1. ACE Personal Trainer Manual 5th Edition
Chapter 14: Exercise and Special Populations
Lesson 14.2

2. LEARNING OBJECTIVES
Discuss the following special populations and recommendations for exercise programming:
Cancer
Osteoporosis
Arthritis
Fibromyalgia
Chronic fatigue syndrome
Low-back pain
Weight management
Older adults
Youth
Pregnancy

3. CANCER Cancer is a group of more than 100 diseases
Uncontrolled growth and metastasis of cells in the body
Develops when DNA is damaged producing cell mutations
Cell growth causes tumors and may spread through blood and lymph systems
May eventually interfere with organ function and lead to death
Malignant: harmful cells that typically metastasize
Benign: local; cells do not spread, yet may still interfere with functioning
Physical activity:
Can help protect active people from acquiring cancer
Improves risk factors associated with cancer development
May improve immune function
The cause of cancer is complex and linked to many factors, such as environmental exposures (e.g., pollutants, ultraviolet light, and chemicals), lifestyle practices (e.g., smoking, physical inactivity, alcohol use, and diet), medical interventions, viral infections, genetic traits, gender, and aging.

4. The goal of exercise in the treatment of cancer is to:
CANCER AND EXERCISE
The goal of exercise in the treatment of cancer is to:
Maintain and improve cardiovascular conditioning
Prevent musculoskeletal deterioration
Reduce symptoms such as nausea and fatigue
Improve the client’s mental health outlook and overall quality of life
The specific exercise program should be tailored to the client’s:
Needs
Type of cancer
Current treatment
Current medical and physical-fitness status
For the breast cancer patient, adequate daily cardiorespiratory training will decrease the chance of a cancer relapse.
Activity that may be low intensity for one cancer client may be high intensity for another of the same age and gender.
Clients undergoing chemotherapy and/or radiation may be anemic and require reduced exercise intensity; others may have compromised skeletal integrity that may prevent weightbearing activities.
The training protocol should center on aerobic activities, light strength training, and stretching, and be supplemented with recreational activities.

5. EXERCISE RECOMMENDATIONS FOR CANCER
Condition
Mode
Intensity
Frequency
Duration
Comments
Cancer
Weightbearing exercise, particularly walking.
Low-impact or non- weightbearing aerobic machines such as elliptical trainers, treadmills, and cycles are generally considered secondary options, although they may be more appropriate for some individuals.
Light- to moderate- intensity exercise (RPE of 9 to 13 on the 6 to 20 scale).
Clients in remission may be able to increase their exercise intensity levels.
Intensity may need to be adjusted from session to session depending on client responses to treatment and exercise, and associated fatigue and symptoms.
Cardiovascular, flexibility, and balance training can be performed on a daily basis.
Strength training: two to three times a week, with at least a full 24 hours of rest between sessions.
Low-functioning clients may be required to begin with multiple short bouts of activity, three to five minutes in duration with frequent rest breaks.
Progress to 10- minute intermittent bouts and gradually build to 30 to 40 minutes of accumulated exercise.
To avoid irritation, clients should not expose skin that has had radiation or recent surgical wounds to the chlorine in swimming pools.
Activity that may be low intensity for one cancer client may be high intensity for another of the same age and gender.
The training protocol should center on aerobic activities, light strength training, and stretching, and be supplemented with recreational activities.

6. OSTEOPOROSIS
Low bone mineral density and deterioration in bone microarchitecture
Results in structural weakness and increased risk for fracture
Affects more women than men
Most common fracture sites:
Proximal femur (hip)
Vertebrae
Distal forearm (wrist)
Osteopenia:
Less severe condition of low bone density
Possible precursor to osteoporosis
Physical inactivity, poor nutrition and other lifestyle factors impact bone density.
The consequences of hip and spine fractures are significant, especially in older adults. Hip fractures are the most devastating because they are associated with severe disability and increased mortality. The incidence of hip fractures increases exponentially with age due to bone density declines, loss of muscular strength, and poor balance. Falls are responsible for more than 90% of all hip fractures.
During the early growth years, the rate of bone formation is typically greater than the rate of bone resorption, resulting in an overall gain in bone mineral. This “remodeling” balance is disrupted as people age and the amount of bone formation no longer keeps pace with the amount of bone being resorbed.
Additional risk factors include genetics, age, gender, race, and certain hormones that control or influence calcium levels.

7. OSTEOPOROSIS AND EXERCISE
Weightbearing exercises and resistance training are keys in the prevention of osteoporosis:
Bone strain stimulates bone deposition and gains in bone mass and strength
Forces above ADL: jogging, jumping, and plyometric exercises
Higher-intensity strength-training (8-RM) may be most beneficial
Improved strength assists in reducing the risk of falling
To prevent further injury and falls, some clients may need to avoid:
Spinal flexion, crunches, and rowing machines
Jumping and high-impact aerobics
Trampolines and step aerobics
Abducting or adducting the legs against resistance
Pulling on the neck with hands behind the head
Since osteoporosis is a significant medical issue and many of the individuals are older, some activities may need to be modified or avoided, depending on the client’s condition and health status.
Exercise is an important part of the prevention and treatment plan for osteoporosis, along with adequate nutrition (especially caloric intake, calcium, and vitamin D), pharmacologic intervention, and in some fracture cases, surgery. The primary goal of treatment is to prevent or retain bone mineral loss and to decrease the risk of falls and fractures.
Frequent sessions of multiple, brief loading that are separated by a few hours of recovery may have the greatest impact on bone formation.

8. EXERCISE RECOMMENDATIONS FOR OSTEOPORSIS
Condition
Mode
Intensity
Frequency
Duration
Comments
Osteoporosis
Weightbearing exercises: walking, group fitness classes, and resistance training.
Include activities that promote balance and coordination to reduce the risk of falling and associated fractures.
Weightbearing activities: high intensities that promote high strain
and stimulate bone adaptation.
Cardiovascular activities: follow general exercise guidelines excluding any jarring, high-impact activities such as running.
Strength training: high intensity (8- RM) to stimulate bone changes.
Multiple bouts of bone- loading exercises are more effective than a single longer-duration session.
It is important to provide for adequate rest between exercise bouts, depending on the number of strain cycles and the intensity.
The actual number of strain impacts can be small (50 to 100), so the duration of loading activities can be short (five to 10 minutes), depending on the type of activity chosen.
Those with spinal and other fractures may need to avoid:
Spinal flexion, crunches, and rowing machines; jumping and high-impact aerobics; trampolines and step aerobics; abducting or adducting the legs against resistance; pulling on the neck with hands behind the head

9. ARTHRITIS Osteoarthritis (most common type):
Degenerative joint disease
Leads to deterioration of cartilage and development of bone spurs at joint edges
Results from overuse, trauma, obesity, and aging
Rheumatoid arthritis (most crippling type):
A chronic and systematic inflammatory disease; classified as an autoimmune disorder
Affects more women than men
Characterized by joint pain, swelling, stiffness, and contractures
Contracture: an abnormal and usually permanent contraction of a muscle characterized by a high resistance to passive stretching.
The treatment of arthritis can include medication, physical therapy, physiotherapy, occupational therapy, and surgery, depending on the type and severity of arthritis.
Individuals with arthritis can be classified into four categories of functional capacity. Refer to Table 14-5.

10. ARTHRITIS AND EXERCISE
The primary goals for an exercise program for clients with arthritis:
Improve cardiovascular fitness and lower CAD risk
Increase muscular strength and endurance
Improve range of motion and flexibility around the affected joint(s)
Additional benefits of exercise:
Improved daily function and associated quality of life
Improved psychosocial well-being
Decreased pain and stiffness
Improved neuromuscular coordination
Exercise programs should be carefully designed in conjunction with a physician and/ or physical therapist, and must be based on the functional status of the individual.
Exercise is also an important part of the therapy regimen and benefits people with arthritis in a number of ways:
People experiencing chronic pain and inflammation typically shy away from physical activity, thereby causing their health to spiral downward.
Physical inactivity causes significant deconditioning, which results in diminished endurance and muscular strength, as well as joint weakness, all of which accelerate the negative effect of arthritis and associated pain.
Additionally, physical inactivity increases the risk for CAD, diabetes, and other chronic health conditions, while the decreased bone loading that occurs with physical inactivity increases the risk for osteoporosis.

11. EXERCISE RECOMMENDATIONS FOR ARTHRITIS
Condition
Mode
Intensity
Frequency
Duration
Comments
Arthritis
Non- weightbearing or non-impact activities such as elliptical training, cycling, warm- water aquatic exercise, and swimming.
Include recreational activities such as golf, gardening, table tennis, or bowling.
Isometric exercises may strengthen the joint structures and surrounding muscle while placing less stress on the joint itself.
Low-intensity, low- impact dynamic exercise rather than high-intensity, high- impact activities.
Generally, the intensity should be in the 9 to 15 RPE range (6 to 20 scale).
Strength training should focus on increasing the number of repetitions rather than increasing the weight being lifted. Clients can gradually increase repetitions from two or three to 10 to 12.
Three to five times per week.
Prolonged and gradual warm-up and cool-down periods (greater than 10 minutes).
Clients can begin initial exercise sessions at 10 to 15 minutes and gradually progress to 30 minutes.
Some individuals may require intermittent exercise with shorter durations, at least initially.
Put all joints through their full range of motion at least once a day to maintain mobility.
Individuals with rheumatoid arthritis should not exercise during periods of inflammation, and regular rest periods should be stressed during exercise sessions.
Clients who are still experiencing pain or joint discomfort more than two hours after a workout should have the exercise intensity reduced.

12. FIBROMYALGIA The exact cause remains unclear; common symptoms include:
Aches and pains similar to flu-like exhaustion
Multiple tender points
Stiffness
Decreased exercise endurance
Excessive fatigue
Muscle spasms
Paresthesis
Disruptive sleep patterns
Bowel and bladder irritability
Anxiety and depression
Temporomandibular joint (TMJ) disorders
Allergy symptoms
The term “fibromyalgia” comes from the Latin roots fibro (connective tissue fibers), my (muscle), al (pain), and gia (condition of), and the term syndrome refers to a group of signs and symptoms that occur together and characterize an abnormality.
In 1990, the American College of Rheumatology developed criteria for the diagnosis of fibromyalgia. The criteria is characterized by a history of widespread pain occurring for longer than three months, in combination with pain on palpation of 11 of 18 tender point sites (refer to Table 14-7).

13. FIBROMYALGIA AND EXERCISE
People with fibromyalgia are typically deconditioned:
They shy away from exercise and are fearful of making symptoms and fatigue worse
This inactivity brings further decreases in fitness resulting in more fatigue and pain
Exercise eases symptoms and prevents the development of other chronic conditions.
Low- to moderate-intensity aerobic exercise:
Has an analgesic and antidepressant effect
Can significantly reduce pain, depression, and anxiety

14. EXERCISE RECOMMENDATIONS FOR FIBROMYALGIA
Condition
Mode
Intensity
Frequency
Duration
Comments
Fibromyalgia
Walking and low-impact activities: elliptical training, recumbent cycling, warm- water aquatic exercise, and swimming.
Include daily light stretching, along with resistance exercise activities utilizing resistance bands or light weights.
Low to moderate intensity—RPE of 9 to 13 (6 to 20 scale).
Three to five days per week.
Gradually progress to 150 minutes or more per week of aerobic activity.
Some people may need to begin with frequent short-duration sessions (10 minutes) and gradually build over time.
Avoid physical inactivity and develop a pattern of “regular” exercise.
They may require off days during intense flare-ups, but should avoid prolonged inactivity.
Encourage variety to reduce repetitive trauma and potential adverse symptoms.

15. CHRONIC FATIGUE SYNDROME
Characterized by profound, incapacitating fatigue lasting at least 6 months
Results in a substantial reduction in everyday activities:
Occupational
Recreational
Social
Educational
Fatigue does not improve with bed rest
Fatigue may worsen with physical and/or mental activities
Chronic fatigue syndrome is accompanied by characteristic symptoms, including:
Problems with memory and concentration
Unrefreshing sleep
Muscle and joint pain without inflammation and redness
Headaches
Tender cervical or axillary lymph nodes
Recurrent sore throat
Extreme exhaustion lasting more than 24 hours following physical or mental exercise
Some people with CFS also report additional symptoms, such as:
Abdominal pain
Bloating
Chest pain
Chronic cough
Diarrhea
Dizziness,
Nausea
Chills and night sweats
Psychological problems (e.g., depression, irritability, anxiety, and panic attacks)
Visual disturbances

16. CHRONIC FATIGUE SYNDROME AND EXERCISE
The primary objective of exercise for people with CFS:
Create a balance, avoiding post-activity malaise.
Prevent deconditioning to improve function and quality of life.
Utilize rest periods and stop activity before illness and fatigue are worsened.
The following guidelines apply to people with CFS:
Exercise should be followed by a rest period at a 1:3 ratio.
Deconditioned clients should start with ADL.
Several daily sessions of brief, low-impact activity can be beneficial.
Sessions can increase by 1−5 minutes per week, or as tolerated.
If symptoms worsen, clients should return to the most recent manageable level of activity.
Most people with CFS cannot tolerate traditional exercise routines that are aimed at optimizing aerobic capacity and building muscular strength and endurance.
Instead of helping people with CFS, moderate- to vigorous-intensity activities can cause an exacerbation in fatigue and other symptoms associated with CFS. Even worse, these types of activities can precipitate a full-scale relapse that lasts for days or weeks.
However, activity with appropriate rest has been shown to decrease psychological stress and improve fatigue, functional capacity, and fitness.

17. RECOMMENDATIONS FOR CHRONIC FATIGUE SYNDROME
Condition
Mode
Intensity
Frequency
Duration
Comments
Chronic fatigue syndrome
ADL and walking or low-impact activities such as cycling.
Light stretching and light resistance training using resistance bands or light weights.
Deconditioned clients should limit themselves to the basic ADL until their symptoms are stabilized.
Low-intensity exercise.
The goal is to develop a “regular” pattern of activity that does not result in post-activity malaise.
Clients should start with simple stretching and strengthening exercise, using only body weight for resistance.
Increase repetitions gradually: two to four repetitions and building to a maximum of eight.
Three to five days per week.
Clients can begin with multiple two- to five- minute exercise periods followed by six- to 15- minute rest breaks (i.e., 1:3 ratio).
Gradually build to 30 minutes of total activity.
All exercise should be followed by a rest period at a 1:3 ratio (i.e., resting for three minutes for each minute of exercise).
If exercise worsens symptoms, return to the most recent manageable level of activity that did not result in increased symptoms.
Some clients may not tolerate an upright position and may benefit by swimming or using a recumbent bicycle.

18. LOW-BACK PAIN
Very complex and given a specific diagnosis according to the duration of pain:
More recently considered a recurring or persistent condition with a fluctuating course over time
Acute or short term LBP: lasting <3 months in duration
Mechanical in nature
Lasts from a few days to a few weeks
Typical causes:
Trauma (e.g., sports injury, car accident, and lifting)
Certain disorders such as arthritis or aging

19. LOW-BACK PAIN
The causes of chronic low-back pain (lasting >3 months) are challenging to determine:
Spinal strain or compression (disc rupture or bulge)
Spinal stenosis
Osteoporosis or other fractures
Spinal degeneration
Spinal irregularities (e.g., scoliosis, kyphosis, and lordosis)
Lifestyle factors may also be a cause:
Physical inactivity
Being overweight or obese
Poor posture or sleeping positions
Stress
Smoking

20. LOW-BACK PAIN AND EXERCISE
The primary programming components for a client with LBP include:
Cardiorespiratory training
Resistance training
Basic core exercises
Clients with LBP should avoid the following:
Unsupported forward flexion
Twisting at the waist with turned feet, especially with load
Lifting both legs simultaneously when prone or supine
Rapid movements, such as:
Twisting
Forward flexion
Hyperextension

21. EXERCISE RECOMMENDATIONS FOR LOW-BACK PAIN
Condition
Mode
Intensity
Frequency
Duration
Comments
Low-back pain
Walking, stationary biking, and swimming, utilizing variety.
Core strengthening exercises, light resistance training, and stretching should also be included.
Initially, light to moderate intensity.
As conditioning improves and symptoms dissipate, some individuals may be able to progress to moderate to vigorous activity.
Three to five days per week.
Gradually build to 30 to 60 minutes per session.
Some individuals may need to begin with multiple short (10-minute) bouts of activity.
Generally, people with LBP should avoid the following: 

Unsupported forward flexion; twisting at the waist with turned feet, especially when carrying a load; lifting both legs simultaneously when in a prone or supine position; rapid movements, such as twisting, forward flexion, or hyperextension.

22. WEIGHT MANAGEMENT
Rising obesity rates have significant health consequences and contribute to chronic diseases, such as:
Type 2 diabetes
Hypertension
CAD
Some cancers
Arthritis
Alzheimer’s disease
Dementia
They key to successful long term weight-stability is the adoption of:
Lifelong physical activity
Sensible eating habits

23. WEIGHT MANAGEMENT AND EXERCISE
The diagnosis and treatment of obesity can be challenging:
Medical, physical-activity, and dietary histories are necessary to determine the cause(s) of obesity.
Caloric consumption and physical inactivity are directly related to obesity, but they are not the only causes.
In many cases, obesity is caused by complex psychosocial issues that may require referral to a psychologist or professional counselor.
“More is better” may be correct:
Relationship between the volume of exercise, training duration, and fat loss:
150 minutes per week of aerobic exercise is associated with modest weight loss.
225−420 minutes per week results in greater weight loss.

24. EXERCISE RECOMMENDATIONS FOR WEIGHT MANAGEMENT
Condition
Mode
Intensity
Frequency
Duration
Comments
Weight management
Walking, cycling aquatic exercises, swimming, and group exercise classes such as aerobics and resistance exercises.
Begin at low intensity and gradually progress as conditioning improves using the RPE scale.
Five to six days per week to maximize caloric expenditure.
Initially, some clients may need to start out with two to three days per week.
Clients should be encouraged to accumulate 150 to 200 or more minutes of exercise each week.
The key is to find safe, effective, and enjoyable activities that promote consistent physical activity.

25. OLDER ADULTS Signs of aging: Noticeable changes in various systems:
Graying and loss of hair
Loss of height
Reduced lean body mass
Loss of skin elasticity and wrinkles
Thickening of nails
Changes of eyesight
Reduced coordination
Noticeable changes in various systems:
Cardiovascular
Endocrine
Respiratory
Musculoskeletal
Cardiovascular system:
Maximum heart rate declines
Resting stroke volume declines
Drop in cardiac output
Reduction in VO2max
Musculoskeletal system:
Decline in muscle mass
More porous and fragile bones
Increase in body fat
Reduction in basal metabolic rate
Sensory systems:
Decline in balance and coordination
Decline in vision and poor visual acuity
Decline in vestibular system
Mental health:
Cognitive impairment
Increase in depression and anxiety disorders
Loss of social stimulation (fewer friends with age)

26. EXERCISE RECOMMENDATIONS FOR OLDER ADULTS
Condition
Mode
Intensity
Frequency
Duration
Comments
Older adults
Endurance exercise: low- impact aerobics, walking, using cardiovascular equipment such as elliptical trainers and cycles, and swimming.
Weight training low resistance and high repetitions (at least initially) and include balance exercises.
Low to moderate levels (RPE of 11 to 13 on the 6 to 20 scale), with relatively few individuals performing vigorous exercise.
At least five days each week.
Longer and more gradual warm-up and cool-down periods.
Clients can gradually increase exercise duration to 30 to 60 minutes per session.
Intensity-monitoring methods, such as the RPE or the talk test may be more effective than heart rate due to medications and decline in maximum heart rate.
Encourage an active lifestyle and participation in recreational activities (e.g., tennis or dancing) as appropriate.
Refer to Table 14-4 for Exercise Precautions for Client with Diabetes

27. YOUTH AND EXERCISE
Behaviors established at a young age likely persist into adulthood:
Physically inactive youth will remain sedentary as adults.
A sedentary childhood and adulthood puts youth at risk for premature death.
The primary exercise activities for children and adolescents are:
Aerobic conditioning
Fun activities and recreational or competitive sports (e.g., rollerblading and canoeing)
Muscle strengthening
Structured (weight training) or unstructured (e.g., games such as tug-of-war or climbing a wall)
Bone strengthening
Activity to produce a force on the bones (e.g., hopscotch, jump rope, and tennis)
Refer to Table 14-9 for examples of activities for children and adolescents.

28. EXERCISE RECOMMENDATIONS FOR YOUTH
Condition
Mode
Intensity
Frequency
Duration
Comments
Youth
Sustained activities that use large muscle groups: swimming, running, jogging, and aerobics.
Incorporate fun activities and include muscle- strengthening and bone- strengthening exercise as part of their physical activity at least three days per week.
Moderate and vigorous intensity activity.
Inactive youth: start with low-intensity activity and gradually progress.
Daily sessions; do not have to be heavily structured, but should include a variety of play and recreational activities.
Accumulate 60 minutes or more of daily physical activity.
Never perform single maximal lifts, sudden explosive movements, or try to compete with other children.
Never use any equipment that is broken or damaged, or that they do not fit on properly.
Encourage frequent breaks/rest periods in the shade, and have children drink fluids during these breaks.
The risk of injuries to children participating in resistance-training programs is low. However, injuries can occur in any sport or strenuous physical activity.
To minimize the risk of injury during resistance training, personal trainers should adhere to the following guidelines:
Obtain medical clearance or instructions regarding physical needs.
Children should be properly supervised and use proper exercise technique at all times.
Do not allow children to exercise unless the weight-training facility is safe for them.
Never have children perform single maximal lifts, sudden explosive movements, or try to compete with other children.
Teach children how to breathe properly during exercise movements.
Never allow children to use and equipment that is broken or damaged, or that they do not fit on properly.
Children should rest for approximately one to two minutes between each exercise, and for longer if necessary. In addition, they should have scheduled rest days between each training day.
Encourage children to drink plenty of fluids before, during, and after exercise.
Tell children that they need to communicate with their coach, parent, or teacher when they feel tired or fatigued, or when they have been injured.

29. PREGNANCY AND EXERCISE
Women should obtain physician clearance and guidelines before exercising.
Pregnant women with the following health conditions should NOT exercise:
Risk factors for pre-term labor
Vaginal bleeding
Premature rupture of membranes
Generally, pregnant women should follow these guidelines:
Do not begin a vigorous program shortly before or during pregnancy
Use the RPE scale and choose an intensity that is comfortable
After the first trimester, prolonged supine exercise is discouraged
Avoid exercise during high temperatures or humidity
Wear supportive clothing and shoes
Generally, the goal during the initial six weeks following delivery is to gradually increase physical activity as a means of relaxation, personal time, and a regaining of the sense of control, rather than improving physical fitness. Women who have had a C-section may require additional recovery time. After the initial two months, the goal of exercise is to gradually improve the fitness level.

30. EXERCISE RECOMMENDATIONS FOR PRENANCY
Condition
Mode
Intensity
Frequency
Duration
Comments
Pregnancy
Aerobic and strength- conditioning exercises such as brisk walking, elliptical training, stationary cycling, cross-country skiing (no downhill), and swimming.
Light- to moderate- intensity exercise.
The talk test or RPE scale can be used to monitor intensity (e.g., 9 to 13 on the 6 to 20 scale).
Pregnant women should begin with 15 minutes of continuous exercise and gradually build to 30-minute sessions.
Women who are already exercising may be able to start at 30 to 40 minutes.
Three times per week, though some women may be able to progress to four to five times per week.
Gradually reduce the intensity, duration, and frequency of exercise during
the second and third trimesters.
Avoid the following exercises:
Activities that require extensive jumping, hopping, skipping, bouncing, or running; skiing, contact sports, scuba diving, jumping/jarring motions, and quick changes in movement or activities where falling is likely
Prolonged exercise in the supine position (greater than five minutes) should be discouraged after the first trimester.
Wear supportive shoes and a supportive bra to help protect the breasts.
Exercise should be postponed and the client should discuss the condition with her physician prior to resuming exercise training, in the event of the following:
Vaginal bleeding
Dizziness or feeling faint
Increased shortness of breath
Chest pain
Headache
Muscle weakness
Calf pain or swelling
Uterine contractions
Decreased fetal movement
Fluid leaking from the vagina
After delivery, women should adhere to the following general guidelines:
Obtain physician clearance and guidelines prior to resuming or starting an exercise program.
Begin slowly, and gradually increase duration and then intensity. The goal is to develop consistency, not to see how hard one can work.
Start with walking several times per week.
Avoid excessive fatigue and dehydration.
Wear a supportive bra.
Stop the exercise session if unusual pain is experienced.
Stop the exercise session and seek medical evaluation if bright red vaginal bleeding occurs that is heavier than a normal menstrual period.
Drink plenty of water and eat appropriately.

31. SUMMARY
The rapid rise in chronic health conditions provides a challenge for personal trainers as the likelihood of working with one or more “special population” clients is high.
Personal trainers can advance their careers by participating in a variety of continuing education opportunities and by seeking advanced certifications.
Online continuing education options and peer-reviewed journals are also available to assist personal trainers in advancing their knowledge bases.
Visit for options.