Help for New Client

[UConnJulie]

Hey all ... I have a new client starting next week who is very morbidly obese. She is looking to lose some weight before bariatric surgery (stomach stapling I think) or possibly delay/avoid surgery. Although I have trained very overweight persons, I have not had anyone who was this far "gone". She gets VERY short of breath with minimal activity, and I'm just not sure where to start her. If I were in the PT clinic I know what I'd do, but since she is paying me out of pocket, it seems silly and I want her to feel that she is getting her money's worth.
Any tips on where to start?
Thanks in advance for your help! I'd love to help her learn a healthy lifestyle and avoid the surgery ...

Julie

[stingo]

Out of curiosity, how heavy is your client? I was around 350 when I started, and found that I could do about a minute 45 seconds on the elliptical. Would simple walking be an option?

[Aoife]

My MIL is probably in a similar catagory. We got her a walking in place tape with a band to do some light (she's really weak) resistance training. Since your client is likely more motivated, I'd say perhaps bands if weights are just too much for her, and then... gee... Take a look at the old Richard Simmons stuff... and try to incorporate that kind of stuff, perhaps. That was his target audience, after all... people who couldn't do too much.

[UConnJulie]

Tom,
Thanks ... I'm not sure of her starting weight ... we've only spoke on the phone (she wanted to get an appointment with me before she left on vacation ... she won't be back until next Tuesday) but we work for the same company so we've met before.
If she were coming to physical therapy, I would start her out with walking (treadmill most likely) but she wants to workout at home and doesn't have a treadmill or any other equipment. I'd like to do some bodyweight stuff with her ... a simple circuit ... and also some walking outside or in place ... I just don't want to tire her out in 5 minutes when she is maybe expecting more, you know? Other people that I have "trained" are more fit and I can keep them going for nearly an hour ...
But maybe I'm just looking at this wrong ...

[UConnJulie]

Aoife, thanks ... I hadn't thought of that ... although that's not too far off of what I was thinking would be best (see my post above) ...

[Lisa~]

Julie,

What have you tried so far? With my clients I've found that some heavier clients are actually pretty strong. They've been moving a lot of weight around for a long time. I try to focus on that aspect for them and move right into squat, dead, and bench. The energy system training is slower going. Just begin and move up from whatever they can do to doing something more, even if you begin with nothing but walking. You can do uphill walking bursts with flat recovery periods of longer duration.

But for a client who is obese and weak you have to get really creative. For the lifting portion of the program you've got to come up with some kind of exercise for each basic movement. Usually I can give them a bw split squat holding on to a support and if they can get on the floor, then glute bridging variations for hips. Maybe they can bw squat to a bench. Upper body movements are easier, just using DBs. Inclined push-ups might work. Seated cable rows work. Lat pulldowns and DB overhead pressing. Core work can be side planks either from the knees or if they're stronger then with their elbow on a bench. Sometimes their body is just in the way, so using the bench makes front planks work.

Does any of that get you started?

[Aoife]

I would think another option to remember is that an hour or whatever can be achieved over a day. So, if her endurance is so low that she can't tough out anything for that long, splitting up the workout wouldn't be bad. Chair squats and shoulder presses or something with 5-10 minutes walking, then later pulldowns and something else followed by more walking, etc.

Then, she gets value, can work on improving endurance, and still gets in more than 10 minutes of activity a day.

[stingo]

Tiring her out in 5 minutes may be unavoidable if that's what her condition will permit. I'm going by my own experience here - that minute 45 secs was the longest of my life, and I was gasping for air after it. Walking a flight of stairs might do the same for her - what seems like a given to people of more typical bodyweight is a challenge for those of us with higher bodyweights, esp without a history of exercise. In a sense this is putting the cart before the horse, as once you've seen and assessed her abilities I'm sure you'll be able to come up with a much better program adapted to her capabilities and limitations.

[UConnJulie]

Thank you guys ... you have given me some great ideas ...

Lisa, I haven't evaluated her yet as our first session is on the 11th, but I like to plan ahead. I do know her somewhat from the agency where I do physical therapy, but very minimally ... she seems like she is fairly strong, but who knows ... I guess I'll find out!!

[L'ilJ]

Julie. If you think you client may not have the endurance to make it through a longer workout to begin with, consider working in some yoga or meditation techniques to make her generally feel better. Spend some time doing some deep breathing and light stretching before moving into something a little more strenuous in the form of your planned workout. Then, bring it back down to breathing, stretching, relaxing, etc. You know how yoga gives you that nice happy feeling? I think that goes a long way when someone is just starting out their fitness journey. Make it positive experience that isn't too discouraging right off.

[Victoria]

I sure don't know much about the physical stuff, but I agree with what Jill is saying.

Maybe what's important for now is to structure her sessions so that your client feels like what she is doing is actually doable for the long haul. She may see her road to fitness and weight loss as an enormous hill to climb. If she sees it as too high to ever reach the top, she may get discouraged too early in the game. Keep it interesting and challenging and most of all...make it fun, ('cause you ARE fun to be around! ) Could you do the work with her so she feels like she has a workout buddy, play some upbeat music, etc.?

[Leigh P.]

Hey Julie,

There are a few things you need to remember when working with severely obese clients (clients who need to lose more that 150 pounds of fat). Here are some tips that may help you.

1) A max is a max-Obese clients are no different than regular clients if you look at thing in the eye of max effort. Yes there max effort is going to be far less than someone else's but this is what you are trying to achieve none the less. You have to be careful and monitor more, but don't be afraid to push boundaries either. As far as movements I like...

Alternating leg Aerobic Step ups-Now these are step ups where you are going to need to push off with your other foot. Keep the height low to start, raise the height as she progresses.

High Leg Side Steps-Think of the start of a sumo side lunge. It basically is one just with no lowering of the body. Very effective and allows some different plane movements

Plank Ups-No obviously holding up the body weight for an extended period of time isn't possible for these clients, but the goal is to work it towards that. For this I like plank ups. You get in a prone position and raise into a plank and then lower, much like push ups but the elbow raise support allows for the client to not strain their wrists and feel more stable. Over time you can progress how long they hold at the top. move from 2 secs to 3 secs, etc. (this is the prone posititon I am speaking of... http://www.sport-fitness-advisor.com...one_bridge.gif

Toe Touches/DB Deadlifts-Just simple toe touches do wonders, you can progress to DB deadlifts.

So that some movement.

2) Diet is everything-Now you may not be a nutritionists, but if you are talking to them about their diet, your wasting your time. Someone of that level of body fat has severe problems with food and horrible dietary habits. You need to provide them with some little guide or point them to one you support that will help them with their diet.

3) Psychology 101-Usually people in this area are really going to need a friend and someone to take them seriously. This is a hard change, when some of us think about the frustration of losing 20 pounds, try 150 or more. Then have someone tell you it slow and steady that wins the race. Motivation, praise, and constant education is key. Never assume they understand anything, overly explain thing, make it impossible for them to think in their head "well i just didn't know". Take away the excuses and make it clear they are making the choice to not do what they need to do.

Hope that helps, good luck to you and your client Julie.

[UConnJulie]

Thanks Jill and Victoria ... good ideas ...

Leigh, as always good words of wisdom ... I really appreciate the help. You've given me some good things to think about and now I think I can come up with a good plan ...