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Covering All Bases: Working With New Clients

Franke, Warren D. Ph.D., FACSM

ACSM'S Health & Fitness Journal: March/April 2005 - Volume 9 - Issue 2 - pp 13-17
Features: CEC Self-Test

Learning Objective: To learn about the five critical components of developing an exercise program.

An introduction to an easy-to-use guide that ensures personal trainers have not overlooked critical steps when developing an exercise program, especially for a new client.

Warren Franke, Ph.D., FACSM, is an associate professor of exercise physiology in the Department of Health and Human Performance at Iowa State University. He is ACSM Program DirectorSM certified, and is the director of The Exercise Clinic at ISU, an on-campus adult fitness program. His research focuses upon blood pressure regulation and mechanisms underlying cardiovascular diseases in the law enforcement profession.

When working with a client, especially a new client, many issues need to be considered by the fitness instructor or personal trainer. It is important to determine what exercises and exercise equipment are most appropriate for and available to the client. Most trainers devote considerable energy to ensuring that these decisions are made in the best interests of the client. However, when developing an exercise program, a trainer's concerns should extend far beyond these decisions, and, unfortunately, these other concerns are often overlooked. For example, does the client have any medical conditions that would affect how, or even if, an exercise program should be developed? Are there any significant cardiovascular risk factors present? What are the client's goals? What is the best way to achieve these goals? Are other experts, such as a Registered Dietitian, needed to assist the client in reaching these goals?

A number of excellent references, most notably ACSM's Guidelines for Exercise Testing and Prescription (1) and the companion Resource Manual (2), can be used to determine how best to address these concerns. Unfortunately, in a busy fitness center where new members are joining every day, it is relatively easy to forget to consider all these issues with every client. Moreover, remembering all of the details associated with working with a client can be overwhelming if someone is still learning the art and science of personal training. Nevertheless, these details should not be overlooked, because doing so is not in the best interests of either the client or the personal trainer. Consequently, the purpose of this article is to introduce a guide, MR IPL, that will serve as a blueprint for less experienced fitness professionals to remember the important issues to be considered when developing a program for a new client.

MR IPL is an acronym of the five important areas to consider when working with a client and the order in which to do so (Table):

* M: Medical history

* R: Risk factor assessment

* I: Interpreting the data

* P: Prescribing the exercise

* L: Lifestyle counseling

In practice, the pre-participation health screening represented by "M" and "R" are intertwined. They are separated here to emphasize that each provides unique information to the personal trainer. In the acronym, they are separated from "IPL" to emphasize that they need to be addressed before completing the latter three areas. With pre-participation screening, an important first step when working with a new client is risk stratification. Risk stratification means that you screen the client well enough to decide whether a) it is appropriate for you to work with that client in your facility, b) the client should be referred elsewhere for further medical evaluation prior to starting an exercise program, c) the client is better served in a more medically supervised program, or d) the client should not exercise (1, 2). Besides the health status of the client, factors influencing this decision are your education and experience with this type of client, unique facility characteristics, such as the training of other personnel in your facility, the emergency procedures in place, and the clientele for which the facility is designed (3). For example, most personal trainers recognize that a fitness center catering to bodybuilders is not the most appropriate facility for a 75-year-old man who underwent coronary artery bypass graft surgery, just completed a hospital-based cardiac rehabilitation program, and is now looking for a facility to continue exercising. However, would a more typical fitness center be appropriate for this man's wife, who is similarly aged, has not been diagnosed with heart disease, but has multiple cardiac risk factors? Completing the components outlined in "M" and "R" will ensure that you risk stratify this couple and ultimately make correct decisions regarding what to do with them.

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The "M" in MR IPL prompts you to investigate a client's medical history and provides guidance on how to do so. A simple but effective tool for evaluating the health status of a new client is the Physical Activity Readiness Questionnaire, or PAR-Q (1, 2). Alternative screening tools can be found in these references and elsewhere (3). The "R" guides you in completing the pre-participation screening by prompting a review of the client's cardiovascular disease risk factors (1, 2). A useful tool in determining a client's overall risk is the Framingham algorithm (4). An advantage of the algorithm is that it enables you to quantify the relative severity of individual risk factors. For example, how much more does a total cholesterol of 240 mg/dl contribute to heart disease risk compared with a value of 220 mg/dl? In addition, the score derived from the algorithm provides you with insight into the relative risk of your client compared with other people of a similar age and gender. A disadvantage of the algorithm is its dependence upon selected risk factors, that is, age, total cholesterol, HDL cholesterol, blood pressure, smoking status, and diabetes status (4).

Many personal trainers perform fitness assessments on their clients. This assessment is the last step in "M." In other words, you should not perform a fitness assessment until after you have risk stratified the client and determined that it is appropriate for you to work with him or her. After your client has completed the fitness assessment, focus on "I," or interpreting the data. Note that the first two components of "I" (Table 1) prompt you to review the fitness assessment for thoroughness and, if you did not administer the assessment yourself, remind you to consider the quality of the assessment. These two steps are important but easy to ignore. For example, suppose you have a client who lost 20 lbs after exercising for 3 months. Based upon the skinfold measurements done during fitness assessments performed before and after this 3-month period, his body composition did not change. You know he has lost body fat, but you do not know why it is not apparent in his body composition assessment. The skinfold technique for assessing body composition is fairly accurate when performed by a skilled technician but can be woefully inaccurate when performed poorly, for example, when incorrect skinfold sites or an inappropriate pinch technique is used. In this case, two different technicians may have performed the two fitness assessments, with the second assessment performed by the less skilled technician. Thus your client's body composition likely changed, but, because of measurement error, it was not detected during the assessment. Taking the time to consider whether the assessment was done well, that is, the first two components of "I," led you to determine this.

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The second two components of "I" guide you in using the client's assessment results to develop the exercise prescription. First, compare your client's results with age- and gender-specific normative data. Doing so makes it easier to evaluate the relative fitness of your client, to explain these results to the client, and to determine what fitness components need to be prioritized with the exercise prescription. For example, in performing a fitness assessment on a 45-year-old man, you determine that he weighs 242 lbs, has a body composition of 29% body fat, and has a maximal bench press of 225 lbs. When discussing his goals, he states that he "wants to get in better shape" and "look more toned." Professional experience tells you that his upper body strength is good, but 29% body fat is too high. The latter also increases his risk for several chronic diseases, such as diabetes and heart disease. Thus you think that your client should, at least initially, focus upon reducing his body fat rather than toning up, or weightlifting. How do you convince your client to modify his fitness goals? Normative data will help. From Table 4-7 of the Guidelines (1), you see that his maximum bench press/body weight ratio of 0.93 (i.e., 0.93 = 225 pounds on the bench press/242 lbs body weight) places him in the 70th percentile or "above average" category compared with other men his age. Table 4-3 of the Guidelines (1) indicates that 29% body fat is in the 10th percentile or "well below average." Thus, you can tell him that he is stronger than 70% of his peers but leaner than only 10% of them. Percentage body fat and bench press/body weight ratio are esoteric terms to him. However, with these peer comparisons, he can readily comprehend that his body composition is relatively worse than his upper body strength. Thus the use of normative data makes it easier for you to evaluate the results of the fitness assessment, correctly prioritize the exercise prescription, and educate your client about these results.

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As you can see, using norms makes it easier for you to begin working on "P," or prescribing the exercise. Norms enable you to determine what the client needs to work on. However, it is critical that you determine what your client wants to work on, or his or her goals, both in terms of exercise and overall health. This assessment is the first component of "P." The second component of "P" entails weighing these "needs" versus these "wants" and finding an acceptable middle ground between the two. The third component provides reminders of what should be included in well-developed exercise prescriptions that address the most common client goals. These goals are improving cardiovascular fitness, losing weight, and developing muscular fitness. The expertise needed to develop these exercise prescriptions is far outside the scope of MR IPL. However, good starting points for developing this expertise are the references (1, 2), attending ACSM's Health & Fitness Summit & Exposition, or attending a Health/Fitness Instructor's Workshop. In other words, MR IPL prompts you to remember the important aspects of a complete exercise prescription, but it remains up to you to develop the prescription.

Finally, the last component of MR IPL, "L" or lifestyle counseling, reminds you that an exercise prescription should be more holistic than simply providing an exercise program and that adopting this prescription requires changes in the client's behaviors. Unfortunately, it is not uncommon for both clients and personal trainers to focus largely on just an exercise program. The "L" components help guide you in developing a more global wellness prescription while remembering the unique needs of the client. These needs may include considering the unique needs of a beginning versus a long-term exerciser as well as steps to improve the client's overall health. For example, beginning exercisers are much more likely to drop out from a program; consequently, the nature and extent of your personal training interactions will likely differ between a beginner and an experienced exerciser. In addition, helping the client improve his or her health may entail referral to a specialist, such as a Registered Dietitian. As with "P," blending these different aspects together into a coherent, cohesive program depends upon your professional expertise.

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In some ways, being a health/fitness professional is analogous to being a professional carpenter. All carpenters have toolboxes, but the toolbox of a more experienced carpenter is likely better equipped than that of a beginner. As health/fitness professionals become more skilled and more knowledgeable, they add "tools" to their professional "toolbox." For example, one tool that an entry-level personal trainer should have is the ability to recognize the major risk factors for cardiovascular disease. A more experienced personal trainer would have this tool as well as other tools related to how to modify these risk factors. As with professional carpenters, a personal trainer's "toolbox" can become cluttered and disorganized; it then becomes difficult to find the right tool when it is needed. The guide presented in this article, the MR IPL acronym, will not replace the professional expertise and judgment, or tools, needed when working with a client. However, it should make it easier to keep a professional toolbox organized by enabling the fitness professional to remember what and when particular "tools" are needed.

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Thanks to Debra J. Atkinson, M.S., and Stuart M.C. Lee, M.S., for critiquing an earlier version of this manuscript.

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Condensed Version and Bottom Line

An exercise prescription should encompass more than just instruction for participation in an exercise program; it should include a plan to improve the client's overall health through reducing his or her risk for developing chronic diseases. Thus, when working with a client, a personal trainer should begin with pre-participation screening, pay due attention to relevant fitness assessment data, and consider lifestyle changes associated with adopting a program of regular exercise. Remembering and adhering to the MR IPL acronym (medical history, risk factor assessment, interpreting the data, prescribing the exercise, and lifestyle counseling) will ensure that all critical aspects of developing an exercise program have been considered.

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1. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. Franklin, B.A., M.H. Whaley, and E.T. Howley (Editors). New York: Lippincott Williams & Wilkins, 2000.
2. Gordon, N. Preparticipation health appraisal in the nonmedical setting. ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription. Roitman, J.L., M. Herridge, M. Kelsey, et al. (Editors). New York: Lippincott Williams & Wilkins, 2001.
3. Balady, G.J., B. Chaitman, D. Driscoll, et al. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Medicine & Science in Sports & Exercise® 30:1009-1018, 1998.
4. Grundy, S.M., Pasternak R., Greenland, et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: A statement for healthcare professional from the American Heart Association and the American College of Cardiology. Circulation 100:1481-1492, 1999.

Pre-Participation Screening; Risk Factors; Exercise Prescription; Cardiovascular Diseases; Fitness Assessment

© 2005 American College of Sports Medicine