Okay, thank you so much for joining us today. During this session we'll be talking about the importance of fitness for all people, especially for people with disabilities, and what that looks like primarily focusing on functional fitness and what that is, and how it can be adapted for people with special needs. I'm joined today by myself, as well as Dr. Mary Duvon, who's a physiatrist and sports medicine specialist, also as well as Alex Zirkenbach who's founder of the Adaptive Training Academy, he adapts and trains athletes all over the world, as well as Dr. Mary Rosenthal, who is a speech language pathologist. It's also a fitness trainer, and they'll all be talking more about their specialties and different programs that they work with. So we'll start first. This presentation I'm going to explain exactly what functional fitness is, and its importance for those with disabilities. So, background about myself. I am a sports medicine physiatrist for Northwell Health, also a CrossFit trainer, as well. I work in different CrossFit spaces all over the place so it's a subject that is near and dear to my heart. So in this talk we'll first define what function is from a medical standpoint as physiatrists, that's certainly something that we're very much interested in focus on, and we'll also talk about functional capacity and how to increase that. We'll also define functional fitness from a fitness standpoint, what that looks like, and how that's different from traditional exercise. And then we'll also discuss the importance of functional fitness in special populations. For those with physical and cognitive disabilities primarily we'll be focusing on today. As physiatrists, how do we medically evaluate function? And certainly there are many tools that we use to evaluate function. And primarily we look at ADLs, right, so key life tasks that people need to do in order to live at home, live independently, and we're all familiar with these, ambulating, feeding, dressing, toileting, transferring, bathing, etc. For physiatrists it's something we focus on quite a bit and we're constantly assessing for people to be able to live on their own, to be able to get from one place to the other. It's a focus of what we do. The ADLs and the IADLs certainly involve some higher level cognitive tasks as well. So we are always evaluating these, we're always, you know, trying to improve these and find ways to help people improve these tasks. And then we have different functional tests, right, so things like the timed up and go test, sit to stand test, six minute walk test. These are all looking at different functional movements and how people do them, how fast they can do them, how well they can do them. And there have been numerous studies on all of these tests to show how when you lose the ability to do these tests well, you lose the ability to live at home by yourself, you increase rates of falls, hospitalizations, things like that. And then in athletes, there's the functional movement screen, which has been shown. Athletes are tested on these various functional movements. And then, you know, how people do on this screen has been linked to injury rates and return to sport and things like that. So when we're thinking about functional movements and ADLs, we're thinking about the balance between functional demand and functional capacity. So functional demand is essentially the demand on your life to perform function. And the capacity is your ability to do these things. So when your functional capacity falls below the functional demand of your life, that's when we start to see things like injury or the inability to perform functions, inability to perform your job. And the goal of functional fitness is to increase your functional capacity so that exceeds the functional demands of your life. And how do we do that? By functional training and functional fitness training, which is what we're talking about today. The unknown, the unknowable in life is more likely than sort of planned obstacles throughout the day. So preparing people for the unknown, for the unknowable, by giving them a solid foundation in functional movements is what the goal of functional fitness is. So functional fitness, how it's defined sort of in the fitness world, in the CrossFit world specifically, functional movements performed at high intensity. So not just practicing the movements, but also doing them as you become more proficient in them with intensity that tasks both the cardiovascular system, the aerobic and anaerobic pathways. So what functional movements are, they're the foundations of your ADL. So they're tasks that everyone needs to perform in everyday life. They're movements that existed before gyms. So things like squatting and lifting, people were doing this long before any gym designed programs around them. They're movements that are not explicitly taught. So like this child in this picture, sort of naturally do these movements because you have to do them to sort of get by in life. So whether that's squatting or lifting, and they involve complex muscular patterns, involves coordination between the central nervous system and the musculoskeletal system. Also involves multiple joints, complex multi-step tasks within one movement. And functional fitness aims to train these movements to prepare the body for everyday life. And these are just examples of functional movements, how we may see them. So squatting, lifting, something off the ground, how we might train that in a gym, using a barbell to sort of simulate that. Putting something in an overhead bin, carrying a child. I mean, these can all be emulated in some way with a barbell, with a sandbag, things like that. What is not a functional movement is some of the stuff that we see quite often actually in our gym facilities. So muscle isolation movements, single joint movements, use of machines that have pulleys and levers. Often life does not present weight to you on a pulley system. So being able to move something or moving your own body weight in space is important to do, you know, and to train those movements outside of just single joint isolation movements. Certainly these things have their place in the rehab space, but there is a next level to these movements. And certainly there is no, you know, so focus on function rather than focus on aesthetic. This idea of working out to look a certain way versus training your body to move in a certain way so that it's functional. And I think a lot of these sort of traditional, what we call traditional physical therapy, a lot of traditional physical therapy is going to be somewhat based in the single joint movement. So the idea is to kind of expand beyond that. So talk briefly about what this functional fitness looks like for special populations. So talking about spinal cord injury, obviously. So, you know, spinal cord injury, like, so five years after a spinal cord injury, there's an increased risk of weakening. So, you know, people with disabilities have the same, if not more so of a need for fitness because after an injury like that, they're at higher risk of obesity and then other medical complications, including the sort of the rampant metabolic disease that already exists in the world. So up to 67% of people with spinal cord injury are obese, which when you think about that, having extra body weight greatly affects the ability for people to perform ADL. So especially things like transferring and, you know, getting from one place to the other, you don't have a good, if you're overweight or obese and have difficulty moving yourself, you don't have enough strength, this only can make you more prone to having injury or losing the ability to live independently. And then overweight and obese people also have increased risk of things that are typical SCI problems like skin breakdown and urinary tract infection and falls and things like that. That's mentioned the overuse injuries at the shoulder due to wheelchair propulsion are very common in this population, and then the increased rates of depression that follow as a result of some of these things. So, you know, the impact of adaptive sports that's been measured. Participate in adaptive sports, especially those with SCI, have shown improvements in all of these things, quality of life, satisfaction, community reintegration, mood, employment. But we have to ask ourselves the question that what if someone is not fit enough to participate in sport, I mean just like a person without any kind of impairment. They have to have the endurance, the strength to participate in that so that's where the functional training comes into play. Functional training has been shown to promote functional recovery and spinal cord injury. You know, because their shoulder pain usually presents within five years of injury. Functional movements help for transfers, shoulder stability, postural support. People with spinal cord injury have also been shown to really enjoy this kind of training, especially this kind of intensity training, and it can improve the ability to participate in sports, and we already know that the benefits of participating in adaptive sports. And also we think beyond rehab. So, functional training really is a nice place for the post-acute rehab person. So, you know, it's an opportunity for the community to connect with rehabilitation facilities. So, you know, once people leave the rehab facility, then it's sort of a, you know, what next question? What do they do now as far as continuing to build on those tasks and improve? And that's where functional fitness really can play a very, has a very nice role. Not to mention the community that's involved, and these are some programs that are actually in South Orlando, Florida, that have started, that have made connections with the local facilities there to start spinal cord injury programs for the post-rehab patients. And there's certainly been a nice community that's formed as a result, which that helps elevate mood, helps provide motivation for improving fitness, preventing chronic disease, and then continuing to practice the skills and increase the functional capacity of these patients after they leave rehab. And here's another example of what that might look like. So, a person who falls out of their wheelchair, being able to get yourself back into the wheelchair safely is actually can be a lifesaving maneuver in a person with a spinal cord injury or any person who uses a wheelchair. So, functional training, in a functional training setting, you're actually working to, that's something that you practice. You work to build up the strength, and you might use different methods of doing that, but to practice that movement so that something like this won't cause significant injury or lethal death. The same with amputee population. Certainly the type of cause of amputation is important. There's traumatic amputations and disvascular amputations, but obviously the populations who have those injuries, have those amputations, baseline health is very different. But there are combat, the use of functional fitness is shown to greatly improve combat amputees' mood and anxiety. And this also has helped serve Britain some communities through the VA as far as forming. There's been some fitness communities formed by, you know, introducing functional fitness as opposed to rehab setting. So amputees, as many of you know this already, but they have different energy requirements as the more women that you lose, the more energy it requires for you to get from point A to point B. And so the balance and trunk control is required with using your prosthesis. And you know where it attaches can also present new challenges and yes your center of gravity changes. So really practicing a lot of single leg movements, improving the core and hip strength is very important and that has to be maintained after acute rehab. This is an example of injury requirements that you can see someone who's a bilateral transfemoral amputee is requiring over 200% more energy to get around. So you want to train and encourage strength and endurance in this population, because just from getting, you know, around their house requires that much more energy. Then briefly I'll talk about cognitive impairments and we'll have more people talk about this later but there have been studies that have shown that specifically in the Down syndrome population, there's very high rates of obesity. People have low muscle tone and a hypermobile baseline and tend to be more sedentary, have low bone mineral density. So the use of high intensity exercises in this population has been shown to improve all kinds of health measures, improve socialization, but also has had some interesting cognitive and speech outcomes as well, which we'll get more into later. Again, in stroke rehabs, similar findings, so high intensity interval training and functional training for the post-stroke population has been shown to promote functional recovery, cardiovascular health, mobility, and then neuroplasticity. And as we know, neuroplasticity, but high intensity training has been shown to help promote neuroplasticity in these populations. So there's a bunch of cool organizations doing really interesting work with functional fitness. We'll hear from some of them today. Here's just a list of some. Some really interesting things going on. But inclusion, so training functional movements is really essential, increasing independence, preventing debility in these special populations. It's important that they train these movements because the function is already impaired. So we want to try to optimize what function is there and optimize that as much as we can. It can really serve as a great bridge from the rehab facility to the community. We can't forget the social aspect, which is also very important in any person participating in fitness, but certainly in these populations. And then barriers to participation we have to think about as well. So things like transportation, how accessible is the facility, and also the knowledge that these programs exist. So that's where we come in as physiatrists to kind of help make those connections to the community. So thank you, and I'm going to throw it now to Dr. Dubon to talk more about exercise in special populations. Thanks so much, Dr. West. If you want to unshare your screen, I will go ahead and put my slides up as well. Okay, so as Dr. West mentioned, I'm Mary Dubon. I'm a pediatric rehabilitation medicine and pediatric sports medicine physician through Spalding Rehabilitation Hospital, Boston Children's Hospital, and Harvard Medical School. And so my practice is pretty much half and half between Peds Rehab, taking care of kids with disabilities, mostly focused on physical disabilities, although intellectual disability as well. And then pediatric sports medicine, and a big area of overlap in my big niche area of interest is physical activity, sports medicine, injury prevention, particularly for me, for children, but also involved with young adults as well with disabilities. So I'm going to talk a little bit today about what are the actual physical activity guidelines for individuals with and without disability. Just as a refresher, it is something that new guidelines do come out every handful of years. And so it is important that if you are in this arena, that you keep on top of what the current guidelines are, because there have been some changes that have been made over the past 10 years or so. So I did want to just mention my disclosures, none of them will be interests that we're going to be talking about today, but I do have some grant funding. I do have some relationship with Special Olympics, and then did also want to disclose spouse employment and SOC as well. So let's start with kids, and we'll get to adults as well. So physical activity guidelines for children. So the guideline that I typically go to is from the U.S. Department of Health and Human Services. So it's the physical activity guidelines for Americans, and it's currently in its second edition. And they do a really nice job of describing multiple different guidelines for different groups of individuals. And so they have school-age children, they have younger than that. They have adults. They have adults with chronic and medical conditions disabilities as well. So for physical activity guidelines for school-aged children, it's, if you've heard of Play 60, which is the NFL has kind of sponsored this initiative to try to get kids more active. That's a good way of remembering that the idea is 60 minutes a day. So an hour a day of moderate to vigorous physical activity. Now that does not have to mean that somebody is doing an organized sport or activity, but being active. And so at least three days a week, that should be more vigorous. So it should be a vigorous physical activity at least three days a week. And at least three days a week, it should involve some muscle strengthening physical activities. So Dr. West showed us some examples of what that would look like. So again, it doesn't have to mean weights. It can certainly mean squats and other strengthening activities that are using your own body weight. And then at least three days a week of bone strengthening physical activity. So things like jumping, impact that are really healthy for bones and for growing bones. So this is just the general physical activity guideline for children. And so now I'm gonna go over the physical activity guideline for children with disabilities. So what changed on this slide, right? So what changed on this slide was I added the words with disabilities, right? And I kind of changed some of the icons just to kind of represent children with various different disabilities, right? So my point here is we still want children with disabilities to meet these requirements when they're able to. And that's very clear in the physical activity guidelines for Americans. There's a little section where they talk about children with disabilities and say, when able, when it's reasonable, that this is also the recommendations for children with disabilities. Now, obviously we all know as physiatrists that disability can mean so many different things. And so it is important for us to get a little specific, but in general, it's not like, okay, you have a disability. And so therefore you don't want to do as much physical activity or you don't wanna do physical activity, which I think we all know, but sometimes it's maybe not talked about in medicine as much as it should be. And so I think us as physiatrists, it's really important for us to help be voices to promote physical activity and to educate others that we want everyone to be able to reap the benefits of physical activity. So what about physical activity guidelines for adults? So they are different than for kids. And so they've kind of updated the guidelines. So now it's not quite as straightforward, but it's this or this. So it's basically moderate intensity, aerobic physical activity, 150 to 300 minutes weekly. Or if you do vigorous intensity, aerobic physical activity at 75 to 150 minutes weekly, or basically some combination. If you do some moderate, some vigorous, basically a combination of the two that gets you somewhere in that range. And then they also recommended doing muscle strengthening in addition to that aerobic physical activity in all major muscle groups, two or more days a week. So that's general guidelines for adults. And you may have thought that this is what was gonna happen again, but here we are again, right? Just change the words with disabilities and change our logos as well, right? So just like for children, the physical activity guidelines for Americans does also comment that if you have medical condition or a disability, when able, the guidelines still do apply, but certainly there's like the little asterisk, right? The caveat that we know that there are some instances where that's not possible or that is gonna look different. And so I think, you know, if you're somebody that is counseling somebody about physical activity or exercise, what I usually recommend is, you know, kind of do your homework and know a little bit about that population, right? And so we use the example of spinal cord injury. That's the example I'm gonna use today as well. Cause there are guidelines that are specifically created for individuals with spinal cord injury, but you work with somebody with a different condition, just kind of doing your homework. And even if you don't know the specific guidelines of that patient encounter or patient visit, look them up after the visit and counsel somebody once you've looked things up to kind of get a sense of what are the things that are specific to that population. So I mentioned that there are guidelines for some populations. It's not gonna be for everyone, but it's always good to kind of look up even if it's not an official guideline, just some guidance that's out there in the literature. So the evidence-based scientific exercise guidelines for adults with spinal cord injury. So in 2018, they came up with the most recent rendition of this. And it basically is a consensus group that reviewed the literature and really, you know, convened and made guidelines based on what's available in the literature and also what the expert group felt was most appropriate for this population. And I would anticipate over time that this is going to be revised and edited over time. So definitely something that if you're counseling this patient population, that you should be keeping up to date on what the newest guidelines are. So what the current guidelines, so a summary of that is recommending moderate to vigorous aerobic activity for 20 or more minutes twice weekly. That's just like if we're talking about cardiorespiratory fitness, like so at least 20 minutes, but like really, if you can do 30 minutes twice weekly, that would be even greater. And then muscle strengthening, three strength exercise sets per major functioning muscle group. So we did see something mentioned about the major muscle groups in the general guideline for Americans. And this is for, you know, major functioning muscle groups, right? So that's kind of a little bit, it's a little bit of a different guideline in general here, but also just an adaptation because it's recognizing that somebody with a spinal cord injury is not going to necessarily have function in all of the major muscle groups. And then the last thing I just wanted to mention before I pass it on to our next speaker is that it's always important, not only to think about what the guidance and guidelines might be for the patient population that you're working with, but also what are the precautions, right? So is somebody at risk for bone fracture because of low bone mineral density or are they at risk for autonomic dysreflexia? Or are there specific types of exercises from a cardiovascular perspective that may not be safe or from a muscular perspective that may not be safe because of their medical condition? So again, it's really about just doing your homework and realizing you're not going to know everything for every patient population you run into. And so just looking it up, staying up to date on the evidence and thinking about it. That's the most important thing is thinking about what precautions might be in this group. And if I don't know, looking it up so that you can help guide the safest plan for physical activity. And with that, I just wanted to mention that precautions are not about restricting somebody from participating. It's really just about trying to make guidelines to find a way to safely participate, right? So it's not trying to put another barrier in the way for somebody, but I always approach it as a way to know, okay, these are some of the things that are already barriers from a medical and disability standpoint. How do we make a program and a plan that takes that into account so that we can keep somebody safe, free from injury and medically healthy? So with that, I'm going to pass it on to our next speaker and thank you so much for having me. Hello, everybody. My name is Alex Zirkenbach. I am the Executive Director of Adaptive Training Academy. Adaptive Training Academy is a nonprofit organization that provides adaptive and inclusive fitness training education. We do this in the form of seminars and online courses with the intention of training coaches and trainers to be that end state user, to actually be able to train with people with disabilities, either in a therapeutic setting or in a gym setting. My introduction into adaptive fitness world came unintended. I'd spent 10 years in the Navy as an officer. I had a combat injury in 2009, almost lost my right leg. And now I still have dysfunction of that right leg, but lucky to still have my leg. But it was a long rehab process for me. And during that process, I realized that there wasn't a lot of gyms that were available to train people that had various disabilities. And so after my medical retirement from the Navy, I opened my own facility. I started working very closely with the local Naval Hospital in San Diego, developed a recreational therapy program, eventually developed a class and a program for CrossFit specifically. And then we branched out to create Adaptive Training Academy to provide education for all of the fitness community. So quick session agenda, quick intro to Adaptive Training Academy so that you're aware and have a resource to reach out to us if you need help with adaptive and inclusive fitness, whether that be specific exercises, methodology, programming, accessibility, whatever it may be. But the main bulk of today, what I wanna go over is some general adaptive training principles that apply to all adaptive athletes, and that you could apply in the therapeutic session or in a daily health and fitness training session. And then show you some different ways to think about adapting exercises and how we would look at the common functional movement patterns and how you can replicate those for any athlete or any trainee with any disability, whether it be physiological or cognitive. Real quick, the reason why we exist for Adaptive Training Academy and why all these presenters are presenting today on adaptive fitness is that there is 1 billion people worldwide with some type of disability. More significant in the United States, that is one in four Americans or actually 26%, and this is data from 2018 from the CDC, 26% of Americans have some type of significant disability. And there are not facilities and trainers available enough for all of these people in the United States to daily train fitness and health. And so our mission at Adaptive Training Academy is to make fitness accessible and inclusive for everybody, regardless of ability. To this date, we've trained over 2,500 trainers and have provided training in 51 different countries and to 1,600 organizations. But really that number is minuscule compared to the amount of people with disabilities that need daily fitness and health training and that need trainers and coaches, physiatrists and therapists to be able to provide this safe and effective education and training for people. All right, on to our training principles. You've heard previously about functional movements and how important they are and what they are. We would love our trainers and everybody, we're training people with disabilities to utilize functional movements as their primary mode in the primary exercises. And that's because functional movements are required for life. They're required for ADLs and IADLs. When we train functional movements in the gym, they're gonna have the most transference to IADLs and ADLs outside in the real world. Functional movements are also inherently safe. Inherently safe because our bodies are built to do these movements. They are very effective in actually changing a stimulus in our body and having some type of adaptation happen where we can increase fitness. And they're very efficient. If we have a short amount of time to work out and we're doing squats and pushups and pull-ups, that will transfer and be very efficient in increasing our fitness. We don't have to spend hours in the gym to have a significant increase in fitness. We would love to do functional movements using free weights. Dr. West was talking earlier about using machines. Machines are great to be able to use sometimes. They can increase the stability of an exercise. You can use them to make sure you have trained symmetry. But the primary movements we should be doing should be free weight on the floor, things that can be replicated and transferred to the real world. If you look below on the bottom of the slide, you'll see a list of functional movements just to highlight the major ones that we use for Adaptive Training Academy. And those would be hinging, squatting, pushing and pressing together, pulling, and then locomotion is a general term we use to mean moving across space. And so if you look at those, to the right is just a simple explanation of what those are. Hinging or deadlifting is just picking something up and putting it down. Squatting is just moving your body up and down. That can be loaded or unloaded. Pushing and pressing is just pushing your body away or objects away from the body. Pulling would be pulling some object like a door or your body towards something like in a pull-up. And then locomotion, again, that's what we consider conditioning. So we could be doing running, crawling, pushing in your hand cycle, or doing any number of different types of conditioning exercises. The picture on the right is showing an adaptive athlete at the CrossFit Games in this previous year, one of the top end athletes deadlifting 502 pounds. And he's using an adaptive device, a harness, to be able to replicate his amputated arm. All right, I wanna discuss how we think about exercises and how we can retrain our brain to think about them in a different way. So this table is showing on the far left, the functional movement that I just discussed, the squat, the hinge, the push and press, the pull and locomotion. And then the middle column is your movement pattern, or how we typically think about exercises these days is what is being trained. So in the squat, we think about, oh, well, it's leg and hip flexion extension. People may be thinking about, well, I wanna train my quads or my glutes. And then for hinging, exercise would be like a deadlift. Again, we're thinking about hip flexion extension. Maybe if you're thinking specific muscle groups or somebody's bodybuilding, they're training their glutes, they're training their core just to stabilize. But what I would love trainers and physiatrists to think more and use it more is actually thinking, okay, I have somebody and I would love them to do the functional movement of a squat. And instead of thinking about the specific movement pattern or the muscles being trained, we can think about task accomplishment and what is that real world task being accomplished here. So in a squat, it's just simply moving your body up and down. And in a deadlift and a hinge, just picking something up and putting it down. And I'll show you some examples here. We use those two and I have some videos to show you. So here's an example of two different squats and I'm using, I'll use air quotes here. So the training on the left has cerebral palsy and he's doing squats that look like a traditional form, just holding a kettlebell. And really he can just find some way for him to do safely, do squats, and that may be holding on an upright or squatting to a box. But the training on the right is a spinal cord injury athlete. So his version of a squat, he's not gonna be able to use his legs and hips to move his body up and down. Instead, his only major power production joint is his shoulders. And so now he's gonna use his shoulders and his arms to move his body up and down. And what that means is that turns into what is a low box transfer. So this may be how this athlete trains. Again, I'm using air quotes here, squats. And instead of thinking leg and hip flexion extension, training the glutes and the quads, we're training the functionality of the squat, which is really just moving your body up and down, which is very important for spinal cord injury. Again, I'll show you some more examples of squats. The athlete on the far left is an upper extremity amputee and he's doing squats in a traditional able-bodied form that you might see, just holding a dumbbell. The trainee in the middle is doing a beginner version of what we would do for dips. And again, so you can see that he's moving his body up and down and he's using his shoulders and arms to do so. And that's his functionality. And that would be a beginner version. Whereas the trainee on the far right is gonna be doing a box squat. The great thing about this version is he's getting some passive range of motion in his knees and ankles, which is very healthy for those joints and get some blood flow to the lower extremities that don't typically happen. So a little bit more advanced version. But you can see all three of those, they're all doing their own version of what would be a squat, which is the functionality of just moving your body mass up and down. Let's go on to the hinge or the, we'll use deadlifts as an example now, and I'll show you the same thing. So here we have an athlete on the far left, the cerebral palsy doing just some kettlebell deadlifts. He's using a sumo stance for a little bit more stability. The athlete in the middle is that upper extremity athlete. He's using an attachment device that replicates his arm. So he can lift with two points of contact and he's doing a traditional barbell deadlift just with an adaptation of finding a way to connect to the barbell safely and effectively. And then the trainee on the far right is doing the functionality of a deadlift, which is simply just picking things up and putting things down. So she's doing a kettlebell side bend. She could lift that up to her lap, but in this case, she's just doing side bends. And so we're just training the functionality of the deadlift, picking things up and putting things down just in different ways. One more example for the hinges and deadlifts. You can see that the athlete on the left and center, he's using a bench. He's got his legs strapped to the bench so he can do this safely and not fall over. And he's doing kettlebells and barbell deadlift. He's using a pulling back, so quarter extremity motion so that he doesn't really have the motor function of his hip, but he is using his core as much as he can to lift those objects up. That's one version of a deadlift. And then again, the girl on the far right, she's doing what's called a side-to-side deadlift. And again, the trainer in this case would say, hey, I want to train the functionality of just picking things up and putting it down. So that replicates just her everyday life of having to pick something up from the side and both sides of her chair and putting it down on both sides of her chair. So again, just different examples of ways to think about movements, not specifically thinking, oh, I have to train the glutes or I have to train the quads. But instead, let's think about the functionality of what that does for us in the real world. Thank you for your time. I appreciate it. If you would like to get in touch with me, simply our website's www.ata.fit, or you can reach me at alec at ata.fit. I would love to, if anybody has any questions or needs any assistance with training people with disabilities, we're here for a resource. We have lots of educational videos and please feel free to contact me. And with that, I'm going to pass it over to our next presenter, Jenna. Thanks, Alec. So my name is Jenna Muri-Rosenthal, and I'm a speech and language pathologist and a certified brain injury specialist. I work at Mass General Hospital, and I'm also a CrossFit Level 2 trainer and an adaptive and inclusive trainer. And I'm going to talk a little bit today about the sort of blended benefits of working on speech and language and cognitive communication treatment in the gym, so sort of blending fitness with cognition. So just briefly on my financial, my disclosures, I have one relevant disclosure, and that's just that I'm the founder of Fit to Function Recovery, which is a program that provides treatment blending functional fitness and cognitive linguistic rehabilitation in the gym. So I just have a disclosure related to the sort of service described here. So you learned a little bit about adapting for physical limitations, and I'm going to take that just a little bit further to talk about a little bit more of a specialty population. So we have classifications sort of in the adaptive world where we consider a neuromuscular category of individuals, right? So Alec was sharing some of the statistics about those living with a disability. So as far as our neurorecovery population, the CDC estimates that there are 5.3 million individuals living with a disability from a traumatic brain injury. In addition to that, we have over 400 different types of neuromuscular diseases. So if you put this group of people together, that's a wide range of modifications and a way to provide fitness to another group of individuals who could benefit from it. So when we think about adapting fitness for neuro, we're always following those sort of same principles of functional fitness, but what tends to happen in this population because we can have such a range of limitations and disabilities is that the modifications can become a little bit layered. So we learned a little bit about sort of that upper extremity or lower extremity or seated, but when it comes to our neuros or stroke survivors, we might have a hemiparesis or some sort of a movement disorder. Maybe we have a visual deficit or some sort of sensory loss. And so the modifications can be a little bit more complicated as far as accessing the fitness. So, for example, if we have someone with a hemiparesis, we may be using some of the same modifications for someone who can stand, but they may sit. We may kind of have them take away kind of assist for their balance so that they can get a little more involved in the fitness. And similarly for our seated athletes, you know, in the adaptive world, we sort of classify based on our spinal cord injuries as those with hip function and those without. If you add on some sort of neuro condition, perhaps you might have a movement disorder on top of that. We may need to kind of double down on the modifications that we're providing. So this is just a little something that we do one way to modify fitness. We want to give access to individuals for jump rope. So we have these seated, oops, sorry, I didn't realize that had volume. We have these seated, these split ropes that can be used to sort of simulate rope swings. And that's applied to, in that video, to someone who requires a scooter chair. And on the other video here, we have Cheryl, who's a stroke survivor who can stand, can walk, but from a balance perspective and from a single arm perspective, things like jumping rope is not quite accessible to her. So we use this tool, we have her sit. The same athlete that you saw in that video before has a neurodegenerative disease. And so he's an individual who in terms of his fitness capacity has the strength to lift heavy weights overhead, but he also has ataxia. And so in order to increase his access to the fitness, he requires assistance holding that barbell because sometimes those movement patterns don't play out the way that he designed them where we want them to go. And in order to maintain safety while giving him access to strength to lift overhead, in this example, you see, I just have my hands on the barbell to help him do that. So you learned about adaptive, a little bit about adaptive fitness, and we're going to talk more about that when it comes to our neural population. But I said this is a specialty population and that goes beyond the physical adaptations and modifications. So when we think about cognition and communication and the role of the SLP, because I'm a speech therapist, there are a lot of things that most of us take for granted that are actually highly complicated. So if we take language, we know about output, naming, comprehension and sort of the myriad of skills required to create language, to engage in conversation. And on top of that, we have all the cognitive skills and cognition's role in communication. So just to kind of flush out the complexity of it, in order to communicate, we have to pay attention to what it is we want to say. We have to pay attention to our communication partner. We need to be able to filter out competing noise, remember what it was that we wanted to say, hold on to all of that content in your working memory, while at the same time kind of reacting to the information that's coming at you and planning a response. Be able to reason through a potential problem at the same time as you're generating a response, remembering it, and communicating that while filtering out competing stimuli. And so, you know, as much as language is simple, it's also highly complex and it's layered by that cognition. So when it comes to adaptive fitness, the goal is to really minimize limitations. And it's important for the trainer, right, to provide access to fitness. And this can be, we have our physical limitations, like we talked about, seated in upper extremity and lower extremity. But when we're thinking about cognition, that can include any of these domains, right? So we have to think about providing access for those with language or cognitive disabilities. So in the prior talk, you learned a little bit about minimizing these physical limitations. So I'm going to talk about cognition. So just some ways that we can work with those individuals in the gym when it comes to language. We know that there can be breaks down in auditory comprehension or verbal expression. So how do we simplify that? So for language, we can provide more simple instructions. We can break down those multi-unit commands. We can, when it comes to expression, we can give athletes a little extra time to explain the things that they need to explain or provide choices to aid their output. When it comes to memory, we're asking individuals to get through a workout routine and they might need a little assistance remembering what it is that they have to do. So we can write things down. We can give them their own sort of whiteboard. We can help them sequence the steps and cue to them what comes next. That might even include something like a picture board or a visual schedule. And in that instance, we're accommodating for both language and memory. When we think about sequencing, right? In a workout, you go from one movement to the next movement, and that can be a challenge for individuals who struggle with that level of organization. So we can just cue someone to what comes next. Taking the next level down to attention, a gym can be a really busy environment, right? So ways that we can provide, increase the access to the fitness, we can think about limiting those external factors. So maybe there's no music. Maybe we go to a quiet space. Maybe we sort of remove visual distractions like other gear or other members. In terms of memory, within the context of what we're doing, our working memory is also engaged. So the athlete might have to count their rounds, count their reps, know what they're doing next. And we can assist them in terms of the mental manipulation in real time. So I can take that cognitive load off of somebody, count their rounds, tell them what to do next and things like that. And as far as problem solving and reasoning, planning and organization, same thing. Within a workout, sometimes there's some strategy around how do we do that? And where do we break it up? And how do I make sure that I'm maximizing my strength and my cardio capacity? And we can help guide people with some of the planning around that. Here's what some of that might look like, right? The kinds of tools that trainers can create in the moment. There's sort of a whiteboard. You can write the words out. You can draw pictures down to something you might have to make in advance, much like a visual schedule. Or you can use some sort of visual or tactile modification like poker chips to help folks count their rounds. So we talked about some of the approaches to sort of minimize those limitations, but we can flip that a little bit and we can actually treat for language and cognition in the gym. And this is where sort of the modifying then becomes access to the improvements in the learning. So the gym, it's a great place to work on a lot of cognitive skills. So a few, you know, there's a lot of ways that we can go about this. So if we think about language, the gym is rife with opportunities to provide structured naming. We can include generative naming tasks. Perhaps somebody goes through a round of a workout and then you stop and ask them to list items in a category. We can describe what we've just done. We can provide increased complexity and command following. And these are opportunities in which we can treat the language within the context of the fitness. Similarly for memory, there's a lot of things to be remembered in the game, in the gym, like the names of the movements, the names of the gear, other members. And we can practice a lot of these things kind of drilling and helping individuals to work on targeting those memory skills for new information. Same with attention. We have the opportunity, we talked about stripping away some of the things that can be distractions, but we also want to start to engage those athletes and help them build those attentional skills. So we can start to introduce some competing stimuli. We have a type of workout, for example, where every minute on the minute, the clock is going to beep and someone might have to shift tasks. And that's a good challenge for someone who may struggle with alternating and dividing attention. Similarly, we can hand over a little bit more of the challenge when it comes to problem-solving planning and strategizing within a workout. We can also, in between rounds, kind of in a structured treatment way, stop and present someone with a problem-solving situation and say, let's reason through this together. And in addition to all of that, there are a myriad of ways in which we can start to build functional independence in and around the gym. So things like scheduling your sessions, remembering to come, paying, getting to and from the gym. So we have all of these opportunities to treat cognition across the levels. So what does this all look like in the gym? So just one quick athlete profile. This individual, Mike, is a 56-year-old left MCA stroke survivor who has a right hemiparesis. He walks with an arthrosis and he has a plegic right upper extremity. At baseline, he walks with, ambulates with a cane and uses a handrail and assistance for stairs. And he has a mild non-fluent aphasia. So, you know, on the left side, you'll see sort of a sample workout, what an everyday athlete might do. You're going to go through a couple of rounds, three burpees, five squats, seven pulps and nine deadlifts. And if you see how we modify that for Mike, we're going to have him do get up. So he's going to practice just getting down to the floor and back up again, because remember, we want to keep it functional. He's going to squat to a box. He's going to do some ring rows. So engaging that single arm to get him doing some pulling, and then he's going to deadlift a kettlebell, just a single object on that one side. And as far as cognition for Mike, we're going to preview and review the workout before and after, give him his own whiteboard, cue him through the movement transition and help him count his rounds. So for Mike, after 12 sessions, these are just some of the outcomes that we saw. So we repeated that same functional fitness task to get a measure of his improvements. And he was able to increase in that 10-minute workout. The initial timeout, he got four rounds and four reps. And then the latter half, he got five rounds and eight reps. So he essentially increased his pace from roughly two and a half minutes around to just under two minutes. And this was also done for him at an increased load, so a heavier deadlift, and he was able to still do that faster. In terms of working on his cognition and his language, we had targeted some structured naming, which he was able to increase that from 40% accuracy just on standard structured naming all the way to 90%. And he had an increase in his fluency in structured conversational tasks. And Mike was a prior car. Previously, he'd been a car salesman. So for him, engaging in functional dialogue and complex conversation was really important. So within tasks, he'd do a round of workout, and then we'd stop, and he would describe all the things related to a car that I might want to purchase. And we'd do some structured Q&A around how might you help someone negotiate this. In addition to all of that, Mike had some increase in his functional independence. He started to ambulate without his cane indoors, was able to start to go up and downstairs without holding on, was able to start squatting lower, so sitting instead of on a 24-inch target, down to a 20-inch box, which more closely simulated the couch that he had at home. And he started to improve his independence with scheduling and getting to and from the gym and things like that. So kind of just briefly to review, right, so what is our plan here for these individuals? We want to get them in the gym. We want to modify and adapt, and then we want to treat. So we're going to modify for fitness. We're going to lay in some cognitive modifications to make it accessible for those with cognitive and linguistic deficits. And then we're going to start to scale up. We're going to increase the load and the capacity and get in all of those things from a fitness perspective. And similarly, from a cognitive perspective, we're going to start to strip away some of that scaffolding that we've provided. And the modifications really become the treatment, handing over that cognitive responsibility. There's a couple of ways to do this that also help foster that better understanding of what it is that we're trying to do. And then we're going to that also help foster that better functional independence. And we want folks not only to come and go from the gym on their own, but start to build the community within the gym and talk about what they're doing there with other members. And then once they get home, so sometimes we'll do fitness journals and things like that to have a little bit of better carryover. So just generally an increase in the outcomes that we've seen across clients that are doing this blended cognitive communication and fitness training. Like I mentioned before, we're seeing improved functional independence in terms of coming to the gym, traveling, taking Ubers, planning, scheduling, improved initiation for payment and things like that. On structured measures, we're seeing an increase in new learning. So an average increase in working memory of one to two units. And we know that average recall is about seven units at a time. So getting individuals from below there to up into the average range. And an increase in verbal fluency. So just asking individuals to name items and categories, there's a significant increase in that five to eight words on those single minute measures. Improved language capacity, naming, repeating, command following, and a lot of concrete carryover. Individuals kind of engaging more in child care and carrying groceries, which is a big functional task. And just kind of general caregivers are reporting increased family engagement, improved confidence, and better functional independence. So I'm almost done here. But just lastly, those of us in the fitness industry, we see the benefits of fitness across population, and we believe in it, right? But there's a science to all of this as well. There's a lot of research out there about exercise and mental health and mood, and a growing body of evidence about exercise and learning. I offer you a few highlights. Honestly, it would be an entire other presentation all on its own. There are a lot of studies, but I'll point you back to Kottmann's 1995 study of exercise and BDNF in mice, in which rodents who exercise had a significant increase in brain-derived neurotrophic factor, specifically in the hippocampus. And not only that, but the further they ran, the higher their levels of BDNF, right? So it's showing us that exercise is really increasing opportunities for proteins that support learning. A study in 2007 out of Germany found that individuals learned vocabulary words 20% faster following exercise. Another study that shows that cognitive flexibility improves after just one 35-minute session on a treadmill. So if that's just one session, we've got a lot more opportunities for growth there. So research supports that exercise essentially improves learning on three levels. It helps us optimize arousal, attention, and motivation. It prepares and encourages new nerve cells to bind. So it's essentially preparing us for new learning at the cellular level. And it increases development of new nerve cells in the hippocampus. So it's all about that neuroplasticity and the ways that fitness can support the brain on a cellular level for new learning. And I'll leave you with Mike because no one shines in the gym quite like he does, learning and improving, changing both his brain and his body. And feel free to contact me here with any questions. And thank you all for listening. And I will pass this back over to Amy. Great. Thanks so much, everybody, for joining us today. The lights just went out in my office, so I apologize that I'm now in shadow. But thanks so much for joining us. I hope you learned a little bit about some of the amazing things that these people are doing in the community and the opportunities that are available for your patients with disabilities and the importance of functional training specifically and how it can help improve their function and promote their independence. So please feel free to reach out to myself or the people in this session and give them more questions. And thanks so much for joining us.

fitness for all

functional fitness

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special populations

cognitive impairments

adapted exercises

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