EXP 520: Clinical Practice in Exercise Physiology

Final Client Case Report

Josiah Schillinger
May 6, 2015

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Table of Contents
Patient Information
Risk Factor Classification
Intake
Follow Up
Exercise Testing
Aerobic
Musculoskeletal
Exercise Prescription
Cardiorespiratory Fitness
Resistance Training
Goal Setting
Patient Education

Page 3
Page 4
Page 5
Page 6
Page 7
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Page 9
Page 10
Page 12
Page 13
Page 15

References
APPENDIX-A: Initial Exercise Prescription
APPENDIX-B: Updated Exercise Prescription
APPENDIX-C: Summer Exercise Prescription
APPENDIX-D: Exercise Demonstrations
APPENDIX-E: Patient Education 1
APPENDIX-F: Patient Education 2
APPENDIX-G: Patient Education 3

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Patient Information
Cathy Carroll, a 63-year-old Caucasian female, is a project manager at Carroll
University who volunteered to be apart of our wellness program. Refer to TABLE1 for her anthropometric and resting values.
TABLE-1: Current medical exam of the client
Occupation
Project Manager
Sex
Female
Weight
163 lbs
Height
5'4"
Age
63 yoa
RHR
74
RBP
130/78 mmHg
RHR: resting heart rate
RBP: resting blood pressure
YOA: years of age
Lbs: pounds
According to ACSM, her resting blood pressure (RBP) would be classified as prehypertensive because it falls between 120-139 systolic blood pressure (SBP).
Resting heart rate (RHR) is within the normal range of 60-100 bpm. Refer to
TABLE-2 for her laboratory values.
TABLE-2: Patient's confirmed laboratory values
Factors
Values
Cholesterol
296
LDL
206
HDL
83
Blood Glucose
108
LDL: low density lipoprotein
HDL: high density lipoprotein
Cholesterol, LDL, HDL values are reported in ml/dL
Blood Glucose value is reported in mg/dL
According to ACSM, her total cholesterol (TC), low-density lipoprotein (LDL),
levels are elevated classifying her as having dyslipidemia; however, her highdensity lipoprotein (HDL) levels are high enough to be considered a negative risk
factor. The clients fasting blood glucose levels are higher than a healthy range
classifying her with Prediabetes.

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Risk Factor Classification
According to the ACSM guidelines, Cathys cardiovascular risk factors are listed
below in TABLE-3.
TABLE-3: Risk factors and there defining criteria as stated by ACSM
Cathy's
Risk Factors
Information
Defining Criteria
Age
63 yoa
55 yoa
Family History

Sedentary Lifestyle

Maternal

Self-reports
regularly
walking 30+
minutes,
3 days/week

Myocardial infarction, coronary

revascularization, or sudden
death
before 65 yr in mother or other
female first-degree relative
Not participating in at least 30
minutes of moderate intensity,
physical activity (40- <60%
VO2R)
on at least three days of the
week
for at least three
months

Hypertension

Losartin

On a antihypertensive
medication

Dyslipidemia

296 ml/dL
206 ml/dL
*83 ml/dL

TC 200 ml/dL
LDL 130 ml/dL
*HDL < 40 ml/dL

Prediabetes
108 mg/dL
100 mg/dL and 125 mg/dL
YOA: years of age
VO2R: VO2 Reserve
TC: total cholesterol
LDL: low density lipoprotein
HDL: high density lipoprotein
*High HDL levels meets the criteria as a negative risk factor ( 60 mg/dL)
Based on ACSM guidelines, she is classified as moderate risk because she is
asymptomatic and presents with two or more risk factors of CVD. Cathys

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participation in moderate exercise would not require a medical exam or exercise
test; however, vigorous exercise would require that she has a medical exam
done but an exercise test is not required, according to ACSM. A moderate risk
client would not need medical supervision during exercise; she does however
need to be professionally supervised when exercising.
Intake
When I asked the client to describe the type of active lifestyle or fitness level that
she envisioned for herself she self-reported wanting to be back to where she was
previously. She has gained approximately 10 lbs since her left chronic medial
knee pain started 3 months ago. She wants to get back to exercising 4
days/week without any knee pain present whether that is on a treadmill or just
everyday activities such as walking up stairs or working in the garden. My
impression of this is that she wants to be active again without her left chronic
medial knee pain hesitating her. When I asked the client if making a change is
important to her she self-reported that it is very important. She wants and is
willing to put in the time to be active again. She stated she is able to put in 60
min/day, at least 3-4day/wk. My impression of this is that she does not like the
feeling of being more sedentary than normal due to her recent knee pain. She
wants to make this change so she can start living her life like she used to. She
also stated that she would not need much effort in meeting 60 min/day, at least 34 days/wk. My impression of this is that she will be able to easily set aside the
time needed to accomplish her goal.
In order to build on her strengths, questions were asked of what was working for
her now. The client self-reported that walking is working for her now. She is also
actively using her recumbent bike at home either in the morning or at night
approximately 45 min/day, 6 days/wk to loosen up her knee. My impression of
this is that she is limited with the activities she is able to do now due to her knee
pain. She stated that she enjoys the outdoors. Working around the house,
walking, and being on her recumbent bike at home are the activities she enjoys.
My impression of this is that she wants to get back to working around the house
more once summer comes without any hesitation.
When discussing exercise preferences, the client self-reported preferring to
exercise either at home or outside. She stated that when it is cold outside she
would prefer to be at home exercising in her basement. My impression of this is
that she prefers being home with her husband and outdoors, when the weather
permits, rather than working out in a fitness center setting. This is when
questions about any pain or discomfort were felt during any exercises or
activities. Client self-reported experiencing left knee pain. It is located on the
medial side with a cyst-like inflammation area directly in back. She stated that her
pain is an 8 on a 1-10 pain scale when exacerbated by stairs especially. Due to
working at school she is required to walk up and down stairs throughout the day
continuous. She mentioned that it is most aggravated when she has to get up

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and down continuously such as from a floor exercise to standing position. It is
also painful when there is pressure placed on her knee by a jump or downward
step. Making an exercise program must be modified keeping what positions and
exercises which are painful in mind at all times. Avoiding as many floor exercises
as possible; if needed making them last to where she will not have to
continuously get up and down.
While addressing goals the client self-reported wanting to work on toning her
waist including rectus abdominis and external/internal obliques, strengthening
her shoulders and arms, and loosening/strengthening her knees. She stated that
she wants to strengthen what muscles are used the most in working around the
house inside and out. My impression of this is that she wants to also tighten up
her midsection including her obliques and strengthening her knee to where she
can be pain free once again. Exercises to include in the program are core
exercises on the adjustable table. Because of this she will not have to sit or lie on
the ground and constantly aggravate her knee. When asking about motivation
the client self-reported that seeing results is what motivates her the most. She
stated that she has 3 sets of clothes at home, approximately size 10, 12, 14, and
seeing herself fit in a smaller size would motivate her. My impression of this is
that she is a visual person. Similar to most individuals she wants to see results
and that is what will motivate her to continue. Periodically taking measurements
of her waist circumference would help in seeing progression.
Due to clients age and gender it was also deemed appropriate to assess risk for
osteoporosis. Within BSDI, the client took a cardiovascular disease and
osteoporosis risk questionnaire. According to BSDI, the client presented with an
8% 10-year CVD risk and presented with an overall score of 0%, which classified
her as low risk for osteoporosis.
Follow Up
Once the intake session was reviewed, a couple follow up questions needed to
be assessed in order to fully establish a baseline for the client. She mentioned
that walking was working for her now within her schedule but what exercises and
at what intensity was not documented. Once followed up she stated that she is
walking on a treadmill at home in her basement at 2.8mph, 60 min/day, 3-4
days/wk. Another aspect of the intake that was not documented was goals
addressed numerically. Once followed up she stated she wanted to lose at least
10 lbs, lose 1-2 of her WC, and strengthen her shoulders to progress to 3 sets of
exercises per session. My impression of this is that these are some of the goals
she has made for herself for this program but that she will be using this as more
of a stepping-stone. She will gain strength and lose weight but most of all learn
new exercises to be able to continue after the program and semester ends.

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Before exercise testing was performed Metria Lifestyle patch was used to gather
steps, physical activity, and sleeping patterns. Unfortunately data could not be
retrieved due to device error.
Exercise Testing
Aerobic
Over the past ten years, ACSM has learned that older persons can adapt to a
program of regular aerobic training as well as their younger counterparts. Older
adults can achieve the same 10 to 30 percent increase in VO2max in response
to endurance exercise training as young adults. The magnitude of these
adaptations in VO2max in older adults is a function of training intensity; low
intensity training elicits only marginal changes. The increase in VO2max in older
adults is a result of improvements in both maximal cardiac output and a-v O2
difference. In addition, improvements in submaximal endurance capacity and the
greater ability to tolerate higher levels of physical activity are important training
adaptations.
During the pre-test, the Ebbeling treadmill protocol was implemented. The
purpose of this test is to assess aerobic endurance. An equation was developed
to estimate maximal oxygen uptake (VO2max) based on a single submaximal stage
of this treadmill-walking test. This submaximal-walking test based on a single
stage of a treadmill protocol provides a valid and time-efficient method for
estimating VO2max (10). The Ebbeling was chosen for testing because this
treadmill test produced high test-retest reliability and validity with VO 2max for a
sample of middle-aged (45-65 yr) women (12). The client peaked at a speed of
2.5 mph at a steady state HR of 130 bpm. Within the equation this results in a
VO2max of 26.95 ml/kg/min. According to ACSM, this is classified as poor/fair. My
impression of this is that there is plenty of room for improvement. With an
appropriate exercise prescription, improvements may be made with aerobic
endurance.
Musculoskeletal
Muscle weakness is an important risk factor for falls. Resistance training aims to
increase the ability of a muscle or group of muscle to generate force. A large
number of controlled trials have found resistance training can improve strength
and power among older adults (16).
To decrease the risk of injury, it is common for strength training programs for
older individuals to include a warm-up set at a lower intensity. Older individuals
with various medical conditions may still be able to benefit from a strengthtraining program. For example, resistance training has been shown to reduce
physical disability and pain among older individuals with osteoarthritis (16). Ades

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et al. also found that among disabled older female patients, resistance training
led to greater improvements in ability to perform a range of household physical
activities.
During the pre-test a 10-RM lateral raise was implemented. The purpose of this
test is to assess muscular strength and endurance in the shoulders. According to
ACSM, 10-15 repetitions is recommended for older populations. According to
ACSM, recommendations state that healthy sedentary adults undertake a
strength-training program involving one set of 8-12-RM of 8-10 different
exercises twice weekly. It also recommends that older adults carry out similar
programs at a slightly lower intensity (10-15-RM) to decrease the risk of
musculoskeletal injury (16). For 10 repetitions, the client fatigued completely
with 8lbs. According to ACSM, this is estimated as a 1-RM of 11lbs.
A 30s sit-stand test was also performed. The purpose of this test is to assess
muscular strength and endurance in the lower body. This test was terminated due
to client self-reporting pain in her left knee.
A 30s arm curl test was then implemented within exercise testing. The purpose of
this test is to assess muscular strength and endurance in the upper body
specifically the upper arms. This test has been proven to be reliable for
assessing upper body strength and endurance in middle to older aged females
(8, 13, 20). With the client using 5lbs, she performed a curl 10 repetitions within
30 seconds. According to ACSM and her age category, this is classified as
average. My impression of this is since upper shoulder strength is a goal of the
clients, implementing arm curls within comprehensive exercise prescription is
crucial.
In addition, the modified BSSR test was implemented. The purpose of this test is
to assess flexibility in the lower body. The reason why the modified BSSR test
was chosen was due to the high reliability and validity for older populations (5,
14, 17). The client reached 6 for both legs. According to ACSM, this is classified
as 5-10 percentile. My impression of this is that although increasing flexibility is
not one of the clients goal that it should be incorporated within her exercise
prescription and home program. Being classified at such a low percentile
compared to her age group, there is room for improvement.
A re-assessment was implemented 5 weeks into the program due to ACSM,
Dipietro and Wenger et al. stating that cardiorespiratory and musculoskeletal
improvements may be seen as early as weeks 5-8 within a comprehensive
exercise program. However, a clinical decision was made that there had not been
enough time for the client to improve in either. This decision was based due to
the fact the client missed a weekly session due to being ill for a week and reassessing the client after this period may have given skewed results. Therefore,
during the re-assessment only a modified BSSR test was performed. The client

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reached 7.5 for both legs. She improved 1.5 in each leg. According to ACSM,
this is classified as 5-10 percentile as well.
During the post-test, due to client self-reporting hurting her knee and unable to
use the treadmill, musculoskeletal and flexibility were only assessed. With the
10-RM lateral raise, the client initially lifted 8lbs for 10 repetitions but selfreported that she could have done more. An adjustment and increase to 9lbs was
made to where the client lifted 7 repetitions before compensating her form and
using her back as momentum. Due to improper form, this was documented as a
7-RM of 9lbs. According to ACSM, this is estimated as a 1-RM of 11lbs. This
shows that there may not have been an increase of strength and/or endurance in
her shoulders. Next, the 30s arm curl was performed. With the client using 5lbs,
she performed a curl 18 repetitions within 30s. She improved by 8 repetitions.
According to ACSM, this is classified as good. In addition, the modified BSSR
test was assessed. The client reached 9 for both legs. She improved 1.5 in
each leg. According to ACSM, this is classified as 30 percentile.
Exercise Prescription
Most risk factors associated with disease increase with age, so the benefits of
regular exercise are significant from a health perspective. Health benefits
associated with cardiovascular disease risk factors include favorable changes in
lipid profile, blood pressure, and body composition. Older adults can improve
their plasma lipoprotein lipid profiles with exercise training similar to those
observed in younger adults and may include modest increases in plasma HDL
levels and reductions in LDL and plasma triglyceride levels. This results in more
favorable HDL/LDL and light cholesterol: HDL ratios. Aerobic training reduces
resting blood pressure in hypertensive young persons, and this training effect is
evident in older hypertensive adults as well. Changes in body composition are
associated with aerobic exercise training in older populations. A modest yet
significant reduction in total percent body fat is generally observed with exercise
training in older adults, which can occur despite a maintained body weight. It is
important to note that in older men, a decrease in intra-abdominal fat accounts
for the greatest relative loss of fat mass. This finding is significant in that intraabdominal fat increases the most with advancing age and is associated with
cardiovascular disease. In addition to reducing heart disease risk, regular
exercise results in an increase in insulin sensitivity in older adults.

As insulin resistance increases with age, the positive effects of regular aerobic
exercise in older individuals on improving insulin sensitivity and increasing
glucose transporters in muscle are of clinical importance for the treatment and
prevention of adult-onset diabetes.

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Finally, because decreased bone density is more common among older adults,
evidence suggests that participation in regular exercise improves bone health
and thus reduces the risk for developing osteoporosis. Further, this can reduce
the incidence of breaks and fractures associated with falls.

Aging is a multi-faceted process in which a variety of factors interact (genetics,

lifestyle, disease) and frequently is associated with reduced functional capacity
and chronic illness. In addition, physical inactivity and maintenance of a
sedentary lifestyle represent a significant health risk to aging individuals. Older
adults can safely participate in regular exercise programs (aerobic and strength).
Regular physical activity has been shown to elicit a number of favorable
adaptations that contribute to healthy aging. Further, the trainability of older
individuals is evident from their ability to adapt and respond to both endurance
and strength training. Endurance training can help to maintain and improve
various aspects of cardiovascular function as measured by VO2 max, cardiac
output and a VO2 difference as well as enhance submaximal performance. It is
important to note that reductions in risk factors associated with disease states
(heart disease, diabetes) will improve health status and contribute to an increase
in lifespan. Strength training will help offset the loss in muscle mass and strength
typically associated with normal aging.

Additional benefits include improved bone health and thus reductions in risk for
osteoporosis; improved postural stability, reducing the risk of falling; and
increased flexibility and range of motion. Together, these benefits associated with
regular exercise and physical activity will contribute to a healthier, more
independent lifestyle, greatly improving functional capacity and quality of life for
the fastest-growing segment of our population.
Cardiorespiratory Fitness
Maximal oxygen consumption (VO2 max) is the most frequently used indicator of
overall cardiovascular function and maximum capacity. Consistent findings
indicate that VO2max decreases approximately five to 15 percent per decade
beginning at 25-30 years of age. This decline in VO2max can be attributed to
age-related reductions in both maximal cardiac output and maximal
arteriovenous oxygen (a-v O2) difference. Maximal heart rate decreases about
six to ten beats per minute per decade, and is responsible for much of the ageassociated decrease in maximal cardiac output. However, a reduction in stroke

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volume during maximal exercise in older adults also contributes to the decline in
cardiac output. In addition, left ventricular contractility appears to be reduced in
older adults during maximal exercise compared to young adults. Decreases in
vascular capacity and local blood flow regulation, along with a decline in muscle
oxidative capacity, contribute to the overall reduction in maximal a-v O2
difference observed with age. Coupled with poor oxygen delivery mechanisms,
mitochondrial alterations also lead to a reduction in maximal capacity to utilize
oxygen at the level of active skeletal muscle.

For a submaximal exercise bout, cardiac output is lower in older adults, while a-v
O2 difference tends to be somewhat higher in a compensatory response to
maintain VO2. A reduction in stroke volume appears to be the major factor
responsible for the lower cardiac output observed during submaximal exercise.
Blood pressures are also higher at both the same absolute and relative work
rates in older versus younger adults. Associated with the blood pressure
response, total peripheral resistance is generally higher in older versus young
adults for a given exercise intensity.
For improvements in cardiovascular fitness, the American College of Sports
Medicine recommends an exercise intensity of 55/65 to 90 percent of maximum
heart rate (or 40/50 to 80 percent of heart rate reserve). ACSM further
recommends accumulating 20-60 minutes at that level three to five days a week.
The lower ranges are for unfit or even frail individuals who are about to begin an
exercise program.

Before working out, warming up is critical in getting the body ready to exercise.
According to the AHA a good warm up dilates the blood vessels making sure that
the muscles are well supplied with oxygen. For ideal flexibility and efficiency a
warm up also raises the muscles temperature. Due to slowly raising the HR, a
warm up aids in minimizing stress that is put on the heart as well. AHA and
ACSM both recommend a longer warm up the higher the intensity of the activity
is. The activity that is being performed during the session should be mimicked at
a slower pace during the warm up.
A proper cool down is just as important as warming up. After exercising, the body
needs to lower the HR as well as body temperature back to pre-exercise values.
As you will see in APPENDIX-A, APPENDIX-B, APPENDIX-C the clients cool
down includes walking at a slower pace (1.7mph, HR < 100bpm) attempting to
get her HR and BP back to pre-exercise values.
According to ACSM guidelines, for older apparently healthy individuals a
frequency of 3-5 days/week, most if not all days of the week, is recommended.
For this client, the minimum of 3 days/week was prescribed. Intensity was

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prescribed by what she had already been walking at home for the past week.
She self-reported walking for 60 minutes at 2.8 mph with a 0% grade 3-5
days/week depending on her weekly schedule. To make sure the client could
walk at this intensity, exercise anchoring was implemented and resulted in a
steady state HR of 137 bpm, which was 75% of her HRR. At this time, as the
client was walking, an observation was made that the clients knee had been
inflamed. Once the anchoring had ceased, inspecting her knee and reasons why
this occurred was discussed. A clinical decision had been made that knee
strengthening exercises, specifically for her Vastus Medialis, needs to be
implemented into her resistance-training program. Due to this, a prescription was
made to initially start at 3 days/week at this intensity or as tolerate to client with
48 hours between each session for proper recovery. Progression was made to
week 4 by increasing 5% HRR every two weeks. By week 5, the option to work
not longer but smarter and more efficient was explained to her. She agreed that
working harder for less time than 60 minutes per session, with getting the same
benefits, would work better in her busy schedule. For this reason, an increase to
8% grade was made at 3.5 mph 4 days/week for 45 minutes instead. The client
requested to increase intensity quicker and days/week in order to see results
faster. The client was progressed then with this method to 45 minutes at 3.5 mph
and 11% 4 days/week by week 14. At this point the client self-reported hurting
her affected knee and stated that she is in contact with her physician for a knee
replacement. She mentioned that walking on the treadmill since this injury has
been aggravating. Due to this, for her 6-week exercise prescription, APPENDIXC, a step count of 10,000 steps/day was incorporated as a surrogate for her
treadmill work.
Resistance Training
Loss of muscle mass, sarcopenia, with age in humans is well documented. A
primary factor in sarcopenia is disuse of skeletal muscle, resulting in atrophy. A
reduction in muscle strength is directly associated with loss of muscle mass.
Inactivity may also play a role, contributing to other factors affecting aging muscle
mass, including: neuromuscular realignment, reduction in growth factors, and
changes in muscle protein turnover.

The consequences of sarcopenia can be extensive; individuals are more

susceptible to falls and fractures, impaired in ability to regulate body temperature,
slower in metabolism, possibly deficient in glucose regulation and may suffer an
overall loss in the ability to perform everyday tasks. Muscle atrophy appears to
result from a gradual loss of both muscle fiber size and number. A gradual loss in
muscle cross-sectional area is consistently found with advancing age; by age 50,
about ten percent of muscle area is gone. After 50 years of age, the rate of
accelerates significantly. Muscle strength declines by approximately 15 percent
per decade in the sixties and seventies and by about 30 percent thereafter.

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Although intrinsic muscle function is reduced with advancing age, age-related
decrease in muscle mass is responsible for almost all loss of strength in the older
adult. The number of functional motor units also declines with advancing age,
which requires surviving motor units to innervate a greater number of muscle
fibers.

Given an adequate training stimulus, older adults can make significant gains in
strength. A two- to threefold increase in strength can be accomplished in three to
four months in fibers recruited during training in older adults. With more
prolonged resistance training, even a modest increase in muscle size is possible.
Because sarcopenia and muscle weakness are so prevalent in the aging
population, it is important to devise strategies for preserving or increasing muscle
mass in the older adult. With increasing muscle strength come increased levels
of spontaneous activity in both healthy, independent older adults and very old
and frail men and women. Strength training, in addition to its possible effects on
insulin action, bone density, energy metabolism, and functional status, is also an
important way to increase levels of physical activity in the older adult.

As you will see in APPENDIX-A, APPENDIX-B, APPENDIX-C, a proper warm up

was prescribed and cool down that included walking at a slower pace (1.7mph,
HR < 100bpm) attempting to get her HR and BP back to pre-exercise values.

According to ACSM guidelines, an older apparently healthy adult is

recommended resistance training 2-3 days/week. Due to the client being
previously sedentary and without any resistance training experience, 1 day/week
was prescribed. Prescribed exercises that were to improve her exercise tests and
goals were arm curl, lateral raise, tricep extension, crunch, reverse crunch, and
side crunch. Upper body arm exercises were to be for 1 set, for 10-15 repetitions;
core exercises were to be for 1 set, 20 repetitions. These exercises were
demonstrated initially and then were made sure the client could perform them
with proper form to reduce injury and gain the most benefits. Refer to
APPENDIX-D for a handout describing proper form for the client to mimic at
home. During week 2, Vastus Medialis exercises were demonstrated to the client
to strength her affected knee. The lateral pointed foot leg raise and isometric
knee contractions were both performed. With the leg raise the client felt
discomfort in her knee to where it may not have been able to support the weight
of her leg. A clinical decision was made to prescribe the isometric knee
contractions and incorporate this into her comprehensive resistance-training
program. Starting week 6, the client self-reported wanting more sets and an
additional day/week of resistance training to see results quicker. Due to this, an

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increase to 2 sets/session for all exercises had implemented as well as an
increase in frequency to 2 days/week. She was to progress this to 3 days/week
by the end of week 14. By the end of week 14, the client self-reported due to her
being ill the past week and being injured she had not progressed to 3
sets/session. Due to this, for her 6-week exercise prescription (APPENDIX-C),
she was prescribed 2 sets/session and progressed by week 4 to 3 sets/session.
Goal Setting
Based on the pre-test the goals that were made included weight loss, arm and
core strength, and steps. Refer to TABLE-4 for initial goal worksheet.

A weight loss goal of 10lbs was made losing 1lb/week for 10 weeks. According to
ACSM, 5lbs is equivalent to 1 of waist circumference (WC); therefore, her goal
for WC for the 10 weeks was 2. It has been proven that for optimal weight loss,
exercise and nutrition need to be addressed together. Initially for adherence, a
250 kcal loss was prescribed and increased to 450kcal. The goal for exercise
was to walk continuously for 60 minutes at 2.8 mph for 3 days/week. A 10 week
goal was to progress to 60 minutes at 3.0 mph for 3 days/week. An arm and core
exercise goal was prescribed initially starting at 1 set for 1 day/week and was to
progress to 3 sets for 2 days/week. Initially a step goal was not prescribed due to
Metria Lifestyle patch unable to connect; therefore, a step count goal will be
calculated once steps are recorded by BodyMedia armband Week 1.
After the reassessment was performed and recorded new goals were prescribed
for the client. Refer to TABLE-5 for the post-assessment goal worksheet.

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A weight loss goal of 5lbs was made losing 1lb/week for 5 weeks. In addition, due
to 5lb and 1 equivalency, a 1 WC goal was also made. The client by this time
was not continuously tracking calories consumed and nutrition. Due to this and to
assure adherence, a decrease was made for her goal starting at a 200 kcal loss
progressing to 400 kcal. The client walking on the treadmill at this point for 60
minutes at a 0% grade 4 days/week. The option to work not longer but smarter
and more efficient was explained to her. She agreed that working harder for less
time, with getting the same benefits, would work better in her busy schedule. For
this reason, an increase to 8% grade was made at 3.5 mph 4 days/week for 45
minutes instead. The goal was to progress this to 45 minutes at 3.5 mph and
11% 4 days/week. An arm and core exercise goal was prescribed at this point at
2 sets for 2 days/week and was to progress to 3 sets for 2 days/week. The
BodyMedia armband gave a step average for each day. This average was carried
over the first initial 3 weeks and averaged ~ 5,000 steps/day. Due to this, a step
goal was then prescribed for 10,000 steps/day to reach by the end of the
program. An increase and increment of 20% was given per week in order to
progressively reach her goal of 10,000 steps/day. According to ACSM guidelines,
an increase of 10-20% duration per week or every other week is recommended.
Based on the post-test results, summer goals were implemented. The client
wanted to continue to lose weight and increase strength and endurance in her
shoulders. Refer to TABLE-6 for the post-test summer goal worksheet.

A weight loss goal of 6 lbs was made losing 1lb/week for 6 weeks. A goal to lose
at least 1 WC was also implemented. The client self-reported not eating as
healthy as she knew she should be at this point to where the prescription of a
200 kcal loss was still implemented. This progressed by week 6 to 400 kcal. The
client also self-reported that she hurt her knee to where she had to stop
exercising on the treadmill. Walking on the treadmill was exacerbating her knee
pain causing inflammation. Due to this, a step count goal was implemented and

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continued from her previous goal. She self-reported having the opportunity to
walk more now that the weather is getting warmer. From averaging her daily
steps at this point she was walking 10,000 steps most if not all days of the week.
The goal was to replace and incorporate at least 10,000 steps per day for her
treadmill work. With her arm and core exercise goal that was prescribed she selfreported that she has not progressed above 2 sets 2 days/week. Due to this, an
exercise goal was initiated for 2 sets 2 days/week progressing to 3 sets 2
days/week.
Patient Education
Due to the clients left chronic knee pain, pain management, with including
benefits of muscle strengthening, was the first initial patient education that was
discussed. Protect, rest, ice, compression, and elevate (PRICE) has proven to be
the best first line knee pain treatment following an injury or flare up of pain (4, 11,
15). The purpose is to reduce the internal bleeding and knee swelling to reduce
pain and enable fast healing. Protect aims towards preventing any further injury
to the joint. Once a body part is injured, protecting it temporarily can limit any
further injury and speed the recovery process. Protection may include limiting the
use of the knee, applying a splint, knee brace or bandage, or using crutches.
Rest allows healing by avoiding any aggravating activities. Without rest, continual
strain is placed on the area, which can lead to increased knee swelling, pain, and
possible further injury. There is also a risk of the area not healing properly if it is
not allowed to rest. Ice is used to reduce any knee swelling and pain that
develops. Ice applied for 10-15 minutes can help to reduce knee swelling and
pain. When the knee is damaged, you get bleeding into the joint and an increase
in the amount of synovial fluid. Compression includes pressure put on around the
joint which helps reduce knee swelling. This helps to reduce knee swelling and
provides some support to the joint. Although some swelling is inevitable, too
much results in excessive pain, difficulty moving the knee, and eventual slowing
of blood flow which slows healing. Elevation includes raising the leg, preferably
above the level of the heart reduces knee swelling. This can be done by having
leg raised supported on pillows which may be done during the day and also
overnight. Make sure there is some support underneath your knee, rather than
just under your foot otherwise the knee will get very stiff. Elevation can be used
for as long as swelling remains. Then benefits of muscle strengthening were
explained. Exercise is one of the best solutions you can do to help your knees.
Exercise helps maintain range of motion and strengthens the muscles that
support your knees. Stretching the muscles and tendons that surround the joint
also can help ease pain from some knee problems and reduce the risk of further
injuries. Vastus Medialis contraction procedure and form were then shown in
order for the client to mimic while exercising at home. Refer to APPENDIX-E for
the initial patient education handout.
When discussing ideas with the client about another patient education handout,
she mentioned wanting information on healthy snacks and foods for persons with

17
Prediabetes from the American Diabetes Association. Within the second patient
education, healthier snacks with less than 5g of carbohydrates were listed. The
client wanted a broader selection of healthier snacks to choose from on breaks at
work. The client also discussed wanting food categories that were healthier for
her and could use to incorporate into her and her families diet. Types of
superfoods were listed including certain types of beans, berries, citrus fruits, and
nuts (2). Refer to APPENDIX-F for the second patient education handout.
Since the client works at Carroll University and the semester has been coming to
an end, she has self-reported experiencing higher stress levels recently. Due to
this, the third patient education dealt with stress management. The client asked
to have not only stress management tips but also to have a correlation with how
it affects and is interrelated with having Prediabetes. Initially it was explained that
managing diabetes with exercise, diet, and sometimes medication usually keeps
blood sugar levels under control, but stress may cause blood sugar levels to rise
(6, 7, 18). Then a discussion on the link between stress and diabetes was
addressed. There had been proven two reasons why stress could lead to a spike
in blood sugar levels in individuals with diabetes. One reason is that individuals
under stress may stop taking care of their diabetes or health; they may neglect to
check their blood sugar levels, or they may stray from their diet and eat or drink
too much. A second reason is that stress increases the bodys demand for
energy. Then 6 ways to deal with stressed was incorporated including coping
strategies, positive thinking, and time management, balancing work and family,
communication, and breaking the cycle. Refer to APPENDIX-G for the final
patient education handout.
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