Did you know that 81% of people with a disability don’t feel welcome in the fitness industry? 

That means as fitness professionals, leaders and educators, we have a lot of work to do. One of the biggest areas of need is in representation. We are the fitness industry after all, and we know that representation sells our brands. We know the stigmas around sizeism and ageism all too well, but what about ableism? People with a disability rarely, if ever, get to see themselves at the gym, in commercials or on the flyer, and they certainly cannot request a trainer that looks like them at most gyms around the country. 

October is National Disability Employment Awareness Month, and its purpose is to celebrate the achievements of American workers with a disability. This might be easier said than done: According to the U.S. Bureau of Labor Statistics, for individuals aged 16-64, the current unemployment rate for persons with a disability is 8.3 % — that’s 5% higher than for those without a disability. An even more staggering statistic? Using that same source and age range, the labor force participation rate for people with a disability is only 38%. 

Clearly, the fitness industry does not stand alone in its lack of representation. However, there has been progress, as some well-known companies are making strides toward greater inclusion. This year, Peloton came out with their first adaptive training consultant and instructor who has a disability. The Apple Watch has included accessibility features for years, including selecting if you are a wheelchair user as a fitness option and changing the language to “roll” instead of “walk.” In addition, they also added wheelchair-specific workouts to their accessibility features this year. 

Last year, Degree Deodorant launched a #TrainersForHire campaign to challenge the industry to hire more trainers with a disability. Their recent commercial campaign also highlighted people with a disability being physically active, and the first-of-its-kind adaptive deodorant. Nike joined the club by making their fitness apps more accessible with adaptive workouts in the Nike Training Club, which also includes an instructor with a disability leading the class. PopSugar made inclusive efforts by interviewing my colleague and friend Sonja Ast from Lakeshore Foundation for this 10-Minute High-Intensity Workout for People in a Wheelchair. And finally, Move United’s OnDemand provides online fitness classes for and by people with disability. 

The COVID-19 pandemic — which significantly affected people with disability more than those without in the fitness space due to the lack of access to inclusive home equipment, fitness apps and walkable communities — certainly helped influence these changes by larger companies, but it also saw an increase in individuals speaking up and creatively developing solutions. For example, para-powerlifter Ali Jawad who, with a few partners, created a new fitness app for people with a disability or Nicole Walsh, who went back to being a personal trainer after a spinal cord injury. The industry has hit a significant enough shift that you can now google “disabled fitness influencers” and actually get a hit. On TikTok you will find influencers Alyssa Gialamas, a Paralympic swimmer, and Jesi Stracham, founder of the Wheel With Me Foundation. 

While we still have a long way to go to reach true inclusion in the fitness space, especially here in the U.S. where the Americans with Disabilities Act has been around for more than 30 years, we can at least take some time out to acknowledge that we are finally starting to move the needle forward. 

Join me this month in celebrating those who have broken the mold and successfully found their way into the industry, and pledge with me to make it a whole lot easier for the next generation to find acceptance and success in our industry by being the voice of access and inclusion in your respective fields. 

Related Content: 
Certification | Become an ACSM/NCHPAD Certified Inclusive Fitness Trainer
Book | ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities
Resource | Increasing Physical Activity for Adults with a Disability

Kelly Bonner is the Director of Training and Operations at Lakeshore Foundation for the National Center on Health Physical Activity and Disability (NCHPAD). In her work with NCHPAD, she has conducted numerous trainings on Disability Education to organizations like the World Games, Encompass Health, and state health departments. She has also authored publications and blogs for organizations such as ACSM, CDC and NRPA. Mrs. Bonner manages NCHPAD’s training and education components including their on-line E-learning site. For the past 10 years Mrs. Bonner has overseen and delivered the trainings for the Certified Inclusive Fitness Trainer through ACSM. Mrs. Bonner is a certified fitness specialist and has worked at Lakeshore Foundation, an Olympic and Paralympic training center, working with disabled individuals across the lifespan in the fitness center as well as coaching adapted track and field.

There are many pros and cons to any body composition assessment tool, DXA included. Many of you asked my thoughts about other methods — specifically bioelectric impedance analysis (BIA — InBody), air displacement (BOD POD), 3D scanners such as the SizeStream, and ultrasound — compared to DXA. DXA’s precision is greater than any of these measures and is the gold-standard tool for bone mineral density. So if you can afford one, I say go for it. But they are expensive, require radiation and special training, and are not mobile in most cases. 

In summary, my favorite body composition tool is DXA, but that is because I am in a research setting that helps me circumvent its limitations. If you’re in the field and need something cheaper and more portable but don’t want to go the skinfold/circumference tape route, I would recommend a newer InBody from the list above. 

Questions regarding scanning procedures: 

• Q: Any observations in dealing with tactical athletes or older athletes with joint replacements?
• Q: Do you have any recommendations/best practices for using Custom RoI while performing segment-wise body composition? 
• Q: Is it possible to mirror estimate data from left side to right side?
• Q: Do they irradiate the skull and gonads? If so, is this necessary to calculate a body composition evaluation?
• Q: Hi, is there a safe frequency for DXA scan? My lecturer used to say limit to four scans/year due to radiation.
• Q: What are your thoughts on scanning tall athletes as total body less head (TBLH) to monitor longitudinally?
• Q: Does the temperature/humidity in the room influence the test results? 

Lots of good questions fell within the topic area of scanning procedures. Folks had questions about working with tall athletes, tactical athletes, those with joint replacements, how to create novel scanning procedures, scan frequency, radiation exposures and room conditions for scans. 

Questions regarding data reporting and management: 

• Q: When working with younger athletes (between 16 and 18 years) do you use the Z-score based on length or the Z-score based on age? Since we get both those Z-scores when we scan younger athletes.
• Q: I appreciate Dr. Baker mentioning the issues with DXA and the Oregon track program. Could she speak more about her experience with reporting and using data/images among athletes/coaches that discourages unhealthy use of the data?
• Q: I did not manage to register the web address with the automated DXA-result extraction ... is there any place or in any way we could get access to this?
• Q: Hi Dr. Baker, do you compare to the NHANES database with the scans at your practice? 
• Q: I agree with T-score reporting for those over 50 years. However, can you explain to all as to why? 
• Q: Can you recommend a source for the most current guidelines on bone health for general populations?
• Q: Do you think results may differ between Caucasians and Asians?
• Q: How do you educate people that have some curvature in their spine over multiple scans and express anxiety or distress about that?
• Q: Can DXA provide us with details about scoliosis?
• Q: Could a difference in bone density between two legs also correlate with a difference in muscle mass?
• Q: What is your role within the sports teams you work with? How do you organize meeting with the coaching staff?
• Q: Did you say there was an app for DXA data?
• Q: Would it be a good idea to use DXA for clients who have bone issues like arthritis? Would that be within the scope of practice for a personal trainer? 

Questions regarding precision testing: 

• Q: I work in corporate health and wellness, so this is out of my field. But I want to ask about the error percentage. When you do a percentage test you get the error percentage, but how would you use that when gathering your data? Do you subtract that or add the % error to the data, or am I completely off?
• Q: The least significant change and the smallest worthwhile change — are they the same?
• Q: Hologic and GE provide default LSC values.
• Q: I’m thinking of the CV/LSC and wonder how you interpret repeated measurements. And the changes you detect: Do you first subtract the variation and then register the change, or do you register the exact measured change?
• Q: Can default LSC values for the DXA be used?
• Q: How often do you do precision testing? 

The movement to recognize exercise as medicine has incited interest in personalized exercise prescription while simultaneously exposing weaknesses in the existing exercise science literature. As a field, it is acknowledged that differences in an individual’s phenotype (observed characteristics) and genetic makeup will contribute to a marked variability in response to standardized exercise. However, the assumption that this variability in response can be readily and accurately identified and attributed to exercise alone is misguided. 

In our study, published in Medicine & Science in Sports & Exercise®, we performed retrospective analyses of data from three randomized controlled exercise interventions including adults with overweight and obesity. We found that less than 13% and 45% of participants improved cardiometabolic outcome measures and cardiorespiratory fitness, respectively, beyond the day-to-day variability of measurement. In other words, the individual responses for 87% and 55% of the participants, respectively, fell within the random variability of measurement for these risk factors and thus, the response may not be attributed to the exercise prescribed. These findings confirm and highlight that study design and measurement precision is critically important for interpreting individual response to exercise. 

In the last decade, reproducibility in science has been highlighted as an area of immense concern. However, to date the exercise science field has been immune to scrutiny regarding the rigors of study designs required to help ensure the reproducibility of results. Single measures of health-related outcomes to interpret exercise efficacy that ignore the variability inherent in these measures will only serve to increase the rate of disparate findings between studies — equivocal findings that may not be the result of biological differences but rather, weak study design. 

Our findings prompt specific recommendations for both researchers and practitioners. For researchers attempting to determine the efficacy of treatment, improvements in trial design and methodology can help reduce variability and improve the ability to assess the individual’s true response to exercise. Approaches such as including the use of a control group, reporting measurement precision and employing repeated measures of an outcome at the same timepoint should be considered. For exercise practitioners, caution should be used when inferring that the cardiometabolic and/or cardiorespiratory fitness response for a given individual is a direct consequence of exercise alone. At a minimum, practitioners should understand the measured variable’s precision (e.g., coefficients of variability for duplicate measures of cardiorespiratory fitness, anthropometric and functional fitness measures). Subsequently, they should incorporate that knowledge when interpreting a participant’s response to exercise. 

For both the researcher and the practitioner, determination of individual response to exercise prescription is complex. However, given that we base treatment plans and follow-up according to the observed response, we need to understand the precision of our assessment tools as practitioners and employ more rigorous and reproducible study designs as investigators. 

It is important to recognize that our findings do not argue against the established health benefits associated with adoption of exercise consistent with consensus recommendations identified in guidelines worldwide. Following guideline recommendations will be associated with benefit across a wide range of health outcomes for most, but not all adults. Our findings underscore the complexity associated with interpretation of individual exercise response, and strongly suggest that caution is used when attributing the observed response to the exercise dose prescribed. 

Andrea M. Brennan is a biobehavioral research scientist at AdventHealth Research Institute in Orlando, Florida. Dr. Brennan earned her Ph.D. in clinical exercise physiology from Queen’s University in Ontario, Canada under the supervision of Dr. Robert Ross. She has published several manuscripts focusing on response variability in exercise science, including three in Medicine & Science in Sports & Exercise®. She is trained in body composition imaging (MRI, DEXA), immunohistochemistry of skeletal muscle, and cardiometabolic risk factor assessment. Her current research interests include the interaction between nutrition and movement-based strategies for managing obesity and corresponding disease risk in special populations. 

Robert Ross, Ph.D., is currently a professor within the School of Kinesiology and Health Studies and the Department of Medicine, Division of Endocrinology and Metabolism, at Queen’s University. Dr. Ross is the director of the Lifestyle and Cardiometabolic Research unit at Queen’s, wherein his research program focuses on the development of strategies designed to manage lifestyle-based disease. He is a fellow of the American College of Sports Medicine® (ACSM) and the American Heart Association, and is a recipient of ACSM’s Citation Award. Learn more about Dr. Ross’ research program, or contact him via email. 

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.  

One element of the many skills developed as part of a coaching approach is the use of motivational interviewing (MI)⁽¹⁾. MI first emerged as a means of supporting people to manage significant and enduring addictions; however, its efficacy generally in supporting behavioral change is well documented. MI is a collaborative and conversational engagement with the client that does not give primacy to expert knowledge. Rather, this knowledge is offered “just in time” and only when absolutely necessary to support behavioral change. 

One of the very useful features of motivational interviewing is the conceptualization of ambivalence. Coming from two Latin words, ambivalence literally represents the idea of “both options having strength” to the person. In practice, ambivalence is often seen as a problem to be overcome in the client, and this can lead very quickly to the health care provider engaging in an ultimately unhelpful tug-of-war — trying to pull the client toward a particular behavioral change while the client pulls equally strongly, arguing for the value they see in not changing. 

But ambivalence ought not be seen in this problematic way. Rather, it can be viewed as an opportunity to celebrate purpose and drive. Why? The person experiencing ambivalence is feeling driven toward two (or more) quite different outcomes. If ambivalence can be conceptualized in this way, it ceases to be a problem to be solved and can be looked upon as an energy or impetus within the client to be worked with — much better to have a desire for multiple possible outcomes than no desire for any. 

We all experience ambivalence, and we experience it frequently throughout life. If you’ve ever scanned a café menu and felt an urge for two different breakfast options, or experienced the pleasurable dilemma of being invited to two social events occurring simultaneously, or felt thrilled and terrified at the same time as your roller coaster car crests the top of the rise, you’ve had an experience of ambivalence. 

How can coaches work effectively with ambivalence to support client autonomy and create the conditions most favorable to health behavior change? 

Firstly, employ the fundamental tools of engaging communication and connection — deep listening, reflection of what is being said (and not said) and open inquiry to understand more. While there are many types of reflection in interpersonal communication, two approaches that particularly support working with ambivalence are empathy reflections and double-sided reflections⁽²⁾. An empathy reflection seeks to reflect the full experience of the person, not only their words: 

Client: I really wanted to get to 30 minutes of continuous walking this week, but I just couldn’t. 

Coach: You’re feeling disappointed that you didn’t reach the goal you set for yourself. 

A double-sided reflection seeks to capture all aspects of a person’s feelings about change, not only those related to the benefits of change: 

Client: I know that moving more could help, but I’m just so afraid of ending up in the sort of pain I was in last year. 

Coach: You’re keen to experience the benefits of more movement, and wary of unintended setbacks too. 

Learn the signs that indicate ambivalence. It frequently shows up in consultations as a combination of change talk and sustain talk⁽¹⁾ or as the client beginning to redirect or correct your efforts to influence their choice. Change talk embodies the client expressing desires, abilities, reasons or needs to make a change. Sustain talk, on the other hand, represents views expressed by the client that seek to justify or legitimize not changing. As a practice point, it’s important to avoid what Miller and Rollnick refer to as “the righting reflex” — the tendency of the practitioner to respond to sustain talk with change talk. This leads to a polarizing interaction in which the practitioner more and more strongly occupies the change talk space and the client strongly occupies the sustain talk space. If this continues, the client will likely become irritated or agitated with the coach and feel unheard and misunderstood. In practice, the polarizing interaction could look like this: 

Coach: If you were to begin to gently increase the amount of exercise that you do, what do you think might be the benefits? 

Client: Well, I’m not sure. Last time I tried that, the pain in my knees was unbearable.  

Coach: A short-term increase in pain is to be expected here, but it’s important that you understand that your condition won’t improve if you don’t start moving more. 

Client: But I just couldn’t stand any more pain than I have already … 

If you think you recognize ambivalence, then don’t just do something — instead, sit there. Resist the urge, if present, to convince the client through force, facts or fear about the imperative of change. Instead, take time to listen and understand the value the client sees in continuing along their current path. This can be done by using the decisional balance tool⁽³⁾. 

The decisional balance tool provides a means for dispassionately exploring the client’s perceived benefits and disadvantages of modifying their behavior, and also continuing as they are; however, it is best approached in a particular order, beginning with the perceived advantages of not changing. This meets the client at the strongest point of their ambivalence. It also demonstrates a desire to understand the reasons for this and avoids the perception on the part of the client that the coach may be pushing for change. 

From here, move to inquiring of the client the disadvantages they perceive in modifying or changing their behavior. Once this has been explored and reflected, inquiry about the disadvantages of not changing may be explored. Finally, conclude with a discussion about the perceived advantages of modifying behavior. When undertaken in this way, the client has walked systematically through all areas of their perceptions and concerns, and if appropriate, the discussion can continue, focused on what the client might do to begin the process of change. A decisional balance process may look like this: 

Coach: What are the benefits you see for yourself in not making any changes to your exercise and activity habits? 

Client: Well for one thing I won’t get the pain — it’s a killer when that happens. I really can’t stand it. 

Coach: Mm-hmm. What about the disadvantages you see in increasing the amount of exercise that you do? 

Client: Apart from the pain, I guess I’d have to re-organize some things in my day to make time for it. And I’m really not sure if I’d be doing the right thing — it’s a long time since I exercised. And I don’t know what’s going to be helpful and what may not be. 

Coach: OK. You’re uncertain about the steps to take and whether they’re the right ones. Tell me about the risks you see in not making any changes. 

Client: All the things you and I have spoken about already — my mobility will continue to decline, and the pain I get probably won’t ever really go away completely. And in a few years’ time I may find that I’m even less able to do things I want to do. And as I say that now, I worry about that because I really want to travel after I retire. 

Coach: Right. You need mobility for your vision for the future. So what are the benefits to you of making a change to your patterns of exercise? 

Client: I do know that exercise will help — and I do really want to be able to move around more freely and without pain. My wife and I have been talking for years about walking the Camino de Santiago when we retire … 

Lastly, remember the central role that autonomy plays in human behavior. Autonomy is a primary psychological need of all sentient creatures^(4,5). If you want to see it in action, observe your dog next time you try and encourage him or her to move away from a scent that’s exciting and interesting. The drive to preserve autonomy may also be particularly strong in those who have experienced trauma. Nothing guarantees that any particular client will engage in behavioral change; however, honoring autonomy maximizes the likelihood that the client will engage in a behavior that has meaning and value to them and which they will be able to sustain in the long term. 

So we should not be afraid of ambivalence — instead, quietly celebrate the energy and interest your client has in exploring and experiencing so many dimensions of life. By always honoring autonomy, and systematically reviewing all dimensions of a possible change, we can help build a solid foundation on which lasting change — driven by deeply held values — can be cultivated. 

References 

1. Miller WR and Rollnick S. Motivational Interviewing: Helping People Change. Guilford Press; 2012. 482 p. 

2. Moore M, Jackson E, Tschannen-Moran, R. The Coaching Psychology Manual. 2nd ed. Lippincott Williams; 2015. 82-85 p. 

3. Miller WR and Rose GS. Motivational interviewing and decisional balance: contrasting responses to client ambivalence. Behav Cogn Psychother. 2015 Mar;43(2):129-41. doi: 10.1017/S1352465813000878. 

4. Deci EL, Ryan RM. Self‐determination. In Craighead WE, Nemeroff C, editors. The Corsini Encyclopedia of Psychology; 2010. p. 1-2. 

5. Deci EL, Ryan RM. 1985. Intrinsic Motivation and Self-Determination in Human Behavior. Boston: Springer; 1985. 11-40 p. 

Simon Matthews is a Psychologist, Board Certified Lifestyle Medicine Professional and Fellow of the Australasian Society of Lifestyle Medicine. He is a member of the Wellcoaches Faculty and CEO of Wellcoaches Australia.