Shoot for the Moon!

Submitted by: Francine Bigney

Cameron, "Moon"'s Success Story

Update:
June 21, 2011...Six Months and -50+ pounds later...

Moon and I meet periodically and keep in touch electronically. He has had some major life changes these past 2 months and consequently had to take a month off from the gym. None-the-less, he is still eathing more healthfully and moving more and hasn't gained any weight back. He sent me a note recently, reaffirming his committment to his good health practices, "...I am going back to the gym next week.... I so miss it. I really do. Please don't think I am one of these people that are just making excuses [to get] out of it. I really like it [at the gym]." We should all be so motivated, especially in the summer. Moon is the icon of motivation!

His journey...
December 6, 2010

Cameron Howard
Demographic Data: omitted for publication

Physician: John Fothergill, MD
Physician phone: 603-237-8336

History:
11/17/10
“Fair” health, sedentary lifestyle, “moderate risk” with no cardiac signs or symptoms

Medications:
Xalitan, ASA 81mg/day

Initial Assessment:
11/19/10
Age: 56
BP: 136/78
Height: 5’11.5”
Weight: 292
BMI: 40.7
Body Fat: 40.1%
Chest Girth: 50
Waist Girth:47.5
Hip Girth: 49
Thigh Girth: R: 25.5 L 25
Waist/Hip Ratio: .96 “at risk”

Goals:
Long Term: 100 lbs. weight loss/18 months

Description:
With a cherubic face framed by graying hair atop a 5’11 ½” and 292 pound frame, you may be tempted to call Cameron “Moon” Howard “the full moon”. During our first meeting Moon spoke of a history of “yo-yo dieting”. He’s tried Atkin’s, pills, even a stomach balloon procedure. He lost weight on all of them, but gained it right back. For as long as I’ve known Moon – most of our adult lives – I can say I know this for a fact. Tired of too much waxing and not enough waning, he came to me for help. This time he says he’s, “ready to change for good.” The fact that he sought the help of a veteran, ACE Certified, Lifestyle and Weight Management Coach and Gold Certified Personal Trainer attests to his level of commitment.
Moon’s health screening indicated no signs or symptoms of heart/cardiovascular disease, but he is male, over 50 and has 2 primary risk factors – obesity and sedentary lifestyle – and needed his physician’s approval prior to exercise and fitness testing. Recently he had a non-fasting glucose and lipid profile done at work. He brought the results with him, which revealed borderline high total cholesterol with a relatively high HDL and a postprandial glucose of 115. I encouraged him to see his primary care provider, get a check up and fasting blood analysis and gave him a physician’s clearance form to return to me signed, with any restrictions noted.
Moon and I sat about the work of SMART goal setting. Moon stated up front that he “wants to lose 100 pounds in 18 months”. We talked about his diet and exercise history and perceptions, his work and lifestyle. He has a rotating shift at the local Ethan Allen plant and is physically active on the job, (which counts when one is considering calorie balance/deficit). He also reported that he swam regularly last year – 2-3 days per week and that he, “lost weight without dieting and“[had] more energy and felt good when [he] was done.” He added, “It tightened me up and I felt better.”

Short Term: Week 1-2
• Get PCP endorsement/restrictions
• Join Bridge Street Gym
• Go to gym 4 days per week/1-1.5 hours
• Get notebook
• Log workouts
• Track nutrition/food recall at mypyramid.gov

12/2/10
Moon presented at the Bridge Street Gym for fitness testing. He had his physicians consent in hand with no restrictions. He had been tracking his nutrition with a food recall in a notebook (he didn’t have it with him”. He had not joined the gym yet, but had an appointment to do so after our testing (same day).

Cardiovascular Assessment:
BP: 114/78
HR:52
Rockport Walking Test: Pace: 3mph, Time: 20:05, RPE: “13” throughout, Talk Test: Pass, HR 85
Calculated Vo2: 16.75 “poor”
(C/o Right ankle “bothering” him from an old snowmobile injury. Has seen orthopedic doctor for diagnosis and treatment (air cast) “that [was only effective] for 1 month”.)

Muscular Strength and Endurance Assessment:
Curl up Test: 34 (Intermediate/average)
Standard Push up Test: Unable
Modified Push up Test: 10 “Poor”
Double leg lower: knees bent, 30 ˚, “Needs work”
Prone core strength test: 7 secs. “Needs work”
Supine core strength test: 15 secs. “Pass”
Lower extremity stability: R: “Fail” L: 8 secs. “Needs work”

Flexibility:
Sit and Reach: 21” “Excellent”
Shoulder flexion: Pass
Shoulder extension: Pass
External rotation: Pass
Internal rotation: Pass, but right is less flexible
Hip/Lumbar extensors: “Needs work”
Hip flexors: R: “Needs work”; L: Pass
Hamstrings: “Pass
Quadriceps: “Needs work” unable to extend to reach foot on either side, modified with a towel
Gastrocnemius: Pass
Soleus: Pass

Posture Assessment:
Frontal plane:
Head: “Pass”
Shoulders: “Pass”, but right slightly higher
Spine: “Pass”
Hips: “Pass” (even), but show lateral rotation
Knees: Internal rotation (“duck toed” to 20˚ - 30˚
Feet: “Needs work” excessive pronation/eversion particularly on the right side, due to old injury (treated)

Saggital Plane:
Head: “Pass”
Shoulders: “Pass”
Lower back: “Pass”
Abdomen: “Needs work”
Knees: “Needs work” Right Internal rotation
Feet: “pass”

Periodized Program, Phase 1:
Weeks 1 & 2: 1 set; 15 reps unless otherwise noted, 2-3 days/week on alternate days.

Note: Warm up prior to each strength training session with moderate, rhythmic total body movement for 8-10 minutes until you break a light sweat or with your cardio session.

Single leg balance next to a wall or support, eyes open, goal:15 seconds, 5 reps each
Heel-to-Toe walk, eyes open, forward and backward, 12 steps each
Seated single leg raise with inversion/internal rotation
Stability ball table top bridge
Leg press
Stability ball walkout
Reverse flyes with supine 90/90
Straight leg calf raise
Bent knee calf raise
Toe taps

Flexibility Program, Phase 1:
Note: Always stretch after your workout or after a good warm up. Remember muscles have elastic properties. Assume stretch slowly and hold for a minimum of 15 seconds. Repeat as necessary for tight areas.

Anterior shoulder/pec stretch
Add: unilateral upper trapezius stretch
Corner pec stretch
Tricep stretch
Gastroc stretch
Soleus stretch
Seated dorsiflexion with straight leg & internal hip rotation to stretch lateral gastrocnemius
Seated dorsiflexion with bent leg
Supine hip flexor stretch
Supine lumbar/glute stretch
Supine hamstring stretch with towel assist
Prone quad stretch with towel assist

Cardiovascular Exercise: Phase 1, Weeks 1-2
Treadmill walking, elliptical machine, stationary bike or swimming or a combination of any of these for 30 minutes, 4 days per week at a moderate level/RPE 12-13.

12/7/10
Moon is warming up on the treadmill at 3.6 mph, but holding onto the rails. I encouraged him to reduce speed to 3.4 mph, “let go and swing [his] arms naturally.” He continued for 11 minutes. RPE:12
Weight: 282.2
“I’ve just been cutting back on what I eat.” I cautioned him about the hazards of rapid weight loss, i.e., reduced metabolism, increased loss of lean body mass. I recommended he not cut back quite so much and focus on quality nutrition to fuel his fitness and health goals. I advised him to track his food intake, provided food intake tracking sheet examples and an article and referred him to the USDA My Pyramid.gov.

Goals for today: Implement Individualized program – Week 1
Moon had difficulty with a few of the exercises that I had proposed and they needed some modifications:
• He was unable to maintain neutral spine in an unsupported sitting position and do single leg lifts with internal rotation, so we amended the exercise two-fold: 1. use wall support, 2. limit “leg lifts” to internal rotation only.
• Single calf raises proved too difficult without rocking and flexing his knee, so we regressed to bilateral calf raises with a focus on neutral foot alignment and even weight distribution.
• Moon could hold a unilateral stance for about 8 seconds with his eyes open. He will use this as a baseline and stand close to a wall or other support.

Moon’s Goals:
• Exercise 5-6 days for weeks 1 & 2
• Buy a notebook for log
• Bring in 3-day food recall
• Complete goal sheet and success tracking sheets
• Complete Weight loss attitude survey (Daniel Kosich)
• Meet 12/13/10.

12/13/10
When I arrived at the gym, Moon was walking on the treadmill at 3.5 mph and had been on for 30 minutes. (Goal #1 in progress!)
He handed me his Weight loss attitude survey (Goal #5 reached!), food recall in a notebook (Goals #2 & #3 reached!) and we reviewed his goal refining and success tracking sheets (Goal #4 reached!). He kept these to remind him of his focus and work over the holiday break.
He was a bit discouraged that family obligations had cut into his free time to exercise. I reassured him that “life happens” and that his active wood stacking was a great way to burn calories and strength train! Despite limited time for training, Moon demonstrated some success with his training program as we reviewed each exercise.
• He improved his static balance by 4 seconds (right side) and reached 20 seconds on his left side!
• He demonstrated his ability to complete the wall-supported, unilateral leg lift, completing 5 reps on the right side (with some difficulty) and 12 reps on the left side - A great accomplishment given his limited practice.

Because he is unable to maintain neutral spine while sitting unsupported, needs to further improve his static balance before we challenge it further, is unable to perform unilateral calf raise or seated leg lifts without compromise, he will continue to build his base for weeks 3-4.

Moon expressed greater control over his eating and a more realistic eating plan stating, “I’ve slowed down on the ‘diet’. I’m eating more healthy foods like salads and fruits.” Moon weighed in at 280.2 today demonstrating a more reasonable weight loss.
We talked of his goals and perceptions, focusing on his answers to the weight loss and personal perceptions worksheet. Moon has tried every just about everything to lose weight - “pills, Atkins, Miami, you name it“.” He’s gone to extreme measures and describes a stomach balloon procedure that was reversed after 3 months, as well. He lost weight initially, but couldn’t maintain it. He now realizes the missing link: exercise. He acknowledges his support system and his gym membership as tools to help him reach his goals. He is really bothered being classified as “obese” by the clinical definition and, ““ never [wants] to be called [that] again.” Amen!
We discussed the holidays and the built-in tripwires, but Moon has a really great attitude – “just jump right back on track” if he gets sidetracked. I am completely confident in him. I continue to be inspired by Moon’s positive outlook and “can do” attitude. He’s the most motivated individual I’ve ever had the pleasure to work with.
We could all take a lesson from him.
Weight: 280.2
Meet: 12/30/10 at 11:00 a.m.

12/30/10
What a great way to start the new year!
Review of Moon’s diet recall shows evidence of his initial overly enthusiastic approach to his nutrition (skipping meals, small meals, limiting food choices) in an attempt to lose weight. He leveled off after the first week or so, including all food groups on most days (23%-143%)*. His average caloric intake was 1672 kcals. between November 21st and December 12th*. Because Moon’s EER is currently about 3000 kilocalories per day, and a 500 kilocalorie deficit would allow him to lose about a pound per week* without unnecessarily impeding basic metabolic rate, I have encouraged him to eat a bit more and include more lean meats, fruits and vegetables as choice fuel for his activity and lifestyle and to maintain his resting metabolic rate. I gave him a printout from mypyramid.gov individualizing his nutrition plan thru food groups and we reviewed serving sizes again. Because Moon has a past history with dieting, he is well versed in serving sizes, food groups and the difference between high quality calories and lower quality calories. He did have an issue with portion control, and I had previously broken out my “sample” food serving examples and we reviewed in depth the recommendation for each food group. Moon reported the visual was highly effective in helping him get a grip of portion sizes.

*USDA MyPyramid.gov

I will reassess Moon’s ability to perform his base program today. Together we will make modifications to keep him progressing, improve his core strength, hip flexion, balance and ankle/foot biomechanics/foundation.
Moon was warming up at 3.6 mph on the treadmill for 20 minutes and had completed one mile. He had also completed 10 minutes on the bicycle prior to that. We went directly onto his flexibility routine with Moon demonstrating good grasp of technique, but still has a difficult time remembering proper terminology and proper anatomical terms. I will e-mail him an educational primer on this. That said, Moon had taken the initiative to look up certain flexibility exercises and print off examples. I will provide a one sheet primer, as well.
While on the treadmill, Moon reported doing “pretty good” with his program overall and only got “off track” one day during Christmas. He says he feels great about his program, but his weight loss has slowed. Indeed, Moon weighs 280.5, so he maintained his loss of 11.5 lbs. over a six week period, which included Christmas, a feat for most of us. His body fat is down 2.9% and his BMI is down 2.0.
We reassessed his lifting biomechanics with the “bend and lift screen”. He has difficulty squatting due to the excessive pronation of his right foot and compensates by driving with his quadriceps, lifting his right heel (but not his left) and rotating his leg laterally. His spine maintains a close to neutral position with some forward flexion and no head deviation. We reviewed proper squatting and lifting procedure and I made him aware of his compensations so that he could work on them. We practiced with a chair and he was able to learn to dominate the movement with his glutes, and minimize the rotation of the right leg, but exhibited greater forward trunk flexion. He will work on this.
We then reviewed all his strength/core work and I demonstrated the “next steps” in the periodized model for him. I will update his program to include the new modifications. He will implement these when proper form can be demonstrated on the base exercises. Moon plans to purchase a stability ball and also may look into a therapy ball. I also demonstrated the proper form for an abdominal curl and demonstrated alignment techniques with a therapy ball that Moon can implement to help engage his adductors and minimize foot & knee deviation. Although the abdominal curl is not the most effective abdominal exercise, most folks still do it and it makes Moon feel like he’s doing a more typical gym “routine”.
I provided Moon with a Prioritization Worksheet and a time management worksheet. He will complete these for insight into his priorities and barriers to goals, so that we can proactively head them off.
We reviewed the Mypyramid.gov assessment of three random days of food recall. I demonstrated that Moon had over-enthusiastically cut his calories by much more that 500 per day and that had the potential to slow his metabolism (starvation theory). He admits he was overzealous, but has tempered his nutrition by being more aware of his serving sizes and cutting back on them while substituting fruits and vegetables for snacks and pretzels for chips. He also reported he is not cutting out foods, but incorporating them moderately. I gave him a mini lesson about the types of fats and their caloric composition after he said he had cut out butter, but ate “tons of olive oil”. We also discussed the caloric composition of carbohydrates, proteins and alcohol. “I’m trying to get healthier and still not deprive myself at the same time.” Sounds like a good plan to me!

This concludes Moon’s Weight Management package and he wants to “go it alone” for a couple weeks before we “tweak” again.

Periodized Program, Phase 1: Weeks 6-8:
2 sets; 12 reps unless otherwise noted, 2-3 days/week on alternate days.

Note: Warm up prior to each strength training session with moderate, rhythmic total body movement for 8-10 minutes until you break a light sweat or with your cardio session.

Single leg dynamic balance, eyes open, goal:15 seconds, 3-5 reps each
Single leg static balance, eyes closed, goal: 15 secs. 3 reps each
Heel to Toe walk on unstable surface (double mats), eyes open, forward and backward, 12 steps each
Unsupported seated single leg raise with dorsiflexion, inversion/internal rotation
Stability ball bridge, feet together, arms across chest
Leg press: 120-130 lbs.
Stability ball walkout/plank; 3 breath cycles
Seated reverse flyes/scapular adduction and retraction, no weight, use core support
Unilateral straight leg calf raise with even weight distribution, particularly on the right side, avoid tanking/piking
Bent knee calf raise 30 lbs.
Toe taps: 12 neutral, 12 lateral, 12 medial
Rubber resisted dorsiflexion with inversion (12) and eversion (12)

Cardiovascular Exercise: Phase 1, Weeks 6-8
Treadmill walking, elliptical machine, stationary bike or swimming or a combination of any of these for 45 minutes, 4-5 days per week at a moderate level/RPE 12-13.

Flexibility Program, Phase 1, weeks 6-8
Note: Always stretch after your workout or after a good warm up. Remember muscles have elastic properties. Assume stretch slowly and hold for a minimum of 15 seconds. Repeat as necessary for tight areas.
As prior.

January 4, 2011
I received a Happy New Year card from Moon and Lori. On the envelope it read, “ If you can’t grow it, don’t eat it! Get FIT 2011! That’s my goal!” Moon, all I can say is, that’s awesome! (By the way, “get FIT” has a double meaning. My registered name is F.I.T. Program! Cool, eh?)

January 21, 2011
Moon phoned today to work out the schedule for the next month. He described his need to work with me “once or twice a week” to make sure he is doing his exercises correctly. We meet tomorrow!

January 22. 2011
I met Moon at the Bridge Street Gym, where he was warming up on the treadmill. He had gone 1.93 miles in 30 minutes at 3.8 MPH. He usually does 2 miles in 32 minutes.

Testing:
Bend and Lift Screen:
Frontal plane: Demonstrates excessive pronation/eversion on right side and external rotation of the knee with no lateral shifts.
Saggital plane: Demonstrates good calf flexibility and gluteal dominance, but compensatory movement of the trunk in forward flexion.
Discussion: I demonstrated proper squat position with parallel knees and upper body and tibial lines and improper form and we talked about proper lifting technique. Moon could clearly see the difference in my demonstration. I had sent Moon 2 anatomy charts and graphics of each exercise. He had printed these off and had them in his (very organized) 3-ring binder, along with his program and log sheets. He refers to these during his workouts to reinforce his understanding of his body during movement.

Thoracic Spine Mobility:
Moon easily rotates without compensation.

Shoulder (supine) flexion and (prone) extension tests:
Moon exhibits good shoulder flexibility with both flexion and extension.

Supine Shoulder external and internal rotation:
Moon exhibits full range of motion to 90 degrees external rotation and 70 degrees internal rotation.

Note: next week we will test his abdominal contraction with the blood pressure cuff.

Moon completed 2 sets of each applicable exercise in his program, which continues to need tweaking. I logged his exercises on his log sheet and demonstrated how to use it. Moon’s commitment to his program is admirable, to say the least!

His strengths are: He’s sticking to it(!); he has progressed to 2 sets of each applicable exercise; he has noticed an improvement in external rotation of the shoulder, “it’s easier to wash my back in the shower”, he says – a great ADL application of the movement; awareness and self correction/internal rotation of the hip/knee/foot on all exercises; better form on the bilateral calf raises and progression to body weight bent knee calf raises; improved core strength and the ability to add a push up to the ball walk out on the way back “home”.

His weaknesses are: static balance with eyes closed, sitting up straight without the support of the wall, unilateral calf raises aren’t possible at this time, he continues to externall/laterally rotate at the knee. This is especially evident because he had to crawl on his knees at work and chose not to wear protection, thus he has 2 open abrasions- one on each knee that are clearly lateral to the midline. He exhibits improper shoulder stabilization with the seated scapular row. I demonstrated proper form and the musculature involved as primary movers using his anatomy chart. He then exhibited correct form with a visual cue to “crack a walnut between his shoulder blades”.

We will continue to capitalize on his strengths and minimize his weaknesses as we progress over the next month.

January 27, 2011
Moon continues his admirable, steady progress on the road to good health.

When we met at the Bridge Street Gym, Moon had already gone 2 ¾ miles in 42 minutes at 3.9mph. He reported a corresponding RPE of 12-13, “somewhat hard” and is ready for additional cardiovascular challenge. I introduced him to the concept of interval training, using description, charts and graphs and finally a demonstration to show the difference between interval training and steady state training. Moon will “amp” up his cardiovascular exercise by including one (1) interval training day per week in lieu of his steady state training. He will employ a 1:3 work/rest ratio after a 1 mile warm up at RPE 9-11, followed by 2-3 minutes at RPE 11-12 and then cycle thru 4 intervals at RPE 15:11-12 at the aforementioned ratio. This is to be followed by 5 minutes at RPE of 11-12, and one (1) minute each at 10-11 and 9-10 to cool down. He will not employ his intervals on his strength training day, but will follow up with his flexibility program.

Moon weighed in at 268.4 lbs – a loss of almost 24 lbs.! His body fat is down ~4% and his BMI is down 10%. All attest to his conviction and self efficacy. Congratulations, Moon!

Moon continues with his base program, “tweaked” along with his progress. I described it as the “foundation of the house; the footings are poured and set and now we begin building the framework.”

Static balance has improved considerably from just a week ago as has ambulation with heel-to-toe stride on an unstable surface, so I introduced Moon to bilateral and unilateral balance exercises on the wobble disc. This will not only improve his balance, but will continue to challenge the support structure of his ankles and strengthen them, particularly the right ankle. He plans to buy a disc this weekend!

The stability ball plank (narrow foot position on the ball) has improved to such an extent that Moon no longer uses his arms at all. In fact, when encouraged, he self selected the “Y” position and demonstrated excellent stability. Way to go, Moon!

Moon still exhibits some extra trapezius recruitment with the scapular retraction exercises, but is aware of it and continues to work on the correct form. He “warmed up” with 5 reps of wall supported scapular retraction before I introduced him to scapular retraction with a wall supported squat and a 4 lb. medicine ball between his knees to challenge his natural tendency toward lateral rotation and disengagement of the adductors. He aced them, completing 10 reps with relative ease!

Additionally, Moon exhibits excellent form on the stability ball walk out, with a push up on the way “back home”. I feel confident he will quickly progress to push ups on the “walk out” (less support).

Moon also shows progress with straight leg and bent leg bilateral calf raises and no longer rocks or pushes on his support for an “assist”.

We discussed nutrition during his workout, prompted by a Runner’s World article I had brought in to share with him. I also encouraged him to read health and fitness magazines to promote his healthy lifestyle and continue to learn and (not:) grow.

How refreshing and replenishing it is to work with such a self motivated individual! I look forward to meeting with Moon on February 7th and assisting in his continued progression.

February 7, 2011
Moon has increased his treadmill speed up to 4.0 MPH and had 2.30 miles in 33 minutes under his belt when I got to the gym for our meeting. He has successfully been incorporating 1 interval session per week into his cardiovascular program, using his RPE to determine his work:rest ratio.

He described his interval session as:
Warm up: 3.4-3.8 MPH - 1 mile ~ 19 mins.
4.1 MPH – 1 minute
3.8 MPH – 2 minutes
4.2 MPH (jog) - 1 minute
3.8 MPH – 2 minutes
4.3 MPH (jog) - 30 sec.
3.8 MPH - 2 minutes
4.4 MPH (jog) - 30 sec.
3.8 MPH - 2 minutes
3.4 MPH ~3 minutes

I tweaked Moon’s program based upon his progress and to prepare him for his impending reevaluation at the end of the month.

Frequency: 2-3 alternate days per week
Sets: 3
Reps: 10
Method: supersetting/bi-sets

Unsupported unilateral ball bridge
Stability ball walk out/push up
Wall supported squat with 4# medicine ball/ or leg press - 130 #
Seated “Pumping Rubber” Row
Adductor lift - 1 set; 15 reps
Unilateral calf raise – Left; Right with “assist” from left
Resisted dorsiflexion with inversion
Balance: Dynamic – eyes open – 1 each side
Static – wobble disc – 1 each side
Static – eyes closed - 1 each side

Moon is continuing his flexibility program and incorporating it into his weight training, i.e., at the completion of 3 sets of bridges and pushups, stretch chest and triceps in between sets of squats and rows.

To top things off, Moon weighed in at 264 today! Yah Moon!!

February 16 & 18, 2011

Another 4 pound weight loss! That’s a total of 32 pounds in 3 months! Moon’s blood pressure is lower than it was our first meeting (118/76) as is his resting heart rate (50), both attesting to his cardiovascular training adaptations.

Cardiovascular:
Moon is continuing to supplement his steady state cardiovascular workouts with 1 interval training session per week. Additionally he has increased his steady state speed from 3.0 MPH to 4.2 MPH as adaptation demands to keep his RPE 12-14. He puts in 40-45 minutes 4-5 days per week as his schedule allows.

Strength: 3 sets of 12 unless otherwise noted
Wall squat with Versa cuff and/or 8#medicine ball, advanced to stability ball and medicine ball
Stability ball push ups: more stable/12 reps advanced to less stable/4-6 reps
Stability ball bridge with unilateral leg lift advanced to bridge leg curl incorporation (1 set)
Pumping rubber row with double bands and incorporation of pronated grip (1 set)
Adductor raise with Versa cuff
Calf raise with wobble disc: Right: with assist from left advanced to bilateral concentric life & unilateral eccentric; Left unilateral
Dorsiflexion with inversion and elastic resistance 15 reps
Ab curl with arm variations: reaching toward heels; crossed over chest
Tried 1 Pilates criss cross and had some difficulty coordinating the movement. Moon will work on this to develop the neural pathways to pave good form.

I have challenged Moon to do one standard push up with good form on February 28th, his re- evaluation date.

Flexibility:
As previous, 1 or more sets; 15-20 second static stretches for all major muscle groups after aerobic and/or strength activities.

Moon is considering arch supports for his sneakers at my recommendation. He wears them in his work shoes to help support his feet. Because of his severe pronation on the right side in particular, it may attenuate other issues down the road.

Moon asked about “doing cardio and this stuff, now”, and after he loses weight hitting the weight room. It was the perfect teaching opportunity to do some myth-busting and I jumped on it, explaining that his body leverage exercises and core work are every bit as strenuous – if not more, owing to the stabilizer recruitment – than the “weight room” or machines. I reiterated some of the muscle cellular, enzymatic and overall metabolic advantages of preserving and hopefully increasing muscle mass during weight loss and how strength training and cardiovascular exercise go hand-in-hand to assist with fat loss. It was a breakthrough moment for Moon. As Moon’s foundational program progresses we will incorporate additional loading utilizing the weight room.

“One more meeting before re-evaluation. Crunch time!

February 25, 2011
Moon is ready and rearing to go having just completed 2.63 miles in 36 minutes at 4.1 MPH on the treadmill as his cardio/warm up. He also just bought another month’s gym membership, which I congratulated him on and acknowledged his commitment. He reports amping up his interval training session to jogging intervals for approximately 40 mins:
Warm up: 1 mile;
5.4MPH/1 minute;
3.8MPH/1 minute;
5.6 MPH/1 minute;
3.8 MPH /3-2 minutes x 4;
10 minute cool down
He weighed in at 257.4 a loss of 35 lbs! His resting heart rate after stretching was 60 and his BP 118/70. His weight training program is sufficiently stimulating and he feels it’s all “working”
and wants to roll with it for a month. He is ready for his reassessment on Monday!

February 28, 2011

11/19/11 2/28/11 Total

Age 56 56
BP 136/78
110/60 -26/-18
RHR 52 65 +13
Height 5’11.5” 5’11.5” 0
Weight 292 259.5 -32.5
BMI 40.7 35.7 -5
Body Fat 40.1% 35.8 -4.2%
Chest Girth 50 46.5 -3.5
Waist Girth 47.5 43.5 -4
Hip Girth 49 44.5 -5
Thigh Girth R: 25.5 L 25 R: 22 L: 22 -3.5:-3
Waist/Hip .96 “at risk” .97 “at risk” .01

11/19/11 2/28/11
Cardiovascular Assessment (old Ankle Injury c/o pain) (No c/o Ankle Pain)
Rockport Treadmill Pace:3 Tx: 20:05 HR 82 RPE 13 Vo2 16.75 “Poor” Pace: 4.3 Tx: 14:08 HR:113 RPE 13-15 Vo2 33.84 “average”
Nomogram: “below average Nomogram: “Above average”
Strength Assessment
Curl up Test:
34 (Intermediate/average) 37 “advanced”
Standard Push up Test:”
Unable
Modified Push up Test: 10 “Poor 1 standard; 15 modified
Double leg lower: knees bent, 30 ˚, “Needs work” 45o “pass”
Prone core strength test : 7 secs. “Needs work” Pass
Supine core strength test: 15 secs. “Pass” Pass
Lower extremity stability: R: “Fail” L: 8 secs. “Needs work” 12 secs. “Needs Work”
Flexibility:

Sit and Reach:
21 “Excellent” 12 “Average”
Supine Shoulder flexion:
Pass Pass
Prone Shoulder extension:
Pass Pass
External rotation:
Pass Pass
Internal rotation:
Pass, but right is less flexible Pass
Hip/Lumbar extensors:
“Needs work” Pass (barrel chest prohibits)
Hip flexors:
R: “Needs work”; L: Pass Pass
Hamstrings:
“Pass” Pass
Quadriceps: “Needs work”unable to extend to reach foot on either side, modified with a towel “Needs Work” 6” right; 4” left
Gastrocnemius:
Pass Pass
Soleus:
Pass Pass
Supine shoulder Flexion Pass Pass
Prone shoulder extension Pass Pass
Ext. Shoulder rotation Pass Pass
Internal shoulder rotation Pass Pass
Thoracic spine mobility 45o Pass 45o Pass
Bend and Lift Screen:
Right eversion/pronation Right eversion/pronation
Right external lateral rotation Right external lateral femur rotation
Symmetrical Symmetrical
Right foot glide to 45o Some heel elevation
Glute dominance Glute dominance
not parallel tib/spine Pass
Kyphosis/flexion Pass
Posture Assessment:
Frontal plane:

Head:
“Pass” n/a
Shoulders:
“Pass”, but right slightly higher n/a
Hips:
“Pass” (even), but show lateral rotation n/a
Spine : “Pass” n/a
Knees:
Internal rotation (“duck toed” to 20˚ - 30˚ n/a
Feet: “Needs work” excessive pronation/eversion particularly on the right side, due to old injury (treated) n/a
Saggital Plane:
Head: “Pass” n/a
Shoulders:
“Pass” n/a
Lower back:
“Pass” n/a
Abdomen:
“Needs work” n/a
Knees: “Needs work” Right Internal rotation
n/a
Feet:
“pass” n/a

Moon finds working out each day to offer diminishing returns by the 3rd day. “I’m wiped” he says. He will integrate swimming as a lower intensity day, swimming 6 laps, resting with a back stroke for a bitna nd repeating for a total of 30 minutes.

I think I’ll go the month of March on my own”, says Moon. “By then I’ll be ready for you to mix it up.” “I’m not backing down. I’ve come too far for that.” Amen! I’d say a total weight loss of 35 lbs., 19 ½ inches, and almost 5% body fat an amazing success in 3 months!
MICROCYCLE PHASE 2:
Week(s) 8-12
• Stability/Mobility/Strength training 2-3 times per week on nonconsecutive days, preceded by a 5-10 minute warm up or cardio workout. Circuit style total body workout.
EXERCISE INTENSITY REPS SETS REST
UNSUPPORTED UNILATERAL BALL BRIDGE BW 10 3 10
STABILITY BALL WALK OUT/PUSH UP BW 10 3 10
WALL SQUAT WITH 4# MEDICINE BALL OR LEG PRESS BW

Or
130# 10 3 10
SEATED RUBBER ROW Blue pumping rubber 10 3 10
ADDUCTOR LIFT BW 15 1 10
UNILATERAL CALF RAISE BW 12 right “assist” from left 2 10
RESISTED DORSIFLEXION WITH INVERSION Blue band 12 2 10
DYNAMIC BALANCE EYES OPEN BW 1 1 10
STATIC BALANCE Wobble disc 1 1 n/a
STATIC BALANCE; EYES CLOSED Floor 1 1 n/a

• Flexibility training 5-7 days per week after active warm up/cardio and/or strength work.
Static stretches for 15-30 secs; 1-3 reps

EXERCISE REPS/SETS
ANTERIOR SHOULDER/CHEST STRETCH 1-2
UNILATERAL UPPER TRAP STRETCH 1-2
CORNER PEC STRETCH 1-2
TRICEP STRETCH 1
CALF STRETCH
SOLEUS STRETCH 1
SUPINE HIP FLEXOR STRETCH 2
SUPINE HAMSTRING STRETCH WITH ASSIST 2
SUPINE KNEE HUG STRETCH 1
SUPINE CHIRO STRETCH 1 each side
QUAD STRETCH WITH ASSIST 1

• Cardiorespiratory training
WARM UP
FAST WALK (3.4-3.8) ON LEVEL GROUND/TM 1 mile/16-19 MINS

WORKOUT
FREQUENCY INTENSITY TIME TYPE
3-4 DAYS/WEEK 11-13 RPE 40-50 MINS. Steady State
1 day 11-16 30-35 MINS. Interval training
Example to build power to jog.
4.1 mph 1 min RPE 13
3.8 2 mins RPE 11
4.2 1 min RPE 13
3.8 2 min RPE 11
4.3 jog 1 min RPE 15
3.8 2 min RPE 11
4.4 jog 1 min RPE 15
3.8 2 min RPE 11
4.5 jog 1 min RPE 16
3.8 2 min RPE 11
3.4 5 min Cool down

April 11, 2011
I ran into Moon at the grocery. He reports he’s doewn to 246 lbs. He states 200 lbs. is his new goal. I cautioned him about body composition changes and the resulting weight changes (muscle weighs more than fat, but takes up less space). He replied, “I’ve still got quite a big gut.” He also reported swimming most every day for crosstraining. I offered Moon a complimentary body composition analysis to better gauge a relative healthy goal weight. We meet April 21st at Bridge Street Gym.

April 21. 2011
I found Moon fast walking on the treadmill when I arrived at the Gym. He was walking at 4.3 MPH and had gone 1.16 miles in 16 minutes. Obviously Moon had increased his steady state speed significantly since we last met!

4/21/11 2/28/11 11/19/11 Total Difference
Height 5’11 1/2” 0
Weight 243 259.5 292 -49 lbs
BMI 33.4 35.7 40.7 -7.3
Body Fat 34.1% 35.8% 40.1% -6%
Girth: Chest 45 46.5 50 -5
Abdomen 40 43.5 47.5 -7.5
Hip 43 44.5 49 -6
Waist/Hip Ratio .93 .97 .96 -.04
Thigh R: 22 L: 21 R: 22 L: 22 R: 25.5 L: 25 R: -3.5 L:-4

Based upon Moon’s new body composition analysis, his relative healthy goal weight range is: 208-214 based upon a goal lean body mass of 23%-25% - about average for a 56 year old male. Moon's own weight goal is reasonable but ambitious, with a relative body fat of 20% - 70 percentile for a male in his 50’s.

We reviewed his weight training and cardiorespiratory programs. Moon stated he has a new performance goal – to be able to jog slowly for his entire interval time frame of 30-35 minutes. He has already amped up some of his resistance training to include some Phase III – load training. His new program will look like this:

MICROCYCLE PHASE 2:
Week(s) 16-22
• Stability/Mobility/Strength training 2-3 times per week on nonconsecutive days, preceded by a 5-10 minute warm up or cardio workout. Circuit style total body workout. One balance exercises will be chosen at random each session.
EXERCISE INTENSITY REPS SETS REST
UNSUPPORTED UNILATERAL BALL BRIDGE OR MAT SINGLE LEG BRIDGE BW 10 3 10
STABILITY BALL PUSH UP LESS BALL BW 10 3 10
SQUAT WITH 12# MEDICINE BALL & BAND OR BW
LEG PRESS Or 130lbs.
OR SMITH SQUAT 50 lbs. 10 3 10
SEATED UNIVERSAL ROW OR SUPPORTED SEATED ROW 80-100 lbs.10 3 10
ADDUCTOR LIFT Leg weights/3# 15 1 10
UNILATERAL CALF RAISE BW 12 right “assist” from left 2 10
FACE CLOTH PULL 3-4 lbs 12 1 10
DYNAMIC BALANCE EYES OPEN BW 60 secs. 1 1 10
STATIC BALANCE Wobble disc 1 1 n/a
STATIC BALANCE; EYES CLOSED Floor 60 secs. 1 1 n/a

• Cardiorespiratory training
WARM UP
FAST WALK (4.2-4.3) ON LEVEL GROUND/TM 1 mile/16-17 MINS

WORKOUT
FREQUENCY INTENSITY TIME TYPE
3-4 DAYS/WEEK 11-13 RPE 40-50 MINS. Steady State
1 day 11-16 35-40 MINS. Interval training
Example to build jogging endurance
4.4 mph jog 3 mins. RPE 13
4.2 1 min RPE 10
4.4 jog 3 mins. RPE 13
4.2 1 min RPE 11
4.4 jog 3 mins. RPE 13
4.2 1 min RPE 11
4.4 jog 3 mins. RPE 13
4.2 1 min RPE 11
4.4 jog 3 mins. RPE 13
4.2 1 min RPE 11
<4.2 5 mins. RPE <11 Cool down

• Flexibility training 5-7 days per week after active warm up/cardio and/or strength work.
Static stretches for 15-30 secs; 1-3 reps

EXERCISE REPS/SETS
ANTERIOR SHOULDER/CHEST STRETCH 1-2
UNILATERAL UPPER TRAP STRETCH 1-2
CORNER PEC STRETCH 1-2
TRICEP STRETCH 1
CALF STRETCH
SOLEUS STRETCH 1
SUPINE HIP FLEXOR STRETCH 2
SUPINE HAMSTRING STRETCH WITH ASSIST 2
SUPINE KNEE HUG STRETCH 1
SUPINE CHIRO STRETCH 1 each side
QUAD STRETCH WITH ASSIST 1
Interview:
Me: “If you could share one thing about yourself what would it be? “
Moon: “Enthusiasm. It takes enthusiasm to do a workout“and keep doing it.... You have to program your mind to be healthy“.”

Me: “What is different now compared to 4 months ago?”
Moon: “Smaller clothes, less fat, more energy, feel better. I don’t get out of bed with a sore ankle anymore, like I used to.”
Moon: “There’s a place at work I have to get into that’s real tight & I can get in there easily now. Before I had to squeeze in there and it’s something I have to do every shift. I used that as a gauge.”

Me: “What are you able to do now that you couldn’t do then?”
Moon: “Walking. I’m starting to jog a little, too, for the first time in many years. More strength – my arms -my whole body. I can do a push up. I couldn’t do a push up before.”

Me: “What is the biggest/foremost benefit of your health changes?”
Moon: “To get to a healthy weight and maintain it. I put off exercising because I thought I didn’t need it. I thought I could just diet. I lost weight but I gained it right back.”

Moon: “You’ve got to tell yourself you’re gonna do it everyday. You can’t give up. It’s the hardest thing I’ve ever done. The workouts aren’t hard to do, but it’s hard to repeat day after day. But the more you do it the easier it gets”.

Before

Cameron, "Moon" Before

After

Cameron, "Moon" After