ACE Personal Training Manual Chapter 6 Building Rapport And Initial Investigation Stage

ACE exam, ACE studying, ACE Certification, ACE StudyingI have been studying for the ACE exam for a few months now and here are my ACE Personal Training Manual Chapter 6 notes.

Building Rapport

First impressions are everything for building rapport with a new client. Thus, it is imperative to make a strong, convincing first impression. Furthermore, we need to take a targeted approach to building rapport. Our focus should be on developing a solid level of trust, harmony and emotional affinity. Three attributes are essential for building a successful relationship: empathy, warmth and genuineness. First, empathy is the ability to experience another person’s world as if it is our own. Secondly, warmth is unconditional positive regard or respect for another regardless of their individuality and uniqueness. Finally, genuineness is authenticity or the ability to be open and honest.

Rapport is one one of the 4 successful stages of a client-trainer relationship. It is ongoing, meaning it continues to develop throughout the relationship. Additionally, it involves personal interactions between a client and trainer as well as the ability to effectively communicate.  As discussed in previous chapters stages also include the investigation stage, planning stage and action stage (key concept).*

Additional Stages

First, the investigation stage is the collection of all relevant information to identify the needs of the client and their readiness for change. This is the stage in which we collect health and safety information and discover lifestyle preferences, interests, attitudes and previous experiences with exercise. Next, the planning stage is when we collaborate with clients on their goal setting. Then, we design an effective and comprehensive program and apply motivation and adherence strategies. Finally, the action stage is when we implement the program, give instruction and feedback progression, demonstrate, motivate, evaluate, adjust and monitor (key concept).*

Our first objective is always building a foundation for a personal relationship with the individual. Gathering information on goals and objectives is secondary. We need to first get to know them and understand their individual characteristics.

Communication Skills and Factors

Environment and Body Positioning

Pay special attention to how we communicate and the factors effecting our first impression. First of all, environmental – we should meet in a calm, quiet area and sit facing the client. It is important to avoid high traffic areas.

Second, effective communication is more based on nonverbal cues, including: posture, facial expressions, gestures and eye contact. Body positioning should be to face the client squarely and maintain 1 1/2 to 4 feet of personal space, never less than 1 1/2 feet. Posture and position should be open, well balanced and erect but relaxed. Lean slightly forward to show confidence and interest. Leaning or stooping communicates boredom or fatigue. Rigid hands on hips communicates aggressive. Crossing our arms and legs means closed or defensive.

Mirroring and gestures should mimic the client’s posture, gestures, and voice tone and tempo. Use relaxed, fluid hand gestures and reduce distracting movements (foot tapping). Avoid postural changes while listening. Avoid finger pointing or other intimidating gestures. Maintain a relaxed look and avoid fixed stares. Looking away while a client is speaking conveys disinterest and shows what they are saying is not important.

Facial Expressions and Voice Quality

Next, facial expressions should be should include a genuine smile. Finally, voice quality (tonality and articulation) should be firm, confident and professional to convey warmth and empathy. A weak, hesitant voice doesn’t inspire confidence. A loud, overbearing voice can make people nervous. Avoid too many voice fluctuations. One of our primary focuses should be listening effectively. We can speak 125 to 250 words per minute but we can listen at 500 words per minute. We need to listen to both content and the emotion behind it. Avoid indifference (tuned out, not listening), selective listening (only listening to key words), and passive listening (only giving the impression you are listening). Engage in active listening or showing empathy by listening as if you are in their shoes.

Empathy

Trainers should be attentive and empathetic regardless of their opinion. We can do this by separating meaningful content from superfluous information. Additionally, avoid getting caught up on trigger words (hot buttons) that distract from listening and understanding the entire message. Become aware of how the client’s emotional patterns change based on the nature of the content discussed.

Also be conscious of how cultural and ethnic differences affect communication. Distinguish between verbal messages that reflect apparent (cognitive) and underlying (affective) content of the communication. Cognitive is factual. Affective messages are compromised of feelings, emotions and behaviors and expressed via both verbal and nonverbal communication (key concept).*

Interviewing Techniques

It is important for trainers to implement a variety of interviewing techniques to clearly understand a client. First, use minimal encouragers or brief words or phrases encouraging them to share additional content. Second, paraphrase or restate the essence of the content. Thirdly, use probing or ask more questions to gather more information. Next, use reflection or restate the feelings or content of what the speaker said using different words. This displays empathy and understanding. In addition, use clarifying or verify you understand the content the client is communicating. Inform the client or expand upon information shared. Confront clients or use mild to strong feedback. Ask open ended questions instead of those with a yes or no response. Avoid deflecting or changing the focus on the communication from one individual to another. This devalues and diminishes the content from the speaker.

Communication Style

We should use a communication style that matches our client’s needs. First, a preaching style or delivering the content in a lecture type style is judgmental. Next, an educating style is informational and delivers information in a relevant and concise manner. This allows the client to make information decisions. In addition, a counseling style is supportive and utilizes collaboration. This is the most effective style once implementing and modifying a plan. Finally, directing is where instruction and direction are provided. This is most effective for proper safety and form are the goal.

Some questions to ask include:

Tell me about a typical week in your life. What types of physical activities are part of your daily routine (occupational, tasks, household, etc)? Do you participate in consistent business activities, such as travel or entertaining that extend the hours of your work day or week? How do you spend your time away from work? Do you participate in regular exercise, recreational travel or physical play? Do you experience any pain during movement or exercise? When was the last time you were physically active? Leisurely or vigorous? For how long?

Stages of Behavioral Change

Once we have developed rapport, we need to identify a client’s readiness to change or their stage in the behavioral change process. We can use the transtheoretical model of behavior change (TMM) or the stages of change model for this purpose. Determining their stage will help us design and implement a program for their level. When we employ strategies before they are ready, we may end up setting them up for failure. We can administer a questionnaire and a person with more yes responses is more likely to commit to change. Review figure 6-1 on page 116.

Motivational Interviewing and Goal Setting

Motivational interviewing can facilitate behavior change as it helps the client feel in control of their journey. We can use it to enhance intrinsic motivation by exploring and resolving ambivalence to change. This gets the clients “off the fence” and requires careful listening and strategic questions. Goal setting is an opportunity to gather additional information about our clients. We can use goal setting to understand expectations, desires and doubts and create connection.

Health-Risk Appraisal

The purpose of pre-participation screening includes: identifying the absence or presence of CV, pulmonary or metabolic disease, identifying individuals with contraindications to exercise, detecting client’s who are at risk and should undergo medical evaluation first, and identifying people with medical conditions who need to participate in medically supervised programs (key concept).*

A pre-participation screening must be performed on all new clients in facilities that offer exercise equipment ore services. If someone plans to engage in self-guided activity, they should at least complete a general health-risk appraisal such as the Physical Activity Readiness Questionnaire (PAR-Q).  This is a minimal and safe pre-exercise screening for low to moderate not vigorous physical activity. The advantages are it is quick, easy and non invasive. The disadvantages is that it is limited due to its lack of detail. Furthermore, if multiple risks are discovered on the PAR-Q, a more detailed health history is recommended.

Risk Stratification

The basis for performing risk stratification before engaging in an exercise program is to determine: the presence or absence of CV, pulmonary or metabolic disease, CV risk factors, and signs and symptoms of CV, pulmonary or metabolic disease. Physical activity recommendations are based on the number of risk factors present. Additionally, risk stratification is identified as low, moderate or high.

We should perform the following steps chronologically: identify CAD risk factors, performed a risk stratification based on CAD risk factors, and then determine the need for a medical exam and/or clearance and medical supervision.

First, we need to identify the total number of risk factors by giving each positive risk factor a value of 1. Subtract 1 for HDLs greater than or equal to 60 mg/dl.

Positive Risk Factors

  1. 1. Age – male greater than or equal to 45, or women greater than or equal to 55.
  2. 2. Family history – MI, coronary revascularization or sudden death before 55 years of age in father or 1st degree male relative or before 65 years of age in mother or 1st degree female relative.
  3. 3. Cigarette smoking – current, quit within the past 6 months, or exposed to second hand smoke.
  4. 4. Sedentary lifestyle – not participating in at least 30 minutes of moderate intensity physical activity on at least 3 days per week for at least 3 months.
  5. 5. Obesity – BMI greater than or equal to 30 kg/m2 or waist girth greater than 102 cm for men and 88 cm for women.
  6. 6. HTN – SBP greater than or equal to 140 mmHg or DBP greater than or equal to 90 mmHg or on antihypertensive medications.
  7. 7. Dyslipidemia – LBL greater than or equal to 130 mg/dl, HDL less than 40 mg/dl, total serum cholesterol greater than or equal to 200 mg/dl or on lipid lowering medications.
  8. 8. Prediabetes – fasting glucose greater than or equal to 100 mg/dl but less than or equal to 125 mg/dl or impaired glucose tolerance where a 2-hour oral glucose test value is greater than or equal to 140 mg/dl.

Low risk is less than 2 positive risk factors and the client is asymptomatic. Moderate risk is greater than or equal to 2 risk factors and symptomatic. High risk is someone with known CV, pulmonary, renal or metabolic disease. If a client is high risk, they should first have a medical exam before engaging in vigorous activity and the physician should supervise the exercise test.

Activity Level Classifications

Moderate physical activity is 40 to 60% Vo2R or 3 to less than 6 METs. It can also be described as an intensity that causes noticeable increases in HR and breathing. Vigorous activity is 60% Vo2R, greater than or equal to 6 METs or activity that substantially increases HR and breathing.

Signs and Symptoms of Medical Conditions

Signs and symptoms of medical conditions are used in risk stratification but personal trainers should stay within the scope of practice never diagnosing. They must be interpreted by a qualified professional. Signs and symptoms include: pain (tightness) or discomfort (angina) in chest, neck, jaw, arms or other areas that may be a result of ischemia, SOB or DOE (difficulty breathing), orthopnea (dyspnea in a reclined position) or nocturnal dyspnea, ankle edema, palpitations or tachycardia, intermittent claudication, known heart murmur, unusual fatigue or difficulty breathing with usual activities, dizziness or syncope. We must notify their physician of any signs or symptoms of CAD (key concept).*

Evaluation Forms

Addition forms personal trainers should utilize include informed consent or the “assumption of risk.” This is when the client acknowledges they have been notified of the risks associated with the activity. It is used to provide evidence of the disclosure of purposes, procedures, risk, benefits and limitations. It is not a liability waiver and doesn’t provide legal immunity but rather communicates dangers.

Secondly, trainers should use an agreement and release of liability waiver. This releases a personal trainer from liability from injuries the client may suffer. It is the voluntary abandonment of the client’s right to file suit but it doesn’t cover negligence.

Thirdly, the health history questionnaire should be utilized to collect more detailed medical and health information beyond CAD Risk factors. It is important to assess past and present activity levels, medications, supplements, injuries, illnesses, surgeries, family medical history and lifestyle information.

Next, trainers can use an exercise history and attitude questionnaire. This form will ask about previous exercise history including behavioral and adherence experience. See page 125!

A medical release form should also be used. This provides the personal trainer with medical information and limitations and guidelines outlined by the physician.

Finally, testing forms are used for recording testing and measurement data during the fitness assessment.

Regular physical activity can increase the risk for musculoskeletal injury and CV problems, such as cardiac arrest. Injuries usually occur due to aggravation of an existing condition or precipitating a new condition. The primary systems of the body that experience stress during exercise are CV, respiratory, and musculoskeletal (key concept).*

Health Conditions Affecting Physical Activity

Cardiovascular

Atherosclerosis or fatty deposits of cholesterol and calcium accumulate in arterial walls causing hardening, thickening and loss of elasticity. It is considered CAD when it affects the blood supply to the heart. In this case, the increased oxygen demand by the heart during exercise is not met with an increase in blood supply. Which can lead to angina, an MI or a heart attack.

Our blood pressure increases during exercise, especially during heavy resistance training, weight lifting or isometic contractions. This may be an issue for someone who has already been diagnosed with HTN or has untreated HTN.

Respiratory

Anyone who has been diagnosed with bronchitis, emphysema, or COPD may experience difficulty breathing during activity.

Musculoskeletal

The musculoskeletal system consists of muscles, bones, tendons and ligaments and it is the system most commonly injured during exercise. Health screenings are crucial for identifying current injuries and risk for subsequent injuries. Overuse injury is the most common type of injury for someone who is physically active. It is usually the result of poor training techniques, poor body mechanics or both. It includes runners knee, swimmers shoulder, tennis elbow, shin splints, iliotibial band syndrome (ITBS). People have a better chance of avoiding these injuries when they cross train.

Metabolic and Other

Anyone with a current diagnosis of diabetes or thyroid disease must have physician approval before beginning an exercise program. A hernia, either inguinal or abdominal, is a relative contraindication to weight lifting. An increase in abdominal pressure may make it worse and these clients should avoid the Valsalva maneuver. Pregnancy is not the time to pursue maximum fitness goals. Additionally, pregnant women should focus on maintaining a good fitness level. They should obtain physician approval during and up to 3 months postpartum. When a client is dealing with a mild illness or infection they can moderately exercise but if severe it is a contraindication.

Medications

Clients taking medications that have an effect on exercise should obtain a physician clearance first. These include beta blockers, calcium channel blockers, ACE inhibitors, angiotensin 2 antagonists, duretics, bronchodilators, cold medications, and antihistamines. See table 6-2 on page 133 for key concepts.*

Assessments

Physiological assessments to consider include: resting vital signs (HR, BP, height and weight), static posture and movement screening, joint flexibility and muscle strength, balance and core function, cardiorespiratory fitness, body composition, muscular endurance and strength, and skill related parameters (agility, coordination, power, reactivity and speed). Keep in mind we should always measure vital signs and skin folds before activity. In addition, any gains in strength in the first 1 to 4 weeks are usually due to neurological adaptations and not changes in muscle physiology.

Test Termination

We should terminate the test immediately if any of the following occur: onset of angina, significant drop greater than 10 mmHg in SBP despite and increase in exercise intensity, an excessive increase in BP (SBP greater than 250 or DBP greater than 115 mmHg), fatigue, SOB, difficulty breathing or labored breathing, wheezing, signs of poor perfusion (pallor, lightheadedness, cyanosis, nausea, cold or clammy skin), an increased in nervous system symptoms (ataxia, dizziness, confusion, or syncope), leg cramping or claudication, physical or verbal manifestations of severe fatigue, and if the client requests to stop or testing equipment fails.

Testing Environment

Avoid extreme temperatures during testing. Keep it between 68 to 72 degrees Fahrenheit. Additionally avoid uneven surfaces and crowds. Maintain privacy, adequate lighting, power equipment and proper emergency protocol.

Heart Rate

Take the pulse using the radius or carotid and contact a doctor if you feel any irregularities. HR is a valid indicator of work intensity at rest and during exercise. People with a higher RHR may have higher fitness levels as the adaptation to exercise is an increase in SV and subsequent decrease in HR.  The heart classification system is SB is a heart rate less than 60, NSR is 60-100 and ST is greater than 100 bpm. The average RHR is 70-72 bpm, 60 to 70 in males and 72 to 80 in females.

Knowing a clients RHR gives good insight into overtraining syndrome.  A elevation in RHR greater than 5 bpm for days is a good reason to taper training intensities. RHR can be influenced by fitness status, fatigue, body composition, drugs, alcohol, medications, caffeine and stress. Body position affects RHR in that standing or sitting elevate HR more than supine or prone positions. Digestion also increases HR. Anything that places additional stress can also elevate HR – noise, temperature, and sharing personal information.

A true RHR is taken before a client gets out of bed but has been resting comfortably for several minutes.

Blood Pressure

BP is defined as the outward force exerted by blood on the vessel walls. Blood pumping against the ventricular wall creates SBP, while the DBP is the filling phase of the cardiac cycle. Record the first sound as SBP and the 4th (muffled) or 5th (disappearance) is the DBP. Normal is a SBP less than 120 and SBP less than 80. Prehypertension is SBP 120-139 or DBP 80 to 89. Hypertension stage 1 is SBP 140-159 or DBP 90-99 and stage 2 is SBP greater than or equal to 160 or DBP greater than or equal to 100. For individuals 40-70 years of age each 20 mmHg increased in SBP or 10 mmHg increase in DBP doubles their risk of CV disease.

Ratings Of Perceived Exertion

RPEs are a subjective measure of exertion. Use them to complement HR or replace it in cases where it will not be accurate. The 2 standardized ratings include the Borg 15-point scale (6 to 20) and a modified 0 to 10 category ratio scale. Use the borg scale estimate heart rate. For example, 6 equals 60, 12 equals 120 and 20 equals 200 bpm. Men tend to underestimate and women overestimate. Using the scale may be difficult sedentary individuals. Use the scale when HR is unreliable. We can use the 0 to 10 scale when we don’t need to measure HR via the RPE.

Exercise Induced Feeling Inventory

Quantify a client’s emotions and feelings following exercise using the exercise induced feeling inventory. Administer it verbally for better results. Have the client score 12 words on a 0 to 4 scale. The words come from 4 subscales: positive engagement, revitalization, tranquility, and physical exhaustion.


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