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1.

The purpose of this lab was to gain empathy and assess physiological and
hemodynamic responses to physical activity with response to weight gain. Variables that were
assessed are as follows: Heart rate, blood pressure, rate of perceived exertion (RPE), and
dyspnea. Changes in time, distance and biomechanical adaptations were also examined and
compared between the three weight conditions (normal, overweight, obese).
General observations were made regarding heart rate and blood pressure responses for
each variable and increasing weight condition. Heart rate responses increased from normal
weight to both overweight and/or obese conditions. Blood pressure responses did not increase
as expected with the increasing weight for all of the subjects. The typical blood pressure
response with exercise would be a 8-10 mmHg increase for every 1 MET. Blood pressure and
heart rate should have increased because the added weight requires a larger cardiac output. It
would be expected for the subjects heart rate to increase with the increased weight. Heart rate
response should increase 8-12 beats/minute/1 MET. Some heart rate and blood pressure
responses decreased from overweight to obese conditions; this could have happened because
of adaptations made by the subjects. These adaptations could include: postural and gait
changes, as well as, physiological adaptations to increased weight to help the body compensate
for increased weight. Subject two reported having a seizure disorder which affected her blood
pressure responses while exercising. Subject one is a high fit individual which was seen by the
subjects blood pressure response between overweight and obese conditions. Along with an
increase in blood pressure came a greater rating of perceived exertion.
RPE ratings were greatest during obese conditions. The greatest RPE was seen during
aerobic and ambulatory activity. This is important to note because exercises requiring a greater
physical demand will evoke a greater RPE response from the subjects. Considering the
subjects RPE and heart rate during workloads was used to most accurately assess how hard
the individual was working for that condition. Similarly, dyspnea follows the same trend as RPE.
Aerobic and ambulatory activities had the highest dyspnea rating. Seated exercises with a
backrest had the lowest dyspnea ratings for aerobic activities. Seated exercises reduce some of
the strain and pressure applied to legs during ambulatory activities. Cycle ergometry for two of
the subjects had similar dyspnea ratings as treadmill walking. This could be due to that form of
exercise being uncomfortable for obese patients. Cycling caused back pain and forced the hips
and knees to abduct because of the excess abdominal tissue.
Overall, based on the three subjects and their reported values and signs and symptoms;
obesity will affect everyone differently. Exercise prescriptions will vary for each patient based on
musculoskeletal, psychological, and previous physical activity status. As exercise physiologists,
this obesity empathy lab will allow clinicians to prescribe tailored and effective exercise
programs, taking into account patient considerations.
Weight gain is associated with an increase in cardiovascular risk factors. This includes
higher blood pressure, increased vascular resistance, and increased lipid profiles (16). Weight
gain contributes to increased complications through hormonal, metabolic, and mechanical
stress changes (11). Increased adipose tissue slows the rate of blood flow. Patients with a lot of
adiposity will have a resting blood flow of approximately 20 mL/minute per 100 grams;
compared to lean patients with more skeletal muscle who have a resting blood flow of 50-75

mL/minute per 100 grams. With an increase of adipose tissue there is an increase in fluid in the
interstitial spaces (20). This excess fluid exerts an external pressure on blood vessels creating
an increased force blood has to be pumped against. As a result of decreased blood flow and
increased vessel pressure, cardiac output increases. Obesity is related to hemodynamic
overload. Increased metabolic demand by the tissues results in the need for increased
circulation and blood volume. Left ventricular afterload is elevated in obese patients due to
increased peripheral resistance and arterial stiffness (25,20). Resting heart rate will also be
elevated in patients with greater mass because of the increased metabolic demand.
Subsequently, heart rate and stroke volume will increase in obese subjects in order to meet
demands. There is an increased left ventricular end diastolic volume because of an increased
preload reserve, known as the Frank-Starling principle (25). The increased mass can also
create a strain on the lungs which will affect breathing. Patients will have an increased
respiration rate at lower intensity exercises because the body is in need of more oxygen.
At any given intensity of physical activity, cardiac workload is greater for obese patients
compared to normal or overweight patients. During exercise it is not uncommon for obese
patients to increase their ejection fraction. Since the amount of blood being pumped out during
exertion is not changing with the increased demands, the heart will have to beat faster to help
push out the blood needed. With an increased peripheral vascular resistance and added weight
from adipose tissue, more pressure is required to transport the blood to the tissues. A weight
gain of 10 lbs can increase systolic blood pressure 5-10 mmHg and diastolic pressure 3-5
mmHg (12,23). Weight gain that is centralized around the abdomen is related to a greater
increase in blood pressure, both at rest and during exercise. Overweight and obese patients
show an increased hemodynamic with steady exercise compared to normal weight patients.
This could be attributed to alterations in autonomic activity (21).
When assessing the data for heart rate responses with increasing weight, similar trends
are seen between each subject. For cardiorespiratory exercises, such as: treadmill walking,
cycle ergometry, nustep, and stairs. The trend in heart rate response was linear. As subjects
increased weight, heart rate increased as well. Subject one and two did not see increases in
their heart rates on the nustep. However, their blood pressure response increased significantly
more compared to subject three. Subject three was the only participant to see an increase in
heart rate in relationship to an increase in weight. Subject twos blood pressure does not
respond normally to exercise due to her seizures. For the subjects who did not have an increase
in heart rate and blood pressure as expected with increasing weight, they might have had a
decreased sympathetic activation reaction to the weight. Also, the subjects were apparently
healthy, so the transition periods between testing variables may have been significant enough
for their hemodynamic measures to recover closer to baseline. This could be significant
because normal weight subjects will typically have a decreased resting heart rate and blood
pressure compared to age matched obese subjects. Knowing this could affect some of the
results during exertion when heart rate and blood pressure did not increase much from
overweight to obese conditions.
Obese patients typically have an increased sympathetic activation which may be linked
to hypertension and other cardiovascular complications. Normal muscle sympathetic activity in
this study for the control subjects was 18.7 bursts/minute. Obese subjects had muscle
sympathetic activity of 38.6 bursts/minute (14,22). When comparing muscle sympathetic nerve

activity, blood pressure, blood flow, and obesity; obesity is the driving factor that affects the
other variables. Weight gain increases sympathetic nerve activity and vascular resistance which
leads to reduced blood flow to the muscles (22). When exercising, patients with excess weight
have to overcome a steady ejection fraction and increased vascular resistance. Heart rate has
to increase more in obese patients to compensate for the decreased change in ejection fraction
in order to increase cardiac output to sustain the given workload. Blood pressure increases to
overcome the added vascular resistance and increased external pressure due to the excess
adipose tissue and interstitial fluids. This empathy lab showed that an increase in blood
pressure was correlated with an increased dyspnea rating during exertion or functional
activities.
Weight gain can cause respiratory complications that include: augmented demand for
ventilation, elevated workload of breathing, respiratory muscle inefficiency, and reduced
respiratory compliance. Total respiratory compliance in obese individuals is reduced by as much
as two-thirds compared to normal patients. This is due to a decrease in chest wall compliance
because of the increased adipose tissue around the ribs, diaphragm, and abdomen. Inefficiency
of the respiratory muscles can also contribute to difficulty breathing in obese patients (13). The
increased breathing difficulty can lead to a subjects higher rating of perceived exertion. Patients
with increased adipose tissue, which is centrally located, have an increased airway resistance.
This is shown by decreases in forced expiratory volume in one second (FEV1) and exhaled vital
capacity. Maximal voluntary ventilation (MVV) is reduced between 20-45% in individuals with
centralized adiposity. The subjects reported the highest dyspnea values with the highest RPE
values. Dyspnea could have had a direct effect on how hard the subjects perceived themselves
working. Rapid, shallow, and labored breathing is observed in obese patients because of a
length-tension relationship disadvantage for the diaphragm (5). This becomes worse when
these patients exercise. The ratio carbon monoxide diffusion capacity to alveolar volume
increases with weight gain. Respiratory rates will be elevated to help offset the increased ratio
(18,13).
Another factor for dyspnea during exercise is body posture. Increased central adiposity
makes breathing more difficult because of the reasons previously stated. Exercising in a flexion
position makes breathing even more difficult because the lungs and diaphragm are further
collapsed and unable to expand (2,5). All three subjects reported their highest dyspnea ratings
performing aerobic activity and during ambulatory exercises like stairs or squats. When
examining their posture on film, they started in a neutral posture; and with increasing weight
they slowing moved into flexion. All three subjects reported their highest dyspnea value during
treadmill walking. Subject three reported feeling hunched over during treadmill walking. Subject
threes gait analysis video confirmed an increase in flexion of approximately 10. Subject one
wore the central adiposity suit and he reported having to readjust his arm position and lean
forward. When examining subject ones gait analysis this participant had internal shoulder
rotation with arms laterally extended from their side. A forward flexion was also observed in
subject one of approximately 5-10. Postural changes with increased weight can also affect
RPE ratings. The extra weight caused subjects to perform physical activities in compromised
biomechanical positions which created more strain with breathing which caused an increased
RPE response.

Increased body mass requires greater metabolic demand which directly affects
ventilation during exercise. Weight gain directly affects oxygen uptake at rest and during
exercise. At rest, VO2 is 25% greater in obese patients compared to non-obese patients, and
peak oxygen uptake is reduced. The sense of dyspnea in obese patients may be from an
increased breathing work rate to overcome decreases in pulmonary compliance and resistance,
airway obstruction, respiratory muscle weakness, and/or fatigue (18,5). An increased effort of
breathing was correlated a higher rating of perceived exertion.
Variables that affect rating of perceived exertion include: physical strain, dyspnea, pain,
discomfort, and improper anchoring (6). The rating of perceived exertion (RPE) scale was
developed to subjectively measure a patients exercise intensity and to help monitor during
exercise. However, there can be a social, interpersonal, and psychological dimension
associated with RPE during exercise (30). Subjects two and three performed stairs at the same
time, subject one performed stairs alone. Both subjects two and three reported significantly
higher RPEs compared to subject one. This could be due to a psychological component.
Subject three might have thought that since subject two reported an RPE of 14 then subject
threes RPE had to be 14 as well. Whereas, subject one did not have any external influences on
their RPE. Similar trends are seen between subjects two and three for treadmill, nustep, crunch,
and oblique crunch. Similarly, subject one performed those tasks alone and the subjects selfreported RPE shows that. The greatest self-reported RPE was observed when the subjects
reported pain or physical strain that altered their normal biomechanics. These findings with
greatest observed RPE also correlate with greatest dyspnea rating. Each subject subjectively
reported their greatest RPE and dyspnea on the treadmill. This is also where the most
observations were made on gait and postural changes. The subjects reported altered gait
strides, feet deviations, medial heel whips, back flexion, and increased pressure on knees.
Improper anchoring is a reliability issue when assessing RPE. Subject two reported a sit
and reach RPE of 13 and eight repetitions of squats as 13, both with an added 80 lbs. Subject
two also reported balancing exercises with a RPE of 6. Subject one initially reported RPEs of 6
for squats and stairs. RPE was anchored for that subject so a RPE of 6 was at rest, seated or
supine, with no exertion. After RPE was anchored for the subject that individual was able to
anchor more realistically according to the observed heart rate and blood pressure responses.
Anchoring one subject and not the other allows for comparisons to be made between selfreported RPEs. Subject two may have underreported RPE values for less exertional activities
and over reported RPE values for strenuous activities. Subject one showed more consistency in
their RPE reporting which would suggest a better understanding of RPE anchoring.
Another difference in RPE can be attributed to training status. Based on a preassessment self-reported amounts of training, subject one had the highest training status
compared to subjects two and three. This is noticeable in the squats and stairs RPE. Subject
one had significantly lower RPEs compared to subjects two and three. The lower report of RPE
could be due to increased quadriceps endurance, better ventilation, less pain, and better
biomechanics.

2.
When assessing the cardiorespiratory fitness exercises, the greatest mechanical
changes were noted; compared to resistance, flexibility, balance, and functional assessments
among the three testing conditions. Each table represents biomechanical changes between the
three major joint angles utilized during the movement. The tables are organized according to
activity type. Biomechanical analysis is based off of subject 3. Joint angle was analyzed via
Coaches Eye.
Cardiovascular Exercises
Table 1. Treadmill
Hip

Knee

Ankle

Time/Distance

Normal

139 flexion

121 flexion
180 extension

90 flexion

3:00 minutes

Overweight

130 flexion

115 flexion
180 extension

83 flexion

3:00 minutes

Obese

125 flexion

110 flexion
175 extension

78 flexion

3:00 minutes

All subjects had an increased forward flexion during treadmill walking, the greatest
flexion noticed in subjects one and three. Increased weight created a strain on the subjects
spine, causing a forward curvature. Also, the greatest amount of musculoskeletal strain and pain
was self-reported during treadmill walking because the activity is weight bearing.
Table 2. Monark cycle
Hip

Knee

Ankle

Time/Distance

Normal

90 flexion

90 flexion
175 extension

90 flexion

4:00 minutes

Overweight

75 flexion

85 flexion
175 extension

90 flexion

3:00 minutes

Obese

65 flexion

85 flexion
175 extension

85 flexion

3:00 minutes

The Monark cycle had higher self-reports, from all three subjects, of causing the greatest
discomfort of all seated aerobic activities performed. The small seat, confined space, and
increased central adiposity all contributed to causing discomfort for the subjects. More
biomechanical adaptations were noticed during obese conditions compared to overweight,
especially in the hip joint because mobility was restricted from the increased weight and central
adiposity.

Table 3. Nustep
Hip

Knee

Ankle

Time/Distance

Normal

95 flexion
110 extension

99 flexion
147 extension

85 flexion

4:00 minutes

Overweight

90 flexion
103 extension

90 flexion
145 extension

85 flexion

3:00 minutes

Obese

84 flexion
100 extension

79 flexion
145 extension

85 flexion

3:00 minutes

For the seated cardiovascular exercises, nustep and cycle ergometer, the most
noticeable mechanical change was leg position. The increase weight and central adiposity
pushed the legs laterally which affected how the knee joint aligned over the foot. Also, instead of
the patella pointing directly forward it points laterally at approximately a 45 angle. Subject three
reported back pain and increased grip force to help with balance when cycling. It is important to
note that with a recumbent cycle, more support and stability would be provided for the patient.
Subject three did not need as much time during the overweight and obese conditions, during
cycle and nustep activities, to meet her target heart rate because of the added mass and strain
placed on her body.
Table 4. Stairs
Hip

Knee

Ankle

Time/Distance

Normal

N/A

N/A

150 plantar
flexion
100 dorsiflexion

12 seconds

Overweight

N/A

N/A

146 plantar
flexion
95 dorsiflexion

13.9 seconds

Obese

N/A

N/A

139 plantar
flexion
83 dorsiflexion

28.3 seconds

Stride abnormalities and greater precaution was taken by the subjects when having to
walk up and down two flights of stairs. The subjects used greater upper body movement during
the overweight and obese testing to assist with balance and to help propel them up the stairs.
Also, with obese testing, subject three used the railing for support coming down the flight of
stairs. Hip and knee biomechanical analysis was unable to be completed because of the angle
the video was taped at. The video was only taped looking at the sagittal plane. This only allowed
accurate assessment at the ankle joint when ascending and descending stairs.

Overall, mechanical adaptations were made from each exercising condition. Assessing
distal to proximal, lateral feet deviation was observed in all three subjects. Subject three had a
medial heel whip on her right side during the obese conditions. Subjects two and three reported
increased knee pain with the increase in weight. Also, a varus stride was observed in subjects
two and three (15). Flexion was observed starting in the lumbar spine for all three subjects.
Subject one had the greatest amount of flexion because that subject was wearing the central
adiposity suit which placed greater mass anteriorly, compared to subjects two and three which
had their weight equally distributed anteriorly and posteriorly. Subject one had internally rotated
shoulders, with an anterior deviation. This could be attributed to a significant amount of mass
located in his abdomen and chest area compared to the two subjects who did not have an
increased central adiposity mass (7). The same deviations were observed while climbing flights
of stairs. The only other adaptations included an increased balance support and decreased foot
control when stepping up and down. Instead of a soft landing, all subjects had hard landings
going up and down stairs. Similar mechanical deviations were noted on the cycle and nustep.
Less flexion was observed on the nustep because of the added back support and stability.
Based on the symptoms reported by the subjects, overweight/obese patients may have
underlying ankle, knee, hip, and back orthopedic issues. The pain and inflammation may be
exacerbated by exercise if the patient was previously sedentary. It will be important to consider
implementing non-weight bearing activity with these patients to help reduce pain and
inflammation from weight bearing and ambulation. Non-weight bearing activities that are
acceptable for these patients would include: swimming, water aerobics, cycling, nustep, and
UBE. Water based programs would only be implemented if the patient was comfortable and had
access to a pool.
Resistance Exercises
Table 5. Squat
Hip

Knee

Ankle

Time/Distance

Normal

65 flexion

72 flexion
175 extension

73 flexion

12 seconds

Overweight

65 flexion

64 flexion
174 extension

73 flexion

13.7 seconds

Obese

62 flexion

60 flexion
171 extension

73 flexion

23.9 seconds

An overall observance of squat form and technique showed a decreased center of


balance with increasing weight (15). Assessing distal to proximal for mechanical form during
squats, all subjects increased the width of their base/stance with the increasing amounts of
weight. The wider stance allowed for better balance control and increased ROM due to their
being extra room for the increased central adiposity (27). The subjects feet also deviated
laterally. Looking at the knee joint in subject three it extended over the subjects toes. This can
created an increased load and strain on the knee joint because it is not centered over the tibia
which creates extra support. When assessing the movement initiation in normal conditions, the

motion started with hip and pelvic anterior rotation. This pushes the subjects buttocks back and
initiates the sitting motion. There was increase spinal flexion with increasing weight as well. With
spinal flexion, weight is shifted from the heels to the fore foot. This is what causes the subjects
to lose balance while squatting (15,24). Also, with the eccentric contraction, the movement is
initiated through the back instead of the subject pushing through their heels and engaging their
quadriceps, hamstrings, and gluteals. Assessing mechanical adaptations with abdominal
exercises consists of decreased ROM and spinal movement (27). When performing the oblique
crunch, all three subjects reported it was hard to laterally rotate their legs to perform an
abdominal crunch. Reasons reported were increased weight, central adiposity, and decreased
range of motion because of the added adipose tissue. Other mechanical adaptations with the
abdominal exercises were increased spinal flexion, loss of pelvic stability, and inability to
perform crunch (24).
Table 6. Crunch
Hip/Back

Knee

Neck

Normal

131 flexion

83 flexion

160 flexion

Overweight

130 flexion

80 flexion

144 flexion

Obese

125 flexion

74 flexion

136 flexion

Hip

Knee

Upper body

Normal

162 flexion

119 flexion

123 flexion

Overweight

163 flexion

102 flexion

119 flexion

Obese

158 flexion

91 flexion

108 flexion

Time/Distance

Table 7. Oblique crunch


Time/Distance

The first mechanical difference observed between all subjects was how they lowered
himself/herself to the ground to perform abdominal exercises. As more weight was added, the
control the subjects exerted over their body movement decreased. With increased weight and
central adiposity range of motion (ROM) decreased for abdominal and squat exercises.
Specifically with abdominal exercises, the crunch action in traditional and oblique crunches
changed. As weight increased, the subjects scapula would not leave contact with the ground.
Suggesting that their abdominal muscles were not strong enough to maneuver the excess
adipose tissue. Subject three reported a feeling of the weight pulling her back towards the
ground.
Potential orthopedic concerns for lower body resistance exercises include: arthritis,
ankle/knee pain, previous knee injury, hip instability, and low back pain or injury. Upper body
orthopedic concerns would include: low back pain/injury, shoulder pain/injury, arthritis, and
central adiposity. For abdominal exercises, orthopedic injuries might prevent floor exercises so

modifications will be needed. Low and mid back pain/injury might prevent a patient from perform
any flexion abdominal exercises. Modifications would include isometric exercises in the supine
or seated position. It will be very important to analyze movement patterns to detect any potential
mechanical issues that might further exacerbate a previous injury or create a new injury
Flexibility, Functional Tasks, and Balance
Neuromotor assessments and functional and tasks had the least mechanical adaptations
out of all the variables measured and assessed. However, these assessments and tasks have
the greatest impedance from increased weight and central adiposity which may lead to
decreased functional movements (15). Functional reach and tying shoes did not have a
biomechanical analysis completed because of only one clinician performing the test and the
inability to video tape while collecting data and measurements. As weight was added, functional
reach scores declined for the subjects. Two of the three subjects reported the feeling of tipping
over or falling. This was observed because as weight shifted anteriorly from their heels they no
longer had a posterior mode of contact. With added weight, hip and lumbar flexion also
decreased, causing a decrease in achievable distance (8). With tying shoes, the subjects
increased their leg width from normal to obese conditions. Subjects had to increase their leg
width to allow more room for their increased adipose tissue and also to allow them to see their
shoes. There was significant back and neck flexion during the obese testing compared to
normal conditions. Also, with a shift of weight towards the front of the chair, subject two reported
the chair tipping forward. In subjects two and three, the time required to tie shoes increased 5.6
and 12.5 seconds, respectively, between the normal and obese conditions. Subject one selfreported taking their time tying shoes during normal conditions instead of completing the task as
fast as possible. This created a measurement error in the data. Subject three also reported a
dyspnea rating of 1 when tying shoes as an obese subject. With their head being lowered and
between their legs it makes breathing more difficult because the lungs and diaphragm cannot
expand as much.
Table 8. Sit and reach
Hip/Back

Knee

Ankle

Time/Distance

Normal

46 flexion

177 extension

90 flexion

Past toes

Overweight

38 flexion

173 flexion

90 flexion

Touch toes

Obese

29 flexion

168 flexion

83 flexion

Short of toes

Hip/Back

Knee

Ankle

Time/Distance

Normal

98 flexion

48 flexion

108 dorsiflexion

30 seconds

Overweight

105 flexion

56 flexion

104 dorsiflexion

30 seconds

Obese

114 flexion

68 flexion

101 dorsiflexion

30 seconds

Table 9. Seated IT

The same issues with getting to the ground apply to flexibility assessments as they did
for abdominal exercises. As weight and central adiposity were added to the subjects, it was
harder for them to maintain a static stretch for 30 seconds that they could easily accomplish
under normal conditions. Main reasons for a more difficult time included: added weight pulling
on their low back, decreased abdominal strength and stabilization, decreased spinal flexibility,
and decreased range of motion due to excess adipose tissue (15, 8).
Table 10. Foam pad balance
Hip

Knee

Ankle

Time/Distance

Normal

167 extension

178 extension

95 dorsiflexion

30 seconds

Overweight

161 extension

180 extension

99 dorsiflexion

30 seconds

Obese

157 extension

181 extension

106 dorsiflexion

30 seconds

Hip

Knee

Ankle

Time/Distance

Normal

180 extension

170 extension

96 dorsiflexion

30 seconds

Overweight

171 extension

171 extension

79 dorsiflexion

30 seconds

Obese

166 extension

177 extension

68 dorsiflexion

30 seconds

Table 11. Bosu balance

Subject two reported feeling unsafe on the bosu ball under obese conditions. Being
unable to see their feet made balancing harder for that subject. Subject three reported needing
assistance onto the bosu ball, but once stabilized was able to balance. All three subjects
reported having to increase focus and concentration during overweight/obese conditions
compared to normal conditions because of the excess body weight. Wit obese patients it is
important to properly guard the patient and assist them with stepping onto the bosu ball and
stabilization prior to starting test.
Orthopedic considerations for these assessments and tasks include: knee, hip, or low
back injury/pain, weak ankle stability, decreased hamstring and posterior flexibility, and
lumbopelvic instability or weakness. Based off of subject threes dyspnea rating during shoe
tying, a forward flexion with head between their legs might need to be avoided because of the
risk of increased dyspnea. Balance progression for overweight/obese patients should to slow
and with minimal progression. Ground balance assessments should be completed with the
patient exceeding 30 seconds in each of the follow assessments: bipedal stance eyes open,
bipedal stance eyes closed, staggered tandem eyes open, staggered tandem eyes closed,
tandem stance eyes open, tandem stance eyes closed, tandem stance toes and heel touching
eyes open, tandem stance toes and heel touching eyes closed, unipedal stance eyes open,

unipedal stance eyes closed, and the next progression would be foam pad, bipedal with eyes
open.
3.
Cardiorespiratory
Initially, exercise and physical activity should focus on cardiovascular modes of exercise.
The primary reason for this approach is to focus on the greatest amount of energy expenditure
possible in a given period of time. Exercise modality selection is important for enhancing
adherence and reducing the risk of injury. Overweight/obese individuals may have pre-existing
musculoskeletal issues from the added weight and strain on the joints, which could prevent
certain modes of cardiovascular exercise. These issues often relate to pain in the lower back,
hip, knee, and ankle joints that may be chronic. However, these problems may improve, as
weight is lost. The clinician should assess any painful conditions and make recommendations to
avoid this type of pain. In general, aerobic exercise should be categorized as either weight
bearing or non-weight bearing. When possible, walking is the best form of exercise for several
reasons. Walking has few disadvantages; all patients have experience with the activity and a
typical goal is to remain functional and independent. Walking is an excellent, low-intensity
activity with little risk of injury. It is an easily available form of exercise to most patients and does
not require special facilities. Neighborhoods, parks, walking trails, shopping malls, fitness
centers, and so on offer walking opportunities. However, after completing this lab it is important
that the clinician be empathic and aware that weight-bearing exercises may be too difficult at
first. The clinician needs to pay special attention to gait, biomechanics, and exercise form. Also,
taking note of any signs or symptoms during exercise along with self-reports. These
observations will help the clinician design the most effective and enjoyable CRF prescription.
Non-weight-bearing exercise options include stationary cycling, recumbent cycling,
seated stepping, upper body ergometry, and seated aerobics. These activities are useful at any
time but are particularly useful for those with joint injury or pain. The clinical exercise
physiologist should adapt these modes of exercise by providing larger seats and stable
equipment. People who are obese often have difficulty getting on or off these types of
equipment or moving through the full range of motion required by a given piece of equipment.
The clinician needs to be prepared to make modifications so proper form and technique are
used. For example, in our lab one participant had a limited ROM on the nustep due to
abdominal adiposity, so the clinician increased the participants step frequency in order to get
their heart rate up. For some individuals, seated aerobics may be an excellent option to reduce
the typical orthopedic limitations that some people experience, including back, hip, knee, and
ankle pain. Another advantage is that seated or chair aerobics can be performed in the comfort
of a persons home. These types of exercises are good for home based exercise programs
because they limit the risk of injury, reduce risk of falls, and the patient can perform seated
exercises while watching TV.
Resistance Training
Resistance training is vital to increasing muscle mass and metabolism, creating a more
functional body, and enhancing mobility and balance. However, progression is key. Modify every
strength exercise so that it meets the clients level and progress for there. When starting an

exercise program the clinician should be aware that the client may have range of motion
limitations. Because of these limitations, the clinician may need to modify the exercise to
decrease the motion of action. Squats are undoubtedly one of the most functional exercises and
a great way to build leg muscles. When working with an obese client have them being with
squats to a chair, allowing them to rest in the chair a split second, and then stand back up. The
clinician can then progress from there, when the client is ready. Obese individuals may have
trouble with balance because of their increased adiposity, so the clinician should consider
having an object for the client to use for balance. Abdominal work is challenging because an
obese clients have a hard time getting to the floor. Instead, have the client perform core
exercises either sitting or standing. Resistance training should also focus on extension and
strengthening the posterior muscle groups because obese individuals tend to have increased
flexion. Dumbbells are a vital training tool for obese clients. Whether they perform the exercise
standing or on a sturdy bench, dumbbells allow you to train specific muscle groups in a safe
manner. The clinician needs to be aware of other musculoskeletal considerations such as knee,
back, and ankle pain. The clinician should always have backup plans in case the client comes in
with a significant pain level or some other condition where the exercises would need to be
altered (24).
Flexibility
Obese patients may have a reduced range of motion as a result of increased fat mass
surrounding joints of the body. As a result, these patients often respond slowly to changes in
body position and have poor balance. This is seen in our lab data with both the functional reach
and the sit and reach. All subjects functional reach score decreased when obese. For the sit
and reach, Subject two had a wider leg angle because of the extra weight and central adiposity
during the obese trials. Whereas, Subject one had a reduced range of motion because their
central adiposity impeded movement. Individuals who are obese are also at a greater risk of low
back pain and joint-related osteoarthritis because of their condition. Therefore, range of motion
may improve spontaneously with weight loss. Still, to the degree possible, patients should
perform a brief flexibility routine focused on the legs, lower back, and arm and chest regions.
4.
Unfortunately, for most individuals with obesity, several physical, psychological, and
environment obstacles hinder the adoption of exercise as a consistent lifestyle behavior. This
underlines the importance of recognizing the psychological determinants of exercise behavior,
and developing effective strategies to improve the patients adherence to exercise.
The first step is educating patients about the benefits of exercising and the need to
increase the level of physical activity for long-term weight control (17,29). The second step
involves creating a pros and cons to change table. Patients should be asked to evaluate their
reasons for and against adopting an active lifestyle. Clinicians should emphasize that change is
a necessary step to achieve a long-term weight control and to improve the physical and
psychosocial negative effects of obesity. The list of pros and cons should be put on a table and
discussed in detail. During this discussion, clinicians should urge patients to focus on the longterm goals and not just on the present. Every reason for change should be reinforced. It is also
important to analyze the cons of changing; helping patients reach the conclusion that the

positive aspects of increasing the level of activity are attained in the long term, and are always
associated with positive gains. The final step is to help patients reach the conclusion that
adopting an active lifestyle will be a positive opportunity for a new and healthy life and long-term
weight control.
A key aspect of engagement is to stimulate patients to make spontaneous statements
such as If I start exercising I will because it is the sign that they see the need to change
their lifestyle. In these cases, clinicians should make a confirmatory statement such as I realize
that you have decided to try and change your exercise habits. At this point, clinicians should
actively suggest and encourage that patients try to change their physical activity habits (28).
Another way to help with exercise adherence is through a physical activity questionnaire.
Patients will be more compliant if they are enjoying the activities they are performing.
Several cognitive behavioral strategies such as assessing patients activity levels,
tailoring activity goals to individual patients, self-monitoring, stimulus control, involving
significant others, and responding to non-adherence help to improve patients adherence to
exercise. These should be included in the treatment of obesity. An initial assessment is needed
to determine the patient's current activity levels. Clinicians should ask patients how they judge
their actual level of physical activity, and if they believe that it is adequate to lose or maintaining
body weight. If, as usual, patients report being sedentary, clinicians should ask the reasons of
their sedentary life, and if there are barriers to exercise.
Clinicians should evaluate which type of activity is physically possible for patients, and
the barriers that can prevent a successful increase in activity. Accordingly, they should assist
patients in developing a physical activity plan, based on the initial assessment. Clinicians should
always keep in mind that obesity per se is an important barrier to physical activity, as it poses
several unique challenges to the obese individual (1). The most typical barriers reported by
patients are being too fat, shy or embarrassed to exercise, being too lazy or unmotivated,
having an injury or disability or being not the sporty type (4). Women with obesity reported
lower pleasure ratings during exercise of increasing intensity and lower energy scores
immediately after the exercise than non-obese women (9). These two factors may partly explain
the lower level of participation to exercise of obese individuals. A careful assessment of barriers
to physical activity caused by obesity per se is mandatory in all cases and exercise prescription
must be changed accordingly (e.g., switching to non-weight-bearing exercise, or to lowerintensity exercise).
Self-monitoring (of energy intake and expenditure) is the cornerstone of the behavioral
treatment of obesity. The larger the use of self-monitoring, the larger the amount of weight loss
(3). Monitoring raises patients' awareness of their exercise habits and helps them identify ways
to maximize their energy deficit. Physical activity can be recorded in a monitoring record in
minutes (of programmed activity) and/or steps (of lifestyle activity), using a pedometer (10).
Patients interested in having a more precise measurement of their daily caloric expenditure may
use an accelerometer, which measures total energy expenditure, the energy expenditure in
physical activity, the duration and the levels (METs) of physical activity and sleep time. Patients
may also benefit from recording activities, moods, and thoughts associated with exercising. This
information may help identify obstacles to exercising. Self-monitoring records can also be used
to provide information to identify activity contingencies that can be targeted for intervention (10).

These strategies are based on the principles of classical and operant conditioning. The
main focus is to modify the external environment to make it more conducive to making choices
that support exercising. Patients should be instructed not only to remove triggers of inactivity,
but also to increase positive cues for healthy activity (e.g., lay out exercise clothes before going
to bed). Stimulus control may also be used to reinforce the adherence to exercise by
establishing a reward system (e.g., encouraging patients to set weekly behavioral goals and to
reward themselves in case of achievement, not through food or inactivity) (10).
Social support is a key ingredient for behavioral change. Data shows that social support
is considered to be an important aid for weight maintenance (19,31). Significant others may play
an important role in encouraging patients to increase daily physical activity and to reinforce the
changes. With the consent of patients, clinicians should involve significant others in the
treatment in order to create the optimum environment for patients' change. Significant others
should be educated about obesity, weight management, and physical activity. They also should
be actively involved in exploring how to help patients develop and maintain an active lifestyle.
The needs vary from patient to patient; the general advice to give to significant others include
creating a relaxed environment, reinforcing positive behaviors, adopting a positive attitude,
exercising together and accepting patients' setbacks.
Long-term adherence to an active lifestyle and weight control can be extremely difficult
because of a complex combination of biological, environmental, and psychological pressures.
Clinicians should congratulate the patients for every small success they achieve, and should
never criticize failures (26). Criticism may produce guilt and loss of self-confidence, leading to
attrition. An unconditional acceptance of the patients' behavior and a problem-solving approach
to address barriers will preserve the clinician-patient relationship. This approach will also help
patients understand that the long-term success in weight management is related to a set of
skills rather than simply to willpower.

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