This case study is of a 70-year-old client named Ella who, at nearly 300 pounds, decided to undergo bariatric surgery (vertical banded gastroplasty – “lap band” procedure), and had lost 83 pounds when our relationship began in April of 2008. Ella was referred to my practice by a friend.  She had several different health concerns that would impact the proper design of an appropriate exercise program.  In addition to battling obesity most of her adult life, she had undergone a double hip replacement, had mild degenerative disc disease in the lumbar spine, and patellar osteoarthritis of the right knee.  A group exercise program she attended at a women’s fitness club had aggravated her knee, thwarting a previous attempt to improve her fitness level. My assessment revealed:

• Normal resting heart rate.
• Stage I hypertension.
• Rounded shoulder syndrome with extreme internal shoulder rotation.
• Restricted cervical rotation and lateral flexibility, as well as a slight excessive cervical lordosis.
• Restricted mobility of the internal shoulder rotator muscles.
• Restricted dorsiflexion of both ankles, which drastically increases the risk of falling in older adults.
• Very weak upper and lower body.
• Inability to get up and down from the floor.
• Overweight.

The program I designed for Ella incorporated the following elements:

1. Chair-based strength training exercises for the upper and lower body at 55-70 percent 1-rep max, depending on the exercise.  I recommended strength training three times per week.
2. Open-chain (isolation) lower body strength training, and an avoidance of weight-bearing lower body exercises. (Although weight-bearing closed-chain exercises are more functional, they can aggravate pre-existing orthopaedic conditions in some clients).
3. Flexibility exercises for all muscle groups, with a particular focus on the pectorals, subscapularis, and anterior shoulder capsule.
4. Strengthening of the tibialis anterior, stretching of the calves.  (This capitalizes on the principle in exercise physiology called “reciprocal inhibition” – that when one muscle group is strengthened, the opposing group relaxes.)
5. One hour of low to moderate intensity (40-60% VO2 max) cardiovascular exercise 4-5 times per week, preferably walking.  I suggested 30 minutes of consecutive cardio, with the remaining 30 minutes discontinuous and spread throughout the day.
6. Take the stairs to her 8^th floor apartment once a day, five days per week.
7. Referral to family physician to investigate elevated blood pressure.
8. Pre- and post-exercise blood pressure readings, and monitoring of heart rate while exercising.
9. Continue with healthy nutritional choices, and consider joining a weight management group of some sort.  (Research has demonstrated that group support drastically increases the success rate those trying to lose weight and keep it off.)

One and a half years later, Ella had lost a further 30 pounds, and had achieved success in incorporating exercise into her daily routine.  Furthermore, we were able to progress to multi-joint, closed-chain lower body exercises now that a solid base of strength had been established.  I am pleased to say that, 6.5 years later, Ella continues to be a regular client.   Issues Specific to Bariatric Surgery Bariatric surgery is extremely effective for individuals who have repeatedly failed to lose weight through conservative methods.  It results in an average initial weight loss of 25-30 percent, depending on the procedure performed.  The average lap band patient will eventually lose 48 percent of his/her excess body weight.  Improvements in mood, hypertension, asthma, sleep apnea, and diabetes have been observed.  As with any elective procedure, patients typically undergo rigorous screening to determine if there are any medical or behavioural contraindications present.  Generally speaking, patients must have a Body Mass Index (BMI) of ≥ 40, or ≥ 35 in the presence of co-morbidities.  Bariatric surgery is becoming more and more common, with 218,000 procedures expected to be performed annually in the United States by 2010 (Santry et al., 2005). For those who opt for bariatric surgery, adherence to a post-surgery exercise program is necessary for long term success.  It is possible for bariatric surgery patients to regain weight, although this rarely exceeds 10 percent of the initial loss.  That being said, exercise is one of the strongest predictors of long-term success for maintaining weight loss, according to Cedric Bryant, PhD, chief exercise physiologist for the American Council on Exercise.  Weight loss typically occurs rapidly at first then tapers off.  These clients require a carefully designed exercise program, proper supervision, and an opportunity to address the poor self-esteem that usually accompanies morbid obesity. References: American Council on Exercise (2009).  ACE Advanced Health and Fitness Specialist Manual.  San Diego: American Council on Exercise. Muth, Natalie Digate (2006).  Weighing the benefits of bariatric surgery.  IDEA Fitness Journal, 3(3). National Weight Control Registry website: nwcr.ws Santry, HP (2005).  Trends in bariatric surgical procedures.  Journal of the American Medical Association, 294(15), 1909-17.