records about each client. Since several associated conditions (e.g., spasticity, hypertension, joint pain, exacerbations and pressure sores) can accommodate a physical disability, the fitness instructor should maintain current records and note any new medical conditions that may develop during the training program.

9. Progressive disorders often result in a gradual loss of muscle mass and strength. When muscle soreness occurs in persons who have a progressive condition, it may be an indication that the overload or intensity was excessive. Get approval and recommendations from the client's physician for the optimal training volume and specific exercises that will reduce the likelihood of injury.

10. Individuals with physical disabilities must overcome the physical and psychological challenges of living with a disability, and depression is a common secondary condition. The fitness professional should be aware of any signs of depression and contact the client's physician or health care provider if necessary. Occasionally, depression can cause a person to drop out of the program.

Through a grant from the Centers for Disease Control and Prevention, Disability and Health Branch, The National Center on Physical Activity and Disability (referred to as NCPAD) was established in 1999. The NCPAD Website at http://www.ncpad.org offers a wealth of information about exercise and disability, including fact sheets, monographs, a comprehensive resource directory and education information. Soon the site will help fitness professionals develop customized exercise programs - including pictures of exercises, instructions and precautions - for clients with various types of disabling conditions. Information specialists also are available during business hours to answer questions (800/900?8086).

As aging baby boomers reach retirement age, the number of Americans with disabilities will continue to grow, imposing new demands on fitness managers and professionals to make their facilities more "disability friendly." With the resources currently available to develop safe, effective programs, this is a win-win situation for people with disabilities and fitness professionals.

Table 1. Common Disabilities1
Physical Cognitive Sensory Chronic Multiple Sclerosis Alzheimer's Disease Blind Diabetes Stroke Parkinson's Disease Visual Impairment Asthma Spinal Cord Injury Stroke Deaf Arthritis Post-Polio Mental Retardation Auditory Impairment Heart Disease Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease) Mental Illness   Chronic Obstructive Pulmonary Disease Limb Loss Head Injury     Parkinson's Disease   Head Injury   Cerebral Palsy   Spina Bifida   1Some conditions are classified under more than one disability category depending on their severity. For example, a person who has had a stroke may end up with a physical disability (paralysis to one side of the body) and a cognitive disability (loss of memory).

Table 3. General Safety Guidelines for Wheelchair Users

1. Reduce the distance as much as possible between the transfer surface and the wheelchair. Removing armrests and detachable footrests will permit closer positioning to the transfer surface.
2. Always secure wheelchair locks (one on each side of chair).
3. Provide surfaces of equal height if possible. Lifting someone up on a surface if the height is higher than the wheelchair is much more difficult.
4. Keep a wide base of support and use the legs (not the back) to lift a person.
5. Make sure the person knows when you are ready to transfer him/her.
6. Before pushing a client in a wheelchair, make sure the person is prepared to move.
7. Never tip the wheelchair forward to get over an obstacle, such as a curb or door threshold, as this could cause a fall. Always tip the chair backward onto the larger posterior wheels.
8. For optimal safety, use two people to transfer a client from the wheelchair to the floor or a machine.

Table 4. Summary of Exercise Training Guidelines for Persons with Physical Disabilities

1. Know and understand the pathology of each condition and how it may interact with your training program (e.g., progressive diseases often result in increased weakness).
2. Determine which muscle groups are still functional (neurological innervation) and which muscle groups are either weak or paralyzed.
3. Determine the progression of exercise through consultation with the client's physician or physical therapist. With certain individuals, the progression may vary regularly because of exacerbations. Periods of exacerbation may require you to return to baseline or below baseline levels of strength.
4. Focus on muscle groups that are essential for performing activities of daily living
5. Make sure that blood pressure and heart rate responses remain in safe zones. Monitor blood pressure frequently during the early stages of the program to detect any potential problems.

References

1. Lockette, K. F., & Keys, A.M. 1994. Conditioning with physical disabilities. Champaign, IL: Human Kinetics.
2. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C. Physical activity and public health: recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995; 273:402?407.
3. Rimmer JH. Health promotion for persons with disabilities: The emerging paradigm shift from disability prevention to prevention of secondary conditions. Phys Ther 1999; 79: 495?502.
4. Rimmer JH, Braddock D. Physical activity, disability, and cardiovascular health. In: Leon AS, editor. National Institutes of Health. Physical activity and cardiovascular health. A national consensus. Champaign: Human Kinetics; 1997:236?244.
5. Rimmer JH, Rubin SS, Braddock D, Hedman GH. Physical activity patterns in African?American women with physical disabilities. Med Sci Sports and Exerc 1999; 31:613?618.