Program for obese client with recurring knee pain
I have a client who is obese. She has been with me about 2 months and progress is slow, of course I can't control what she eats. That said, she has an old knee injury that flares up, was injured about 30 yrs ago. She needs to lose a significant amount of weight but complains that exercise hurts her knee. Any suggestions?
Upon clearance and a written release and or protocol from a PT if that's the case:
I would start with strength training and very small increments of "aerobics" to tolerance of course.
Swimming would be great, flat surface walking, using a pedometer and also having her use myfitnesspal.com to track her food intake:
As you know: you can't exercise your way out of a bad diet
She can workout all day long but if she's not eating correctly it's a mute point.
For exercise, swimming is a great idea as Susan mentioned. Some strength training focusing on large muscle groups will help with the weight loss. You can initially work on exercises that don't involve the knee joint, or find exercises that don't cause pain in the knee joint; for example if a regular squat is too much then perhaps an assisted chair squat might be beneficial to start. I'll sit someone on a movable bench or chair in front of a smith machine; they hold onto and use the bar to assist in the squat to the chair. Of course, again it's important to work within your scope of practice and work within the suggestions of a physical therapist.
With that said, maybe the largest culprit of her slow progress is her eating habits. This is where the tough love may be most necessary. Whether the knee pain is from an acute injury long ago or from the chronic wear and tear from having excess body weight, it would certainly promote knee health if she were to lose an appropriate amount of body weight.
Diet is always important and will will be especially crucial when there are limitations for physical activity, in the beginning progress will be slow while she builds a strong foundation - including her knee health - for physical activity; the only way to accelerate progress is through healthier eating habits.
I agree that you would want your client to see her doctor about her knee. With the amount of years that have gone by, she could have scar tissue, arthritis, or something more serious that is causing her pain. Once she has clearance, you can start to slowly work to strengthen the muscles around her knee as tolerated, but it may be some trial and error to find what works for her.
Swimming is definitely a great, no impact activity that she could do, and very easy on the joints. Perhaps an elliptical or bike, but the angle of both on the knee joint will matter--and you may need to try a few things to see what doesn't cause her pain.
Also, she can still do strength training for upper body (until you know her diagnosis). Chest and back are large muscle groups and will burn more calories.
Hopefully she is tracking her daily caloric intake for you, as nutrition is the bigger part of the equation. Good luck!
I'd also have her identify if she has constant knee pain or only while doing certain activities. If you can find exercises she enjoys, exercises that don't cause pain or a range of motion that works, start there. Check in with her and see if she believes the homework and goals you have set are realistic. If not, then break it down even smaller.
Clients who struggle with obesity have failed at losing the weight and making behavior changes, have failed before and may not think they can make the necessary changes even though they know they need to and may know what to do.
I see she is cleared for exercise by the doctor.
I also use a pain scale before, during and after the workout.
Making small goals, even just one small thing to change at a time, might be enough for now.
About the diet log, it seems someone is hiding something from you. When the topic comes up, there may be a way to tell her that you are there to help, not judge, and everything is kept confidential. We all make decisions we are not happy about sharing with others; but, in this case, being honest in private with the trainer may be very gratifying.
Maybe you could recall a time you had to push through an unpleasant time in your life and share that experience with the client of how you got through.
Small progress is better than no progress; we all move at our own pace.
NAPS 2 B Fit
I started using a pain scale with her today, had a great workout. I so want to see her succeed.
thanks for all of the great suggestions!
Also was she receptive to the idea of using MyFitnessPal?
My advice.... focus on fun during the workout.
The picture that I have in my head of your client isn't of someone who has really put much concern into her health and fitness until this point. Again, I could be very wrong but this sounds like an individual that does eat a whole lot and knows it. Maybe, I'm wrong but this is unfortunately like many.
My thing is, that these kinds of people know all these facts. They know that they hate exercise, and they know they like to eat bad food in large amounts. I mean, usually these kinds of folks, know plenty about nutrition after trying a number of diets and weight-loss programs. So my question is, do you same to be another, or do you want to change her forever?
If you choose the later than in my opinion, you really need to make her want to come see you. Because a food log is really no good if nobody is looking at it anyway. I mean, imagine yourself in her position. The gym represents so much that had been contrary to her type of living, its a huge accomplishment just to walk in there. In addition to that, everyone in the world knows that she isn't eating well. Why in the world do we need to embarass her by continually asking her everyday what she is poisoning herself with? Knowing that, isnt going to change a thing.
For me, I think the best approach is just being her friend and modeling good behaviors. Find out if she likes to cook and just casually talk about a "new" recipe you tried or food you ordered differently at a fast food place. We can't take a baby from a womb and get them walking right after their first breath, we need patience in coaching a new lifestyle.
Back to your real question about knee pain. That is a real sticky situation. Although, neither of you are doctor's, she is bound to have some pain in places. From exercise acne con all the stresses that net won't contributes to her joints. This really can't be avoided.
What I could say, is that you should probably do a daily inventory with her and figure just how she is doing. Not just how she feels at each joint but more so how ready she seems to exercise for the day. This is really how I would base her programming and it could help you determine whether you should play balloon volleyball for an hour with her or if she can do some functional training for a workout.
In addition, so that she knows that you really care and address concerned with her wellbeing, I would make sure that you give her some myofascial and flexibility homework that she can do while watching tv. Probably DONT DO A FORMAL ASSESSMENT. She likely had a number of common deviations and doesn't need to feel worse about herself. What I do is really emphasize how much better she will feel if she can get her muscles the correct lengths. So, maybe slow her 3 or 4 exercises she can do at home that will affect her knee. Maybe ask her how much time she could spend sound them each day, take a couple pictures if her doing them, wrote down some cuts to help her remember them and let her go to work.
Hope this helps