PART TWO
CONDITIONING
EXERCISES
NEWSDAY/J . CONRAD WILLIAMS, JR .
INTRODUCTION
The physical conditioning routines included in ing, and type of prosthesis used . The prosthetist,
this book offer possibilities for individuals with therapist, and exercise instructor can help identify
lower limb amputation . We begin with calisthenics the best opportunities for exercise based on these
and stretches to improve flexibility and range of variables.
motion, followed by exercises to develop strength The exercises illustrated in this book are per-
and muscular endurance in specific muscle groups formed by athletes who train on a regular basis . All
for the arms, shoulders, legs, abdomen, chest, and are in excellent physical condition and demonstrate
back. exercises that require a range of skill and practice.
The conditioning exercises are performed with Beginners should not attempt to perform any of the
equipment such as Nautilus, available in most health exercises without first consulting a physician.
clubs . An individual with a lower limb amputation
can usually work the same muscle groups on the
same equipment as can a nondisabled person, but CAUTION
not always in the same manner.
Special adaptations or modifications that will People with back injury should avoid lifting
help to make these exercises safe and effective are heavy weights in their exercise programs . To develop
noted in the corresponding descriptions . In many strength and endurance, they should do more
cases, the prosthesis alone provides the necessary repetitions with light weights rather than increasing
support for the movements required . Exercises that the resistance.
will help strengthen the muscles of the residual limb Any exercise has the potential to cause injury to
are also indicated in the descriptions . Many of the the back, whether or not one has had previous back
exercises in Part Two are performed while the injury . In particular, this would include sit-ups and
participant is seated ; this allows the participant to other exercises involving hyperextension of the back,
concentrate on the exercises and weights without as noted in Chapter 10, Abdominals, Leg exercises
having to worry about maintaining balance while requiring special caution, as noted in their descrip-
standing. tions, are squats and dead lift . Exercises that make
Variations for some of the exercises depend on the lower back vulnerable to injury are noted in
the level of amputation . Range of motion and Chapter 12, Back Exercises.
balance may not be the same for a person with an It is important that persons entering an aerobic
AK amputation as they are for someone with a BK exercise program obtain medical clearance prior to
amputation . Besides level of amputation, other outlining the exercise regime . This precaution is
variables include the surgical history, previous train- repeatedly stressed throughout this text . Individuals
23
24
RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss
who have hypertension, for example, are particu- Establishing a Target Heart Rate Range
larly at risk in weight training as well as aerobic
programs . Coronary artery insufficiency is another A target heart rate range for exercise can be
example of a risk factor in undertaking an aerobic predicted as follows : 1) a person's age in years is
exercise program . These risks apply for the subtracted from 220 to give the maximum predicted
nonamputee as well as the amputee . Medical clear- heart rate (beats per minute) ; 2) the range is
ance at all ages is absolutely necessary. determined by figuring the percentage of the maxi-
mum rate that the person must work during exercise
in order to achieve his/her target goal (70 to 85
MONITORING THE INTENSITY OF AEROBIC percent is the range which is considered to be the
EXERCISE most effective for receiving adequate aerobic bene-
fits) . For example, a 35-year-old person will have a
In order for exercise to promote optimum maximum predicted heart rate of 185 (220 minus
aerobic benefit, it must cause the heart to work at 35) . If this person begins an exercise regimen with a
an accelerated rate and in a steady state for a period goal of maintaining a 78 percent target heart rate,
of time . Monitoring the heart rate during exercise is his/her target will be 144 heartbeats per minute
the best way to determine whether the routine is (0.78 times 185).
providing the desired aerobic benefits while ensuring Exercise at the targeted rate should last from 15
that the heart is not being overworked . It is done by to 30 minutes . During this time the heart rate is
establishing a target heart rate and monitoring the monitored . Immediately after the routine is com-
beats per minute immediately after the conditioning pleted, the pulse should be taken to determine the
exercise routine is completed . The goal is to main- heart rate. Most people take a 10-second, rather
tain the target heart rate throughout the exercise than a full minute, pulse count . The 10-second
period (warm-up and cool-down are not part of this count is then multiplied by 6 . Any irregularity in
period) . heart rate, including rapid variations, calls for
SAMPLE CIRCUIT TRAINING
SIT UPS
BENCH PRESS
LATERAL PULL DOWN
LEG PRESS
SIT UPS
MILITARY PRESS
PULL UPS
INCLINE PRESS
25
Conditioning Exercises : Introduction
discontinuing the exercise immediately and consult- tinuous circuit, eliminating rest periods between
ing a physician. each set . A high number of repetitions and light
weights are usually recommended for this type of
A Target Heart Rate Range for Moderate Exercise training.
Certain individuals may not be able to exercise A sample of circuit training follows:
as strenuously as others . A 60 to 65 percent of The pulse should be checked periodically while
maximum heart rate is a safe and still effective exercising to confirm that it is in the target zone . In
target range, especially for an older person . An even time, the exerciser will be able to tell by his or her
lower rate may be necessary for some individuals; breathing rate whether he/she is in the target zone
therefore, when the intensity is lower, the exercise and will only need to monitor pulse rate after com-
period should be extended from 30 to 50 minutes. pleting the circuit . The weights used can be adjusted
Indications of overuse include fatigue, poor to help control the heart rate, but heavy weights
sleeping patterns, and discomfort for extended should not be used for aerobic conditioning . Run-
periods of time following exercise . If it is difficult to ning or jumping rope for 30 seconds between sets is
reach a heart rate of at least 60 percent of another option for maintaining circuit training.
maximum, a lower rate will give adequate aerobic
Muscular Benefits
benefits if the number of repetitions of each exercise
is increased. Whether or not one participates in sports and
recreational activities, muscular conditioning is im-
RELATIONSHIP OF MUSCULAR CONDITIONING portant for good physical fitness . Toning, strength-
TO HEALTH ening, flexing, and stretching muscles through a
regular program of progressive weight resistance
Muscular conditioning is vital to overall fitness. exercises will aid in developing good posture, help
Most body movements rely on the relationship prevent injury, increase endurance for daily tasks,
between the muscular and skeletal systems . Weight create higher energy levels, improve circulation, and
training can reduce the resting heart rate and is add to a person's total self-image . Muscular condi-
effective for relieving stress . With the proper diet, tioning is also basic for successful participation in
body fat can also be reduced while muscle mass is sports that require strength and endurance, and
being increased. should always supplement aerobic training pro-
Exercising properly with weights is the most grams.
effective way to build strength and muscular endur- Conditioning through weights results in in-
ance . Heavy weight resistance with a low number of creased muscular strength and size (hypertrophy)
repetitions builds strength, while light weight resis- that cannot be attained in any other way . Circula-
tance with a high number of repetitions builds tion through the muscles increases, and the number
endurance. and density of capillaries within muscle fiber may
also increase . Muscle enzyme levels rise along with
Cardiovascular Benefits blood volume and hemoglobin . Weight training
Weight training is essentially anaerobic exercise. strengthens bones, as well as ligaments and tendons
While it does not develop the cardiovascular system that connect muscles to bones . Some physiologists
as well as running, swimming, or bicycling, weight- contend that weight training aids in digestion and
resistant exercise will develop strength and endur- can improve elimination.
ance in the muscles of the legs and upper body so
Applications to Physical Rehabilitation
that those muscles do not tire before the cardiovas-
cular system can be improved. Progressive resistive exercise (PRE) as a physi-
If the intensity level of weight training is kept cal rehabilitation technique was the result of medical
high, it can have a positive effect on the cardiovas- experiments performed by an orthopedist, Thomas
cular system . To do this, the exercises must be L . DeLorme, MD, following World War II .* Mus-
performed in such a manner as to maintain between
60-90 percent of maximum heart rate . One way to * T .L . DeLorme, "Restoration of Muscle Power by Heavy Resistance
achieve this is to do each set of exercises in a con- Exercises, " Journal of Bone and Joint Surgery, 4-B, 1945, pp . 645-667 .
26
RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss
GUIDELINES FOR TRAINING WITH WEIGHTS
GENERAL Start with light weights and lift weights progressively . Never start with the
DO'S heaviest set first : the muscles and tendons are not prepared for sudden
AND exertion.
DON'TS Do not continue lifting the weights to your maximum ability on the first set of
repetitions.
Increase the size of the weights by 5 to 10 pounds after you are able to
perform 10 repetitions per set with ease.
Always work the larger muscles of the body first . Small muscles are needed
for lifting heavier weights but they become fatigued more quickly than larger
muscles . For example, the smaller muscles of the arms often become
fatigued before the large muscle groups of the chest or back can be
effectively worked.
Learn and always use the correct form for lifting the weights.
FREQUENCY Frequency and duration depend on personal goals . Maintain a minimum
AND commitment of time in order to keep the body in good physical condition.
DURATION An exercise workout 3 times a week is usually needed to gain significant
results . Workout sessions should last from 30 to 90 minutes with a rest day
in between, which allows the exercised muscles to recover and grow
stronger.
A schedule should be established and maintained . Nothing should interfere
with your workout time . If you do miss a workout session, get back on
schedule as soon as possible.
A competitive body builder or power lifter may train as many as 5 or 6 times
a week . Even in this type of routine, each muscle group is usually given a day
of rest between workouts.
INCREASING The following are Nautilus recommended guidelines for increasing the number
THE of repetitions when training with weights . (These guidelines will be repeated
NUMBER in the introduction of each chapter presenting weight-training exercises .)
OF Always do warm-up exercises before lifting weights.
REPETITIONS
Start with a minimum of 8 repetitions with a given weight . If a minimum of 8
repetitions cannot be completed, the weight is too heavy for you and the
resistance should be lowered until 8 repetitions can be completed.
CAUTION When 12 repetitions can be successfully completed, the weight should be
Beginners are encour- increased by 5-10 pounds . When 12 repetitions can be completed with the
aged to have a spotter increase in pounds, the weight may be increased again.
present when using
free weights . Certain Work up to 1 5-20 repetitions per set for muscle maintenance, endurance,
and tone.
exercises will require a
spotter regardless of When performing exercises with free weights, it is recommended that 2-6
skill level (e .g ., squats) . sets for each particular muscle group be used .
27
Conditioning Exercises : Introduction
GUIDELINES FOR TRAINING WITH WEIGHTS
LEVEL OF A general level of difficulty is rated for each of the conditioning exercises in
DIFFICULTY this book . You can vary the level of intensity by adjusting the amount of
AND INTENSITY weight.
Do not lift to your maximum ability on the first few sets of repetitions . In this
way you will not experience excess fatigue, which could keep you from
finishing the workout.
Work at your own pace . Do not compare your own progress with the abilities
of others . Always maintain proper form.
As you irnprnve, you may add more exercises, increase the number of sets,
add more weight, and shorten rest periods.
BREATHING Do not hold your breath while lifting . This could stop the flow of oxygen to
the brain, which might result in fainting . Holding your breath while lifting can
also close off the escape of air through the glottis, causing a sudden
increase in thoracic pressure . For this reason, many physicians do not
recommend weight training for postcoronary patients.
Breathe in a rhythmic pattern . Some people find it best to exhale while lifting
a weight or moving against resistance and inhale as the weight is lowered or
resistance removed . Others find it better to reverse the breathing for certain
kinds of exercises, such as those involving movements above the head or in
chest expansion workouts.
PROGRESS Keep a record of the number of sets and repetitions for each exercise in your
workout in order to monitor your progress and increase the resistance of the
weights in a regulated fashion.
If your goal is to gain or lose weight, gain muscle mass or lose bulk, you may
wish to keep a record of your body weight and measurements on a regular
basis for future comparison and a record of progress . Photos with front,
baok, and side views are also ho!pful.
28
RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss
cular conditioning through PRE is now used in pre- time to 30 seconds . For very heavy weight sets,
and postoperative care, chronic orthopedic condi- longer rest periods are acceptable.
tions, asthmatic and cardiac conditions, postural In the first week, only one set per muscle group
problems, postpolio care, neurological conditions, should be performed in order that the movements of
motor coordination, and other postinjury therapy. each exercise may be learned and the muscles
Training with weights not only helps one look allowed to adjust to the new stresses . Two sets may
and feel better, it can also improve self-image . For be performed during the second week and three sets
the disabled individual, increasing muscle size, during the third week . This routine should be
strength, and endurance can help to restore self- continued for a total of 8 weeks . When the eighth
confidence . Feeling strong results in feeling well and week is completed, the program should be evalu-
healthy . Muscular conditioning can help people with ated . If this routine is suitable, the exerciser may
disabilities feel more positive about their bodies by continue increasing the number of sets and weights
emphasizing areas of the body which still have func- each week . Intermediate and advanced conditioning
tion and by working to rehabilitate weakened areas. programs require increasing weight repetitions and
The results of regular muscular conditioning sets, as well as adding new exercises.
will be beneficial to the young or old, disabled or
nondisabled . Whatever the goal, there is a program WARM-UP AND COOL-DOWN EXERCISE
that can be tailored to the current physical condition
of anyone in reasonably good health . A physician Flexibility and range of motion are developed
should be consulted before any type of program of and maintained by calisthenics and stretching exer-
muscular conditioning is undertaken. cises before and after the strengthening routine.
A good warm-up prepares the muscles, liga-
Principles of Training
ments, and tendons for action . It steps up blood
Physical fitness programs for rehabilitation, circulation, raises the body temperature, and en-
strength conditioning, body building, and toning hances flexibility of the joints. By limbering the
have different routines . Guidelines are needed to muscles and joints, these exercises can prevent many
safely and effectively begin any of these programs. injuries . Warming up before strenuous or active
In time, individuals usually discover what kind of exercise is especially important in cold weather.
routine and which exercises are best for their partic- The warm-up should consist of some calisthen-
ular needs . An experienced trainer and a rehabilita- ics, stretching exercises, and light resistance exer-
tion team should work with the person with lower cises . It should take from 10 to 20 minutes . Each body
limb amputation in designing such a program. part should be moved through a full range of mo-
A basic training principle is that each muscle tion, first without resistance, then with light resist-
group should be worked every other day, not on ance. (Most experienced weightlifters use a light first
consecutive days ; thereby giving the muscles a set of their resistant exercises as a part of their warm-
chance to recover from the stresses of exercise. up .) Bicycling and running in place are also good
Exceptions to this are the calf and abdomen mus- forms of warming up for weight-resistant exercises.
cles, which may be exercised every day because they Cooling down after completing the entire exer-
are used in daily activities. cise routine is very important . It helps the body
A program should start with a light routine make the transition from high-intensity activity to a
performed three times a week with a day of rest normal level. Stretching and low-grade calisthenics
between each session . The program will usually are best for the cool-down . Cool-down stretches can
consist of three sets of exercise for muscle groups of help prevent muscle soreness . A light jog or bike
each part of the body, with 10 repetitions per set. ride is also a useful means of cooling down . At least
Each body segment should be worked using one or 10 to 20 minutes should be allowed for cool-down
two different exercises . In the beginning, there exercises.
should be a 60-second rest period in order to let the Many weightlifters cool down individual body
muscles recover . Once a routine is established and parts as they complete sets of exercises by doing 8 to
successfully performed, one can increase the inten- 10 repetitions using a lighter weight than that used
sity of the workout by gradually reducing the rest in the routine .
29
Conditioning Exercises : Introduction
BASIC BEGINNING WORKOUT PROGRAM
Warm-up Exercises ; repeat for Cool-down Exercises
Chapter Page
3-5 minutes : calisthenics
Jumping Jacks 5 40
Neck Rolls 5 41
Trunk Twists 5 45
Supine Leg Raise 10 120
Push-ups 11 144-148
3-5 minutes : stretches
Overhead Bent-Arm Stretch 6 53
Shoulder/Arm Stretch 6 54
Quadriceps Stretch 6 63-64
Hamstring Stretch 6 65
* Include any additional calisthenics or stretches you feel are appropriate.
* 3-5 minutes of stationary bicycling (see Chapter 18) or jogging (see Chapter 15)
also may be used for warm-up and cool-down exercises.
BASIC BEGINNING WORKOUT PROGRAM
Resistance Exercises
Repetitions Sets Title Chapter Page
8-12 or 15-20 3 Nautilus Abdominal Chair 10 129
8-12 or 15-20 2-3 Single Knee Extension 9 93
8-1 2 or 15-20 2-3 Leg Curl 9 109
8-12 or 15-20 2-3 Push-ups 11 144-148
8'12 or 15'20 2-3 Nautilus Bench Press 11 152
8-12 or 15-20 3 Overhead Press 8 82
O-12 or 15-20 3 Nautilus Lat . Pull-down 12 169
8-12 or 15-20 3 Triceps Curl 7 71, 74
8-1 2 or 15-20 3 Seated Arm Curl 7 76
30
RRDS Clinical Guide . Physic& Fitness : A Guide for Individuals with Lower Limb Loss
PROFILES OF THE EXERCISERS
Samantha Ellis
Samantha Ellis is an exceptional person . She is
missing both limbs above the knee, but the ability to
bear weight on the end of one of her residual limbs
has given her an advantage in being able to develop
her remarkable skills in physical activities.
The prostheses Ms . Ellis uses for most activities
are Endolites with Contoured Adducted Trochan-
teric/Contained Alignment Method (CAT/CAM)
Flexible Sockets made with a polyethylene inner
socket and polypropylene outer frame socket . She
also uses a Mauch Swing Phase Hydraulik TM Knee
Unit for increased knee stability, along with the
Endolite Stabilized StanceFlex Knee.
Ms . Ellis swims to stay in good physical
condition and also plays golf . She discovered the
benefits of health club equipment for strength
conditioning and has taken up downhill skiing for
recreation . Born and raised in England, Ms . Ellis
now works part of the year in the United States at
a.f.i . Endolite in Hialeah, Florida as a customer
relations representative .
31
Conditioning Exercises : introduction
John Everett
John Everett is a Vietnam veteran who has
bilateral below-knee amputations . He works out
regularly with the same prostheses that he uses for
his daily activities . He rides a stationary bicycle and
walks for aerobic exercise . In the winter months, he
enjoys downhill skiing . He feels that exercise enables
him to be an active participant in recreational
sports, as well as helping him to have more energy in
his everyday routine.
His prostheses are exoskeletal in design with
Seattle Feet, pelite liners, silicone end pads, New
Skin cosmetic finishing, USMC's Adjustable Leak
Rate Small Suction Socket Valves, and the
ActivSleeve Suspension System. Although the
ActivSleeve System produces a suction-type suspen-
sion, the addition of the small suction valve helps to
purge any extra air from the socket (a 3-ply socket
fit with a DAW Sheath underneath), which ensures
true atmospheric suspension . When working out in
the gym, Mr . Everett sometimes adds an extra ply
sock and interchanges his pelite liner with the PM
liner, which helps absorb the extra forces placed on
his residual limbs.
Mr . Everett counsels people with drug addic-
tions, does peer counseling in amputee support
groups at Harborview Hospital and other locations
in the Seattle area, and is a volunteer at the
Prosthetics Research Study, a firm in Seattle .
32
RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss
Richard Hughes
Richard Hughes has a below-knee amputation.
He enjoys a variety of sports and stays in good
physical condition by sculling in his own boat . He
competes in triathalons, which requires him to
maintain several types of prostheses for several
sports activities . Mr . Hughes is chief of the Techni-
cal Marketing Department for a .f.i . Endolite in
Hialeah, Florida. He has also worked as a clinical
prosthetist.
The artificial limb Mr . Hughes uses most
frequently consists of a skin-fit suction below-knee
prosthesis with a flexible wall polyethylene inner
socket and a polypropylene outer frame socket,
which is cut out over relief areas for increased
comfort and lighter weight . An Endolite prosthesis
is also incorporated into the design with an adapted
Seattle Foot and the ActivSleeve Suspension System .
33
Conditioning Exercises : Introduction
Greg Mannino
If Greg Mannino looks familiar to you it is
because he is a highly visible professional amputee
athlete . He trains year-round to maintain his rank-
ing as one of the top downhill three-track skiers in
the world . When he is not race training in Vail,
Colorado, or traveling to a ski race, he is working
on staying in good physical condition by lifting
weights regularly . He also enjoys bicycling, running,
cross-country skiing, and horseback riding.
Mr . Mannino, who has an above-knee amputa-
tion, wears an Endolite prosthesis with the Stabi-
lized StanceFlex (Bouncy) Knee, with the Mauch
Swing Phase Hydraulik Knee Unit . He feels that the
comfort of his CAT/CAM flexible walled socket has
contributed to his ability to achieve a high level of
performance.
34
RRDS Clinical Guide. Physical Fitness: A Guide for Individuals with Lower Limb Loss
Mike Nitz
Mike Nitz was a competitive power lifter before
losing his leg above the knee . He has since returned
to the gym and has designed a program that
accommodates for his limb loss and prosthesis and
still allows him to maintain a high level of intensity
during workouts . The only exercises he has not
continued are standing squats and the dead lift.
Mr. Nitz was back at work soon after receiving
his first prosthesis . Because his job as a sanitation
engineer is physically demanding, he feels it is not
only important for him to stay in good physical
condition but also to have a prosthesis that can
perform adequately . He uses a Narrow ML Flexible
Brim Socket with a Mauch Swing and Stance Phase
Knee Control Unit (Mauch SNS Knee Unit) and the
Flex-Foot .
35
Conditioning Exercises : Introduction
Linda Pedersen
Linda Pedersen works out on Nautilus equip-
ment at least three times a week . She enjoys snow
skiing in the winter and has competed in regional ski
races sponsored by the National Handicapped
Sports and Recreation Association (NHSRA) . She
plays tennis, water skis, and has played several
seasons of crutch soccer as co-captain of a Seattle,
Washington team . A former track star in high
school prior to losing her leg above the knee, Ms.
Pedersen is an excellent foot-over-foot runner.
She uses an everyday walking prosthesis for
most of her activities . It consists of a quadrilateral
suction socket, Mauch SNS Knee Unit, and Otto
Bock SACH Foot . This exoskeletal prosthesis is
simple in design and requires very little mainte-
nance . For running, she often wears the Terry Fox
Spring Shank and the Seattle Foot.
Ms . Pedersen is an administrative assistant in
the Property Department of the Johnson and
Higgins Insurance Brokerage firm in Seattle and
does volunteer work at the Seattle Prosthetic Re-
search Study .
36
RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss
Albert Rappoport
Albert Rappoport, one of the authors of this
book, had been athletic prior to losing his leg below
the knee and has worked to regain his abilities . He
enjoys weight training, swimming, and skiing for
fitness and plays tennis and racquetball.
Mr . Rappoport wears primarily one prosthesis
for his everyday activities, as well as for the
weightlifting exercises shown in this book . The
below-knee exoskeletal prosthesis uses a petite liner,
silicone end pad, wool sock and sheath, ActivSleeve
Suspension System, and Seattle Light Foot . Mr.
Rappoport also wears a Flex-Foot prosthesis fabri-
cated with a graphite epoxy socket for activities that
involve running . The socket is a duplicate of that
used with his regular prosthesis and utilizes the same
liner . Stationary rowing photos show him using an
endoskeletal prosthesis with Otto Bock components,
ActivAnkle, and the Carbon Copy II Symes Foot.
Mr . Rappoport is a prosthetist in private
practice and director of the Performance Prosthetic-
Orthotic Center, Santa Monica, California . Previ-
ously, he was chief research prosthetist at the
Prosthetics Research Study, Seattle, Washington.
He also has worked as a Nautilus instructor and has
taught courses in physical conditioning at the Uni-
versity of Southern California .
