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Hinojosa, Jeramie R. M.S., HFI

doi: 10.1249/FIT.0b013e31818453c9

LEARNING OBJECTIVE • To provide a case study for the development and implementation of a successful, safe, and effective medically supervised exercise program in a medical fitness center.

Medically supervised exercise is a growing need for older adults. Learn how to develop and implement a successful, safe, and effective medically supervised exercise program in a medical fitness center.

Jeramie R. Hinojosa, M.S., HFI, is the director of the East Texas Medical Center Olympic Centers. East Texas Medical Center operates eight medically integrated fitness centers throughout the East Texas region, serving more than 7,500 members.

According to the U.S. Social Security Administration, 78 million baby boomers will begin retiring in 2008 (1). In approximately 30 years, there will be twice as many older Americans as there are today, in part, because of advances in medical technology, improvements in health care, and public education.

Clinical research consistently suggests the overwhelming benefits of physical activity in the prevention and treatment of a variety of health conditions (2,3,4). This knowledge continues to drive more and more older individuals to become physically active and some to participate in structured exercise programs. Building on the theme of Exercise is Medicine, the American College of Sports Medicine (ACSM), in partnership with the American Medical Association, recently launched a campaign to encourage physicians to prescribe exercise to all patients at every visit. This initiative provides a platform for health care providers to become more involved in the promotion of physical activity that will be especially beneficial to aging baby boomers.

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Traditional fitness centers typically cater to a younger and more independent population. These facilities often offer minimal assessments and minimal assistance in exercise program setup, progression, guidance, and equipment orientation/instruction. A basic orientation may be provided, and new members can receive additional instruction through the purchase of personal training services. Some of these centers may only address senior fitness needs in a group setting.

The group approach is frequently not sufficient for many older and debilitated individuals who have a variety of physical and psychosocial issues and require an individualized exercise program. Such individuals require more time and effort to be appropriately introduced to basic exercise principles specific to their condition(s) and to be taught how to safely use equipment that will be a part of their exercise program.

Photo courtesy of Jeramie R

Photo courtesy of Jeramie R

Medical fitness centers have grown rapidly in response to the demand of the older exerciser who seeks a safe nonthreatening environment in which to improve their health and fitness. According to the Medical Fitness Association, the number of medical fitness centers has grown from 79 centers in 1985 to 950 in 2008. The number of members served has grown to more than 3.3 million and is projected to reach nearly 4 million by 2010 (5). The average age of members reported by medical fitness centers in 2008 is 49.2, compared with 47.1 in 2006. As life spans continue to increase and medical technology and knowledge grow, there continues to be a growing need to accommodate the very old and the more debilitated individual. Some may be unable to exercise independently and/or may be transitioning from clinical therapy services, whereas others may need additional time to acclimate to exercising in a health and fitness center.

Medical fitness centers are staffed by trained and certified professionals who provide appropriate individualized programming and accommodate those members who need assistance with exercise routines and equipment setup. However, some members may derive additional benefit from more structured programs that provide enhanced supervision to maximize the safety and effectiveness of the exercise regimen.

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The Healthy Pursuits program at East Texas Medical Center (ETMC) Olympic Center began in 1998 and was designed to provide a structured and supervised exercise program for individuals for whom regular membership may not be safe or appropriate. The ETMC participants have a variety of diagnoses including but not limited to heart disease, chronic obstructive pulmonary disease, diabetes, obesity, neuropathy, arthritis, cancer, osteoporosis, Alzheimer, and dementia. Others may have no preexisting conditions but find the fitness environment threatening and desire a supervised approach when starting an exercise program but cannot afford ongoing personal training. The supervised setting can break down the fear barrier and allow people with disabilities and/or chronic disease to slowly transfer to an independent exercise program.

Photo courtesy of Jeramie R

Photo courtesy of Jeramie R

Participants are not considered members of the center; rather, they are considered health enhancement participants and, as such, are not bound by a membership contract or agreement. They can begin or end the program at any time and as often as needed because of illness or as their condition changes. Because of the nature of the program, the monthly fee is higher than the monthly membership fee, and no enrollment fees are required. The only stipulation is that participants may only come to the center during class times.

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Many program participants are referred to ETMC from areas of our hospital such as cardiac rehabilitation and outpatient physical or occupational therapy. An integrated medical fitness center serves as an excellent referral base for a supervised exercise program because participants may already be familiar with staff and the equipment to be used. The integrated design allows therapists to easily communicate with exercise specialists regarding the specific needs or precautions of referred participants. Therapists complete a transfer form that includes information such as diagnosis, treatment goals and attainment, and details on exercise and equipment usage during the rehab treatment period. The exercise specialists use this information to create an individualized and effective exercise program for the participant.

Other potential participants may present themselves for membership at the center and are identified in the screening process as most appropriate for the Healthy Pursuits program. We require that each participant be able to independently move from one piece of equipment to the next without assistance and that he/she receive medical clearance from a physician to participate in a supervised exercise program.

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The Healthy Pursuits program meets three times per week on Tuesday, Thursday, and Friday for approximately 1 hour. Our center is not as busy on these days, allowing for decreased congestion and confusion between participants, facility members, and shared equipment. Class size is limited to 12 participants with a 1:6 staff-participant ratio to ensure adequate supervision and to allow for a backup individual should an emergency occur.

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Staffing Requirements

It is imperative that staff involved in this type of program have a thorough knowledge of the exercise responses associated with a variety of medical conditions. Our program is staffed by degreed exercise specialists from our fitness center and a registered nurse from the cardiac rehabilitation department. Exercise specialists with a minimum of a Bachelor's degree in Exercise Science, Kinesiology, or another related field are highly recommended. Staff also should possess a nationally recognized professional fitness certification, preferably the ACSM Health/Fitness Instructor® or ACSM Exercise Specialist®. All staff must hold cardiopulmonary resuscitation and automated external defibrillator certification.

The ETMC Olympic Center is privileged to have a registered nurse assist with the program because this adds an additional level of comfort for the staff and participants. In a truly integrated center, having a registered nurse in proximity, even if not directly involved, is beneficial. In addition, having a facility located on or near a medical campus also allows for quick access to emergency services if needed.

It is important that staff members possess exceptional interpersonal skills such as patience, compassion, and active listening. Participants in a program of this nature will require extra time and effort, and your program will not succeed if staff are not customer service oriented.

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The Exercise Session

Participants gather shortly before the class time, and preexercise heart rate and blood pressure are checked and recorded. After a brief warm-up of stretching and range-of-motion exercise, participants are given a weekly exercise card and, with the assistance of our staff, begin a strength training or cardio training routine. Staff specifies seat, pad, and weight settings on selectorized machines and assists with speed, incline, or resistance settings on cardio equipment. The staff circulates among the participants, checking exercise heart rates on each cardio modality, and monitors the exercise response. After the exercise session, participants walk the track to cool down and then have postexercise heart rate and blood pressure recorded.

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Exercise programs are developed by assessment of a participant's medical history and current functional level. Periodic assessment of fitness and functional levels are assessed using a variety of age-appropriate health and fitness tests such as resting heart rate, blood pressure, and the 6-minute walk test.

Each week, exercise specialists review the participant's exercise log that includes heart rate, rate of perceived exersion, and subjective comments from each exercise session and make appropriate changes when indicated. Emphasis is placed on progressing participants from nonweight-bearing equipment such as arm ergometers or seated steppers to weight-bearing equipment such as ellipticals and treadmills. The goal is to gradually increase the exercise stimulus so that gains are achieved in strength and endurance.

Throughout the program, emphasis also is placed on progressing participants to independent exercise and, optimally, fitness center membership. This is achieved by gradually encouraging independent equipment setup and exercise program performance. Once this goal is achieved, if desired, the participant may transfer to a regular fitness center membership and independent exercise program. The membership enrollment fee is waived for these individuals as an additional incentive.

It is important to discuss changes in health conditions with participants during each visit to the center. This will ensure that the exercise program is modified accordingly. Attendance may be irregular at times because of medical issues. We have placed a number of participants "on hold" because of hospitalizations or lengthy illnesses. Upon returning, participants are reevaluated, and their exercise program is adjusted based on their current condition. Regardless, participants should be encouraged to constantly improve their fitness level in an effort to decrease their risk of disease.

Many program participants may never be candidates for membership or an independent exercise program. Also, many, who might be able, will not wish to do so because they enjoy the accountability and safety aspect of a structured program. Forcing a participant to join can result in the loss of that customer and the health benefit of exercise for that individual.

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An important program consideration is the type of equipment in your center, its availability and location. Because of the variety of preexisting conditions of many participants, some non-weight-bearing equipment will be necessary. Arm ergometers, recumbent cycles, and seated steppers are most commonly used in our program. Many manufacturers are now producing more accessible equipment such as steppers with swivel seats, step-through recumbent bikes, and equipment with removable seats for the wheelchair bound. Strength equipment with easy to adjust seats, pads, and weights are a must for building confidence and independence during exercise sessions.

Participants should be able to easily identify equipment, especially selectorized strength equipment. We place large vinyl numbers on the equipment and list these numbers on the participant's exercise card. It often is easier for these individuals to relate to the "number" of a machine rather than a machine or movement name such as "lat pull down."

Equipment proximity also is a concern. We have arranged the equipment to be in proximity to each other for easy transition that limits excessive trips across the fitness floor. This allows staff to easily monitor participants.

The staff prefers to use equipment with integrated heart rate sensors to monitor participant heart rates. However, this does not provide an accurate heart rate assessment for some, so we also use a pulse oximeter, stethoscope, and manual palpation.

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Rome wasn't built in a day, and neither was our program. Originally, it was offered twice per day, once in the morning and once in the afternoon, and participants arrived at a designated time. As the program grew in popularity, we added another class in the morning for a total of three classes. Over time, we began to realize that many participants were more debilitated than others and needed more assistance with equipment setup. Tasks such as adjusting a seat or weight setting on a selectorized machine were difficult tasks for these individuals, and the staff found they weren't able to monitor all the individuals because time was spent with the few who needed more assistance. As a result, we decided to stratify members according to their dependence on staff assistance during exercise.

Therefore, one class was designated for participants with the lowest functional level who were unable to make any adjustments on equipment, particularly the selectorized strength equipment. In addition, it was decided that administering the strength training regimen in a group setting would be most beneficial for these individuals. After warming up, these clients participate in an instructor-led strength training session using dumbbells and ankle weights. This minimizes the staff requirement and allows low-functioning individuals to participate. After the strength training routine, the participants progress to their cardiovascular exercise routine similar to other class formats.

The remaining two classes were stratified into a session with participants who required moderate assistance with equipment setup and a session with participants who required minimal assistance. This allows adjustment of staffing levels as needed and provides an environment to easily transition participants into a facility membership when necessary.

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Medically integrated health and fitness centers must have a systematic process in place to continuously assess and improve all aspects of health and fitness delivery, including but not limited to individual user outcomes, clinical and nonclinical programs/services, and operational/business processes. In terms of outcomes, data indicate that after 6 weeks of exercise in the Healthy Pursuits program, both systolic blood pressure and diastolic blood pressure have decreased an average of 6 and 4 mmHg, respectively, per person, and resting heart rate has decreased an average of 7 beats per minute per person. Changes in weight have varied among participants, depending on an individual's goal of weight reduction or the need to increase lean tissue.

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In its present format, the Healthy Pursuits program addresses the physical activity needs of individuals with a wide variety of functional levels. The varying classes provide for a natural progression to independent exercise as participants look forward to moving from one class to another as their fitness improves. As this population continues to grow, ETMC will adapt the program as necessary to meet the needs of these individuals.

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A supervised exercise program is a beneficial service that can meet the fitness needs of an aging and medically complicated population. Program success requires adequate resources that include a well-trained and knowledgeable staff, appropriate exercise equipment, and effective referral sources.

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1. U.S. Social Security Administration. The Future of Social Security: SSA Publication No. 05-10055, May 2007, ICN 462560.
2. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Rockville: U.S. Department of Health and Human Services, Office of the Surgeon General, 1996.
3. Thompson, P.D., D. Buchner, and I.L. Piña. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Circulation 107:3109-3116, 2003.
4. American College of Sports Medicine. Position Stand: Exercise and Physical Activity for Older Adults. Indianapolis: ACSM, 1998.
5. Medical Fitness Association. Benchmarks for Success 2008. Richmond: Medical Fitness Association. 2008.

Older Adult; Program Development; Exercise Monitoring; Referrals; Fitness Programming

© 2008 American College of Sports Medicine