1 Exercise and Rehabilitation Program for Gender Affirming Chest Masculinization Surgery Alysha Monk Department of Kinesiology, Capilano University KINE 499: Capstone Caroline Soo & Emma Russell April 11, 2023 2 Table of Contents Title Page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Table of Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Client Context Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .6 Surgical Outcomes and Survey Results . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Exercise Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Training Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Client Needs. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .17 Initial Six-Week Recovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Phase 1 - Stabilization and Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19 Phase 2 - Strength Endurance. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .21 Phase 3 – Hypertrophy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Phase 4 – Strength . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 24 Phase 5 – Power. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 3 Proposed Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .26 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Ethical Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Application to KINE and Future Directions. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 32 Appendix A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Appendix B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Appendix C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Appendix D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Appendix E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Appendix F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Appendix G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Appendix H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Appendix I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 4 Introduction Gender identity is becoming increasingly more acceptable in today's society (Watson et al., 2020). According to the 2021 census, there are over 100,000 genderqueer individuals living in Canada (Statistics Canada, 2022) and approximately 1.6 million in the United States (Herman et al., 2022). Unfortunately, the genderqueer community, which falls under the 2SLGBTQI+ acronym (see Appendix A), faces disproportionally poorer health outcomes; some of these poor health outcomes include higher rates of physical disability, mental health disorders, obesity, chronic conditions, and worse overall health (Fredriksen-Goldsen et al. 2014 & Herrick, 2018). It is well known that modifiable behaviors like physical activity and a healthy diet can help mitigate some of these conditions; however, historical stigma and discrimination has led to multiple barriers for genderqueer participation in physical activity (PA). Transphobia, unsafe environments, gender binarism, access to facilities and economic cost are some of the major PA barriers identified in the literature (Úbeda-Colomer et al., 2020). It is important to note that being queer or transgender is not a risk factor to poor health; in fact, it is the patriarchal society and cis/heteronormative structures that are a risk factor to queer health. To differentiate these risk factors is important to all queer people with lived experiences in the healthcare system, so we can deconstruct the colonial beliefs within research that is littered with transphobic and homophobic language. For genderqueer folks that have gone through gender affirming surgery, there can be additional barriers to exercise such as lack of rehabilitation knowledge or exercise guidance postsurgery. Because of the shift away from binary gender norms, more transgender and genderqueer individuals are receiving gender affirming surgery (Merrick et al., 2022); a lifesaving intervention aimed at helping individuals transition to their self-identified gender. The process of 5 receiving gender affirming surgery can be a long and difficult journey; navigating the healthcare system can be traumatizing and many doctors do not receive training to provide safe and equitable care (Kattari et al., 2020). It is crucial for healthcare staff to have the appropriate knowledge to facilitate a healthy transition for genderqueer people, which will ultimately lead to a better quality of life for this population. The aim of this project is to create an exercise and rehabilitation plan specific to individuals that have received gender affirming chest masculinization surgery (GACMS), which includes, but is not limited to transgender men, transmasculine people and non-binary folks. For a population that already has lower physical activity levels, gender affirming surgery can be an opportunity to inform individuals on the importance of rehabilitation and continued regular physical activity. Physiotherapists and kinesiologists should be a part of the healthcare team included in the aftercare of GACMS; however, there is a lack of literature on rehabilitation protocols for GACMS, showcasing the lack of involvement of rehabilitation professionals post-surgery. Because of the lack of research in this area, it was essential to gather information from queer people who have received GACMS. As a part of the preparation for this training plan, an online survey was filled out by four queer individuals who have received the surgery. The aim of this survey was to identify the current training and rehabilitation protocols recommended by healthcare professionals as well as the ways GACMS could improve their post-surgery recovery protocols. The training plan will consist of a six-week stabilization and movement program that can commence at the six-week post-surgery date. This training program will be aimed at genderqueer folks themselves, as well as personal trainers and health care professionals that are helping patients through recovery. The training program will include resistance exercises, cardiovascular 6 training, postural training, mobility and flexibility; similar to the components of the American Council on Exercise (ACE) and the National Academy of Sport Medicine (NASM) sports performance training models. Even though the goal of this program is not sports performance or high intensity, the NASM models follow an integrated and comprehensive training approach that is necessary to build functional strength and neuromuscular efficiency (McGill & Montel, 2019). McGill and Montel (2019) identify the importance of training in all planes of motion, training with optimum posture, and training for optimum muscle balance and function, which will be essential to re-gain function and strength post-surgery. Client Context Literature Review The previously mentioned health disparities and physical activity barriers for genderqueer people have been mostly identified by stress and coping models, which focus predominantly on genetic and biological factors (Fredriksen-Goldsen et al., 2014). However, Fredriksen-Goldsen et al. (2014) have created a model to conceptualize queer health disparities that includes social and economic factors, two components identified by the World Health Organization (WHO) as “root causes to health inequities” (Solar & Irwin, 2007, p. 67). The Health Equity Promotion Model looks at health across the lifespan of queer individuals and takes into consideration queer resilience as well as risk factors (Fredriksen-Goldsen et al., 2014). An important aspect of the model done by Fredriksen-Goldsen et al. (2014) is that it’s a collective responsibility to ensure “that all individuals have the right to good health” (p. 5). This framework will be an essential lens when considering post-operative training for queer people who have received GACMS. Health professionals utilizing this training plan need to understand that the majority of queer 7 health disparities are stemming from structural and environmental factors, not solely individual or community factors (Fredriksen-Goldsen et al., 2014). Gender affirming surgeries are an essential part of good health for genderqueer people. Not only do they save lives, but they also decrease gender dysphoria, depression and anxiety, and increase quality of life (Coleman et al., 2022). A study by Agarwal et al. (2018) used pre and post operative questionnaires to determine the self-perceived patient outcomes of GACMS. They found large positive changes in psychosocial well-being, sexual satisfaction, and physical wellbeing after surgery (Agarwal et al., 2018). Russo et al. (2017) found there to be significantly high aesthetic satisfaction with patients who received GACMS, which can lead to improved body image and increased self-esteem. People with high self-esteem normally have a higher sense of self efficacy (Joy et al., 2020), which is an extremely important factor when considering adherence to a new exercise plan (McAuley et al., 2000). There is no lack of literature stating the positive overall well-being outcomes of GACMS; however, there is a lack of literature on the physical and functional outcomes of GACMS. A more commonly researched area for the functional ability of assigned female at birth (AFAB) genderqueer individuals is the negative effects of chest binding, a common practice to reduce the visual appearance of breast tissue before an individual has received GACMS. Chest binding may be the only option for transmasculine and non-binary individuals that don’t have access to surgical options; consequently, it can pose physical risks to individuals that bind every day and for long periods at a time (Peitzmeier et al., 2017). Peitzmeier et al. (2017) found that negative side effects impact 97% of people who bind their chest. Literature shows that these side effects include: musculoskeletal pain, poor posture, limits to daily activity, dermatological outcomes, bruising, fractured ribs, and infection (Peitzmeier et al., 2017; Sood et al., 2021 & Jarrett et al., 8 2018). Since binding can be used as an interim measure before GACMS (Peitzmeier et al., 2017), there is a likelihood that the effects of prolonged poor posture and musculoskeletal pain can carry over after surgery and make the need for an exercise and rehabilitation program even more crucial. Surgical Outcomes and Survey Results GACMS is also called a subcutaneous mastectomy; this procedure removes excess skin and fat and repositions the nipples to create a flat, more masculine looking chest (Cleveland Clinic, 2023). Gender affirming top surgery is an extremely invasive surgery and has a long recovery time. After surgery, patients are unable to lift their arms greater than 90 degrees or lift over five pounds for the first four weeks of recovery (Johns Hopkins Medicine, n.d.). After six weeks, patients are given clearance to lift heavier items and return to regular activity routines. As previously mentioned, the credible information on immediate post-surgery protocols is lacking and the exercise protocols after the 6-week recovery time is non-existent. Therefore, the survey implemented for this project was useful to see what kind of information people were getting regarding exercise advice. The results are disappointing (Appendix B). None of the participants were given any pre-surgery exercise recommendations or any exercise recommendations outside of the initial 6-week recovery time. The recovery and rehabilitation information given to participants for the immediate six-week recovery time included: limiting upper body movement for two weeks, followed by introducing upper body movement after four weeks; no arms overhead and no lifting over five pounds for four weeks; bending over and doing progressively larger arm circles. There were no specific exercises given to participants by the surgical team or primary care doctor and there was no explanation of upper body movement progression post-surgery. Lastly, there were no resources, physiotherapy, 9 kinesiology, or personal trainer contacts that were given to participants after surgery. Clearly, there is a major gap in post-surgery care for genderqueer individuals that needs to be addressed. There needs to be significant rehabilitation and direction after the immediate six-week recovery time. Exercise Techniques The lack of industry norms for post-GACMS exercise requires the program to rely heavily on recommendations for individuals that have received breast cancer mastectomies or breast reduction surgeries. Kilgour et al. (2008) showcased range of motion (ROM) improvement in patients that completed an 11 day at home rehabilitation program almost immediately after surgery. Other breast cancer organizations such as the Canadian Cancer Society (CCS) and the American Cancer Society (ACS) highlight the importance of ROM exercises in the initial recovery period, some starting as early as three days post-operation. The CCS with help from the Canadian Physiotherapy Association (CPA) have created a document that outlines recovery exercises for the 6-week initial post-surgery recovery time. They include exercises that promote upper limb movement, elbow flexion and extension, shoulder girdle circles, shoulder joint extension and flexion, and passive chest stretching. Gentle walking and breathing exercises are also two important components during the 1-4 weeks post operative phase (Canadian Cancer Society, n.d.; Wilson, 2017); both will increase blood flow and help promote recovery to the surgical site. Wilson (2017) states the negative impact that mastectomies have on posture and shoulder function, “After a mastectomy with or without reconstruction, a patient may develop rounded (pronated) shoulders, a hunched over upper back, and the head in a forward position” (p. 99). Therefore, regaining normal ROM and implementing a mobility program immediately postoperation is key (Wilson, 2017). 10 Assessments The exercise program will be easily modifiable to meet all skill levels; however, a thorough assessment is necessary to ensure required individualization throughout the program. For the purpose of this project, there will a combination of tools and assessments gathered from the Canadian Society of Exercise Physiology (CSEP) PATH textbook, the NASM Essentials of Sports Performance Training textbook, and Capilano Universities’ School of Kinesiology KINE 241 course. A combination of physiological, lifestyle, functional, and aerobic assessments will be used prior to program implementation, which will help the healthcare professional gain a full picture of the individual’s history, goals, and abilities. First and foremost, a consent form stating the risks and benefits associated with assessment and exercise protocols must be signed by the client (see Appendix C). Additionally, a Physical Activity Readiness Questionnaire (PAR-Q) needs to be completed to inform the client and practitioner if further medical clearance is required (see Appendix D). This should be followed by a thorough conversation of previous medical history and injuries. Blood pressure (BP) and resting heart rate (RHR) are two biological measurements that will be taken prior to exercise or the assessment. If the clients RHR is over 100bpm the practitioner will not be able to continue to the active part of the assessment; additionally, if the clients systolic BP is over 160mmHg or their diastolic BP is over 90mmHG, physical activity cannot commence (CSEPPATH, 2019). It is important to use motivational interviewing techniques to gain a sense of readiness, goals, lifestyle habits, and barriers to exercise. Motivational interviewing helps people work through exercise hesitancies by using empathetic and reflective listening skills; indeed, the main goal is to enable discussion about the client’s desires and needs for change (Hettema et al., 2005). Appendix E shows an example intake form for individuals starting this exercise program. 11 The form asks questions relating to current lifestyle and sleep habits, fitness and health goals, and specific genderqueer related barriers to exercise. Aerobic, ROM, postural, flexibility and core stability assessments will constitute the second stage of the assessment process. Table 1 shows the assessment protocol in chronological order, along with a movement description and reason for selection. Because this exercise program starts after the six-week initial recovery phase the individual will likely be underconditioned, therefore a light-moderately vigorous aerobic assessment will be completed to find the client's estimated VO2max. Aerobic fitness assessments are used to evaluate the oxygen transport efficiency of the client's heart, lungs and blood vessels and the efficiency of oxygen use by the working muscles (CSEP, 2019). Since poor cardiorespiratory fitness is a risk factor for many chronic diseases, this test not only assesses aerobic fitness ability, but it can also be used to create conversations around the implications associated with low levels of aerobic fitness. ROM assessments will focus on the thoracic spine, shoulder girdle and shoulder joint, which are the main structures that will be affected by GACMS. Taking baseline measurements will provide a reference point while the client works through the program to regain normal ROM; therefore, a goniometer will be used to measure shoulder flexion and extension, and thoracic spine rotation (Howe & Read, 2015; Wilson, 2017). Static and dynamic posture need to be assessed to determine the structural integrity and alignment of the client through multiple positions and movements (McGill & Montel, 2019). Proper posture allows an individual to maintain center of gravity over their base of support, otherwise known as structural efficiency, while also maintaining proper posture during movements, also known as functional efficiency (McGill & Montel, 2019). Some examples of dynamic posture tests include upper body push/pull, overhead squat, single leg squat and plank. 12 As stated earlier, GACMS patients are at a higher risk of poor posture, which can lead to altered length-tension relationships, altered force-couple relationships and altered joint arthrokinematics, resulting in joint dysfunction and risk for overuse injuries (McGill & Montel, 2019). On account of the history of poor posture, the training program will focus on attaining structural alignment which will allow the client to build functional strength and optimal neuromuscular efficiency (McGill & Montel, 2019). Table 1 13 Functional Assessment protocol Assessment Description Treadmill Instruct the client to secure the walking HR monitor. Calculate 50%, test 70% and 85% of HRmax Stage 1 (0-4min): Warm-up. 0% grade at a speed that brings the clients HR between 50-70% of their HRmax. Stage 2 (5-8min): Immediately increase the grade to 5% and do not change the speed. Record HR after every minute. End: complete the test when steady state HR has been attained (when the HR does not vary by 5bpm). Add additional time if needed. Calculation: See Appendix D Have the client stand how they Static normally would and assess from posture lateral and posterior view. Shoulder In a standing position and flexion/exte keeping the elbow extended, the nsion client raises both arms in front of them as high as they can and behind them as far as they can. Segmental In a seated position with arms intervertebr behind their head (if possible), al motion instruct the client to move slowly from a neutral spine position to flexion followed by extension. Repeat several times. In a seated position with a small Seated rotation test ball between the knees (to prevent hip movement) the client will hold a dowel in front of them and is instructed to Reasoning To assess the client's aerobic capacity and calculate their estimated VO2max. This test is low risk and accessible to all skill levels and ages. If disability or joint pain prevents the individual from walking, complete a lower impact assessment (Seated cycling machine or arm ergometer). Reference CSEPPATH (2019) To assess the position of the head, cervical spine, scapula, thoracic spine, lumbar spine, pelvis, hip joint and ankle joint. Looking for postural deficiencies and excessive thoracic kyphosis. To assess shoulder ROM and measure with a goniometer for baseline measures. (McGill & Montel, 2019) To assess thoracic spine flexion and extension. Adequate thoracic spine extension is essential for shoulder girdle and shoulder joint function. (Genz, 2020; Takatalo et al., 2020) To assess thoracic spine rotation. A goniometer can be placed at T1-T2 and used as a baseline measurement. (Howe & Read, 2015) (Wilson, 2017) 14 Overhead Squat Single leg balance Single leg squat Plank Seated chest press machine Cable row Double leg lowering test rotate as far as they can in both directions. Instruct the client to stand with both arms overhead and squat to about chair height (use chair if needed). Repeat several times, keeping the arms overhead. Instruct the client to cross both arms in front of their chest and raise one foot a few inches off the floor. Record the amount of time they can balance on each leg. Instruct the client to stand with their hands on their hips and staring straight ahead. One foot is lifted off the ground while the client is directed to squat to a comfortable level with one leg. Repeat several times. Instruct the client into a prone position on a mat, while propped up on their elbows and toes. If needed, go from knees. Time the client until they stop, or exercise position deteriorates (excessive low back arch). Use a chest press machine or light band with handles. Instruct the client to stand with one leg forward and handles at either side of their chest. Have the client press forward and complete several reps Use a cable machine and instruct the client to row both handles towards their chest. Repeat several times. In a supine position instruct the client to raise both legs to 80-90 degrees. Instruct the client to slowly lower their legs while maintaining lower back contact This assesses dynamic flexibility, core strength, balance and neuromuscular control. It also indicates lower body movement patterns and strength deficiencies in hip abductor and external rotation strength. To assess the client's ability to maintain center of gravity with unstable support. Balancing is critical for activities of daily life and a normal gait cycle. (McGill & Montel, 2019) Similar assessment reasoning to the overhead squat. Knee valgus, hip drop/hike and torso rotation indicate overactive or underactive muscles. (McGill & Montel, 2019) To assess abdominal core strength and the muscular endurance of the upper body. CSEPPATH (2019) To assess movement efficiency and muscle imbalances during an upper body push movement. (McGill & Montel, 2019) To assess movement efficiency and muscle imbalances during an upper body pull movement. (McGill & Montel, 2019) To assess neuromuscular control and core strength. Measure hip angle with a goniometer for baseline measurements. (McGill & Montel, 2019) CSEPPATH (2019) 15 with the ground. The test stops when the lower back loses contact with the ground. Sorensen Instruct the client to lie prone on To assess neuromuscular erector a mat and extend the lumber control and spinal extensor spinae test spine to 30 degrees (or to a strength. comfortable position). The client will hold the extended position for time. Sit and Instruct the client to sit on the To assess hamstring and lower reach test floor with both legs extended in back flexibility. Poor flexibility front of them. Have them slowly in these areas can lead to poor reach forward towards their feet. back health. Use a measuring tape from hip crease to fingertip. Note: fillable assessment form can be found in Appendix F (McGill & Montel, 2019) CSEPPATH (2019) Training Program This training plan will use a combination of training models gathered from NASM, ACE, and CSEP as well as GACMS-specific recommendations from sources that have focused on mastectomy rehabilitation. The training plan will be periodized through five phases over an eight and a half month time span which will allow for optimal progression, so the client can advance through the plan safely. Periodization is an important aspect of any structured training regime as it will create a systematic plan that will remove any ambiguity of exercise direction and implementation (McGill & Montel, 2019). With this in mind, the GACMS training plan will consist of a yearly macrocycle to depict the flow of training phases (see Appendix H), a monthly mesocycle to indicate the specific days of each workout (see Appendix H), and a weekly microcycle that will show a detailed workout plan for each workout within a phase. For the purpose of this project, the microcycle will highlight the first phase of this program– a six-week stabilization and movement training phase (see Appendix I). 16 The primary goals of the six-week stabilization and movement training plan are upper body ROM, improving muscle imbalances, core function and stabilization, dynamic balance, and improving posture. Six weeks of stabilization and movement training will allow the client to progress through to the next phase of training, strength endurance, which is followed by hypertrophy, strength, and power (Bryant et al., 2014; McGill & Montel, 2019). After the sixweek stabilization and movement training phase, the client will spend four weeks in each of the subsequent phases; additionally, within the macrocycle there will be several four-week de-load phases consisting of components similar to the stabilization and movement phase. The de-load phase will allow for proper recovery between strength and power phases and ensure optimal levels of stability needed to create adaptations during the different phases (McGill & Montel, 2019). The five phases follow progression guidelines set forth by the ACE Integrated Fitness Training (IFT) model and the NASM Optimum Performance Training (OPT) model. Both models represent an integrated training approach that focuses on functional capacity, functional strength and neuromuscular efficiency to optimize health, fitness and performance (Bryant et al., 2014; McGill & Montel, 2019). In addition to the general principals of training (overload, specificity, and progression), there are four training principles that will be utilized throughout the five phases which include training for optimum muscle function, optimum muscle balance, optimum posture, and training in all planes of motion (McGill & Montel, 2019). In line with training for optimum functional capacity, exercises will focus on movements that challenge the local muscular system (stabilization system) and the global muscular systems (movement systems). The local muscular system includes core muscles that are directly attached to the spine (ie. pelvic floor muscles, transverse abdominis, multifidus, internal oblique, and diaphragm) as 17 well as muscles that provide join stability (ie. rotator cuff muscles) (McGill & Montel, 2019). In contrast, muscles in the global muscular system connect the pelvis, rib cage and lower limbs and are primarily responsible for movement (ie. erector spinae, hamstrings, latissimus dorsi, gluteus maximus) (McGill & Montel, 2019). The global muscular system is broken down into four subsystems: the deep longitudinal subsystem (DLS), the posterior oblique subsystem (POS), the anterior oblique subsystem (AOS) and the lateral system. These subsystems are comprised of muscles that work in tandem with each other, otherwise known as force-couple relationships, to produce fluid movements (McGill & Montel, 2019). Using these principles will ensure that stabilization, strength and power exercises are utilized to develop efficient neural patterns for all static and dynamic movements (Bryant et al., 2014; McGill & Montel, 2019). The first phase of the training program, stability and movement, will focus on overall functional ability to be able to perform activities of daily living as well as introduce exercise specific movement patterns and some loaded movements (Bryant et al., 2014). The second phase, strength endurance, aims to continue working on joint stabilization while adding loaded movements to improve capacity for the following hypertrophy and strength phases (McGill & Montel, 2019). Hypertrophy, the third phase of this program, will primarily focus on muscle growth while increasing training volume and the fourth phase, maximal strength, will focus on higher intensities (McGill & Montel, 2019). Lastly, the power phase will aim to increase the rate of force production by implementing plyometric and agility exercises (McGill & Montel, 2019). The start of each phase will be determined by the successful completion of the previous phase; progression to the strength and power face won’t continue until the client has optimal stability, core strength and efficient movement patterns. 18 In alignment with the general exercise recommendations put forward by ACE and CSEP, the training program will include evidence-based frequency, intensity, time and type (FITT) recommendations. This training program utilizes the Borg rating of perceived exertion (RPE) scale and percentage of one rep max (1RM) for intensity measurements (see Table 2). Aerobic exercise will be completed three to five days per week of 30-60 minutes at a moderate intensity or three to four days per week of 20-60 minutes at a vigorous intensity or a combination of both moderate and vigorous. Depending on the activity level of the client, aerobic exercise may start at light to moderate intensity. Resistance exercise will be completed at least three days pers week and range in intensity depending on which phase the client is in. Static, dynamic and PNF flexibility training will be completed at least 2 days per week at a mild to moderate intensity. Lastly, mind-body practices such as breathing techniques and yoga will be utilized for physiological and cognitive benefits (Bryant et al., 2014). Table 2 Rating of Perceived Exertion (RPE) Rating Perceived Exertion Level 0 No exertion, at rest 1 Very light 2-3 Light 4-5 Moderate, somewhat hard 6-7 High, vigorous 8-9 Very hard 10 Maximum effort, highest possible Note: amended from Borg, G. (1998). Borg's perceived exertion and pain scales. Human kinetics. Client Needs This training program is designed for anyone who has recently received GACMS, however it is important for the healthcare professional using this program to do a thorough 19 assessment to determine unique needs and abilities of the client. The six-week stability and movement training plan will focus on the fundamentals of these two components, while also focusing specifically on posture and upper body mobility. The history of poor posture for genderqueer people due to chest binding or attempts to hide one's chest have been previously mentioned. Mastectomies can exacerbate these postural issues by creating tight pectoral muscles anteriorly and creating a more forward trunk inclination; additionally, it can significantly change scapula and shoulder position, creating shoulder girdle asymmetry and excessive shoulder protraction (Haddad et al., 2013; Rangel et al., 2019; Rostkowska et al., 2006; Wilson 2017). Decreased glenohumeral joint ROM and increased thoracic spine flexion have also been identified as postural issues resulting from mastectomies (Rangel et al., 2019). These postural dysfunctions can lead to muscular imbalances and altered length-tension relationships, reducing the ability generate force or produce efficient movements while exercising (McGill & Montel, 2019). Initial Six-Week Recovery Rehabilitation and instruction for the immediate six-week post-surgery recovery time are outside the scope of this project. However, there are important general activity guidelines that individuals should follow during this time. During the first 7-9 days of recovery the individual needs to prioritize rest, a nutritious diet and very light movement or short walks (Gender Confirmation Center, n.d.). Walking at a light pace will help increase blood flow, which can aid in the healing process (Gender Confirmation Center, n.d.). Breathing exercises can also be utilized throughout the entire six-week recovery time to promote stress relief and relaxation (Canadian Cancer Society, 2011; Wilson, 2017). For 9-21 days (about 1-3 weeks) post-operation, it is encouraged that individuals go on longer walks at a strolling pace; additionally, after the 20 initial three weeks, individuals can commence higher intensity cardiovascular activities such as jogging or cycling (Gender Confirmation Center, n.d.). It is extremely important that individuals do not lift over 5lb for the first two weeks, do not lift over 25lb from weeks 3-6, and avoid lifting the arms overhead or stretching the chest (Gender Confirmation Center, n.d.). Once the initial 6week recovery time is over, individuals can resume regular activities (Liang, 2023). An infographic containing these general guidelines has been prepared and can be seen in Appendix G. Stabilization and Movement The stabilization and movement phase will comprise the six-week microcycle found in Appendix I. This phase will be crucial for an individual who has received GACMS because they will most likely be in a detrained state after the six-week initial recovery period. The primary goals of the six-week stabilization and movement training plan are upper body ROM, improving muscle imbalances, core function and stabilization, dynamic balance, and improving posture. Helping the client to find and hold a neutral posture during static and dynamic movements will be the foundation of this phase (Bryant et al., 2014). Low-intensity exercises focused on joint stabilization as well as core and balance exercises that strengthen the local muscular system will also be key. To combat the postural deficiencies mentioned earlier, thoracic spine mobility will be a major focus. Since scapulothoracic and glenohumeral joint function depend on optimal movement through the thoracic spine, thoracic extension and rotation will be implemented to increase upper limb ROM and decrease the risk of shoulder injury (Howe & Read, 2015). Movement patterns for resistance exercises will also be introduced in this phase, comprising of lower body pull and push movements, upper body pull and push movements, single leg movements and rotational movements (Bryant et al., 2014). An important aspect of 21 any training program is teaching the client proper breathing and bracing techniques. Supine and standing bracing techniques will be implemented in the first two weeks of phase 1 to introduce the client to proper standing posture and teach the client how to effectively breathe and brace during dynamic movements (Figure 1). Cardiorespiratory exercise will increase in intensity throughout this six-week phase: weeks 1-2 will be three 20-minute bouts of light to moderate (35 RPE) exercise such as walking; weeks 3-4 will include two 30-minute bouts of light to moderate exercise (3-5 RPE) and one 18-minute bout of moderate to vigorous (4-6 RPE) exercise such as brisk walking or jogging; weeks 4-6 will include two 35 minute bouts of moderate exercise (4 RPE) and two 18 minute bouts of moderate to vigorous exercise (4-6 RPE). Mind-body practices for this phase will include box breathing two days per week as part of the resistance training cool down protocol and it is suggested the client attend a yoga or meditation class once per week. The mesocycle plan for this phase can be found in Appendix H and the acute variables for this phase can be seen in Table 3. Figure 1 Standing Posture and Bracing Sequence Note: Image taken from Starrett & Cordoza (2015) p. 40-41 22 Table 3 Phase 1 - Stabilization and Movement Acute Variables Resistance Training Balance Core Flexibility Mind-body Reps Sets Tempo % Intensity or RPE (0-10) Rest Interval Frequency 12-20 1-3 slow 4/2/1 12-20 1-3 slow 4/2/1 12-20 1-4 slow 4/2/1 1 1-3 30-60s hold Meditation/breathing/yoga 50-60% (5-6 RPE) n/a 0-90s n/a 0-90s Mild discomfort n/a n/a 3-4 days/week 2-4 days/week 2-4 days/week 2-3 days/week 23days/week 2-4 days/week 0-90s n/a Aerobic Endurance– Steady Low-moderate n/a State (2-4 RPE) 30-60min/session Note: Acute variables chart amended from NASM (McGill & Montel, 2019). Cardiorespiratory Strength Endurance The client needs to successfully complete phase one before moving onto this phase of the training program. If the client has not had previous exercise experience, then intensity percentages should be kept lower. Successful completion of phase one includes having the ability to control posture during static and dynamic movements, the ability to properly brace their core and be able to perform movements with proper form. External load has already been introduced in phase one, however, phase two will implement more movements with external load as well as increase intensity. Strength endurance will increase the client's muscle force production while continuing to work on joint stabilization (Bryant et al., 2014; McGill & Montel, 2019). 23 Submaximal resistance for larger repetition ranges will be utilized to improve muscular endurance; furthermore, a superset combining a stable exercise (e.g., barbell deadlift) with a stabilization exercise (e.g., stability ball hamstring curl) will be used to increase strength of the global muscular system and the local muscular system. Flexibility and mind-body activities will remain unchanged and continue throughout this phase. Additionally, cardiorespiratory exercise will decrease in time but increase in intensity to a moderate-vigorous state. The mesocycle plan for this phase can be found in Appendix H and the acute variables for this phase can be seen in Table 3. Table 3 Phase 2 – Strength Endurance Acute Variables Reps Sets Tempo % Intensity or RPE (0-10) Rest Interval Frequency Resistance Training 12-16 2-4 8-12 2-3 60-70% (6-7 RPE) n/a 0-90s Balance Core 8-12 2-3 n/a 0-90s Flexibility 1 1-3 Str: 2/0/2 Stab: 4/2/1 Medium 3/2/1 Medium 3/2/1 30-60s hold n/a n/a Mind-body Meditation/breathing/yoga n/a n/a 3-4 days/week 2-4 days/week 2-4 days/week 2-3 days/week 23days/week 2-4 days/week 0-90s Aerobic Endurance– Steady Moderaten/a State vigorous (4-6 30-60min/session RPE) Note: Acute variables chart amended from the NASM and ACE (Bryant et al., 2014; McGill & Cardiorespiratory Montel, 2019). Hypertrophy 24 The hypertrophy phase is scheduled to commence 16 weeks post GACMS. It is crucial to still be aware of the muscular imbalances that may be present from surgery or previous postural issues. Therefore, the intensity for this phase will have to be closely monitored and may not reach the maximal intensity of the specified hypertrophy range (70-80%). The purpose of hypertrophy training is to increase muscle growth through high training volumes and short rest intervals (Bryant et al., 2014). Building a strong upper body and improving thoracic posture will still be a primary goal at this stage in the training plan; therefore, upper body exercise selection will focus on the trapezius, rhomboids, rotator cuff muscles and serratus anterior (Rao & Pattanshetty, 2022). The flexibility routine in this phase will focus on active stretching and will be included in a dynamic warmup on resistance training days. Mind-body activities will remain the same with breath routines occurring more frequently as the training intensity increases. Cardiorespiratory training will continue to increase in intensity throughout this phase and aerobic-efficiency training will be introduced (Bryant et al., 2014). Components of aerobicefficiency design include low intensity interval training, which includes rest intervals at 3-4 RPE and work intervals at 5 RPE. The work to rest ratio starts at 1:3 and progresses to 1:1 in the final week of this phase. The mesocycle plan for this phase can be found in Appendix H and the acute variables for this phase can be seen in Table 4. Table 4 Phase 3 – Hypertrophy Acute Variables Reps Sets Tempo % Intensity or RPE (0-10) Rest Interval Frequency Resistance Training 6-12 3-5 2/0/2 0-90s Balance 8-12 2-3 Medium 3/2/1 70-80% (7-8 RPE) n/a 3-4 days/week 2-4 days/week 0-90s 25 Core 8-12 2-3 n/a 0-90s Flexibility 5-10 Medium 3/2/1 1-2s hold 1-2 n/a n/a Mind-body Meditation/breathing/yoga n/a n/a 2-4 days/week 2-3 days/week 23days/week 2-4 days/week Aerobic Efficiency – Moderate Moderate (3-5 n/a Intervals RPE) 20-40min/session Note: Acute variables chart amended from NASM and ACE (Bryant et al., 2014; McGill & Cardiorespiratory Montel, 2019). Strength After the hypertrophy phase, the client will go into a de-load phase that will consist of four weeks in the stabilization and movement phase, before continuing onto the four-week strength phase. The goal of the muscular strength phase is to improve the rate of force production, motor unit synchronization and increase recruitment of motor units within the clients' muscles (McGill & Montel, 2019). Muscular strength gains are elicited through training at high intensities with lower repetitions. Maximal force is measured using a one rep maximum test (1RM) and represents the individual's muscular strength (Bryant et al., 2014). However, 1RM weights can be predicted using a 3RM or 5RM testing protocol which is more suitable for the general population, novice clients and for rehabilitation clients (Bryant et al., 2014; Dohoney et al., 2002; Niewiadomski, 2008). Due to this fact, training intensities of this plan will not reach over 90% of the individuals 1RM. Speed, agility, and quickness (SAQ) drills will be introduced in this phase with an emphasis on the agility portion. Agility is “the ability to change direction or orientation of the body based on rapid processing of internal or external information quickly and accurately without significant loss of speed” (McGill & Montel, 2019 p. 308). Being able to safely and effectively change the direction of movement while keeping balanced over 26 one's center of gravity is fundamental to be able to do many activities of daily living; therefore, agility drills will include controlled ladder, cone and hurdle drills. Cardiorespiratory training will continue to progress in intensity and flexibility and mind-body techniques will remain unchanged from the previous phase. There will be another de-load phase following this strength phase. The mesocycle plan for this phase can be found in Appendix H and the acute variables for this phase can be seen in Table 5. Table 5 Phase 4 - Strength Acute Variables Reps Sets Tempo % Intensity or RPE (0-10) Rest Interval Frequency 80-90% (8-9 RPE) n/a 3-5min n/a 0-90s n/a n/a n/a n/a 3-4 days/week 2-4 days/week 2-4 days/week 2-3 days/week 23days/week 2-4 days/week Resistance Training Balance 4-6 3-5 1-2sec hold 8-12 2-3 Core 8-12 2-3 Flexibility 5-10 1-2 Medium 1/1/1 Medium 1/1/1 1-2s hold Mind-body Meditation/breathing/yoga 0-90s Aerobic Efficiency – Moderate (6-7 n/a Moderate -Vigorous Intervals RPE) 15-25min/session Note: Acute variables chart amended from the NASM and ACE (Bryant et al., 2014; McGill & Cardiorespiratory Montel, 2019). Power The dynamic warmups and SAQ drills implemented in the previous phases will be great preparation for this phase. Plyometric training techniques are powerful movements that utilize the stretch-shortening cycle by creating an explosive concentric contraction after an eccentric 27 contraction (McGill & Montel, 2019). Traditionally, plyometric and power training exercises have been used for sport specific training. However, plyometric movements help prevent the age-related decline of type two muscle fibers, the primary muscle fibers used for power development (Crawford & Jamnik, 2009). Other benefits of plyometric training techniques include improved bone mineral density, increased joint stability, and increases in muscular strength (Crawford & Jamnik, 2009; De Villarreal et al., 2010). In line with the power phase of this program, cardiorespiratory training will incorporate anaerobic training intervals; additionally, because of the intensity of anaerobic intervals cardiorespiratory training frequency will decrease. Flexibility and mind-body techniques will remain unchanged from the previous phase. The mesocycle plan for this phase can be found in Appendix H and the acute variables for this phase can be seen in Table 6. Table 4 Phase 5 – Power Acute Variables Reps Sets Tempo % Intensity or RPE (0-10) Rest Interval Frequency Resistance Training 1-5 (S) 8-10 (P) 3-5 (S) 1/1/1 (P) AFAP 2-3min 3-4 days/week Balance 8-12 2-3 Controlled (S)80-90% (P) up to 10% BW or 3045% (1RM) n/a 0-90s Core 8-12 2-3 n/a 0-90s Flexibility 5-10 1-2 As fast as can be controlled controlled 2-4 days/week 2-4 days/week n/a n/a 2-3 days/week Plyometric Mind-body 8-12 2-3 AFAP Meditation/breathing/yoga n/a n/a Cardiorespiratory Anaerobic endurance + power – mod-high intensity intervals Moderate (35 RPE) n/a 23days/week 2-4 days/week 28 20-60s intervals/1:3 work rest Note: Acute variables chart amended from the NASM and ACE (Bryant et al., 2014; McGill & Montel, 2019). Proposed Results The eight and a half month training plan, if adhered to properly, will elicit numerous positive results. The primary goals of the training plan are to effectively recover from GACMS as well as develop efficient neural patterns for all static and dynamic movements, while also increasing muscle size, strength and power. Phase 1, the stabilization and movement phase, aims to improve upper body ROM, improve muscle imbalances, improve posture and develop core function, stabilization, and dynamic balance. The exercises in phase one (see Appendix I) were specifically selected to attain these results. For example, wall angels, prone swimmers, quadruped scapular push-ups, and shoulder controlled articular rotations (CARs) all help with shoulder joint and shoulder girdle movement and strength. Exercises such as bracing techniques, dead bugs and birddogs will help with core stabilization and strength, while balance improvements will include single leg balance, single leg medicine ball chop and step up with knee drive exercises. Not only will the training program provide physical benefits, but it will also improve physical activity literacy, improve self-esteem and empower genderqueer individuals to feel good in their bodies. Many genderqueer individuals do not feel comfortable exercising prior to GACMS because of gender dysphoria, discrimination, and stigma (Gilani et al., 2021 & Teti et al., 2020). Therefor, the process of GACMS can be an opportunity to encourage genderqueer individuals to participate in regular physical activity. 29 The assessment protocols listed in Table 1 can be used for reassessment after phase one is completed. Reassessment is important because it will allow the client to see their progress as well as indicate specific training needs for the subsequent phases. Most importantly, shoulder flexion/extension and thoracic rotation need to be measured with a goniometer, which will allow the healthcare professional to see if upper body ROM is progressing the way it should be. Static and dynamic posture is easily assessed during the training program, as the health care provider will be able to see improvements or movement breakdowns during exercise sessions. A thorough contingency plan will help ensure exercise adherence when unexpected events or circumstances arise. Sticking with a training program can be challenging, but planning for potential barriers to exercises can help with long-term adherence. First, consistency is key, and it is important the client understands the importance of showing up, even if their motivation is low; a short workout is better than no workout. Second, if the client is unable to make it to a session due to unforeseen circumstances, it would be helpful to provide the client with an at-home workout that can be done with minimal equipment. Lastly, if injury or illness should occur the client will be provided with alternative forms of exercise that will keep them moving, but also provide adequate rest. Discussion GACMS can greatly improve an individual's mental and physical health, but it can also be challenging and emotionally taxing. It is crucial to have a holistic exercise and rehabilitation program that can help an individual recover physically, mentally, and emotionally. That is why this exercise program contains mind-body techniques along with strength, mobility and cardiorespiratory components. The program also contains tips for immediate post-surgery recovery and a thorough assessment form that is meant to identify all facets of health, which can 30 help determine whether the client needs to be referred to any other healthcare professionals, such as counselors or physiotherapists. The exercise program consists of five phases that span an eight-and-a-half-month timeline. The primary focus was phase one, the stabilization and movement phase which comprised the microcycle in Appendix F. Based on the survey results collected for this project, it was evident there is no guidance on exercise or rehabilitation protocols post-surgery. Lack of guidance after a major surgery like this has the potential to have a negative effect on immediate surgery recovery as well as future health implications. The purpose of constructing a detailed exercise plan was to provide accessible exercise information for surgery recovery. Even though this program is meant to be guided by an exercise or healthcare professional, many individuals are not able to afford personal trainers, kinesiologists or physiotherapists; in these cases, the exercise program has provided a video for each exercise along with exercise cues and notes. The importance of regaining shoulder ROM and improving upper body posture cannot be stressed enough. The exercise program focuses on upper body mobility to correct poor posture that may have been due to chest binding or attempts at hiding one's chest, as well as the negative postural effects of GACMS. Posture, upper body strength and overall physical fitness are things that would also be beneficial for the client to begin prior to GACMS. According to the survey results, individuals who have received GACMS do not receive any pre-surgery exercise recommendations either. There are generally long wait times for surgery and this could be an opportune time for individuals to get a head start on upper body strength and mobility. There are several improvements the survey participants highlighted to improve GACMS recovery. One participant stated the need for “better and more hands on after care,” (anonymous participant) they explained that it is difficult to know if an exercise is beneficial or a detriment to 31 the recovery process after the six-week recovery because the chest tissue is still numb from the procedure. Another participant pointed out the lack of information of post-surgery exercise on the Trans Care B.C. website and that it would be helpful to include postural exercises on their website. Lastly, a participant described the need for individualized recommendations after surgery; because of the lack of information, most people search for online information that may not be credible and could be harmful to the recovery process. Limitations In the literature, there are no contraindications to exercise for an individual who has received GACMS; in fact, most individuals are instructed to continue regular activity after the six-week initial recovery period. However, since there is such a lack of information on this subject it is impossible to state that this exercise program can be generalized to all people who have received GACMS. Each person who receives GACMS has unique lived experiences that could impact the effectiveness of the training program. People with disabilities, chronic conditions or mental health disorders may have a more difficult time with surgery recovery and therefore this program might not be appropriate. Additionally, previous exercise experience plays a huge role in the ability to start an exercise program; consequently, individuals with no exercise experience should take caution in completing this exercise program without a trained professional. Another limitation to this exercise plan is the use of breast cancer rehabilitation information. Both GACMS and breast cancer mastectomies involve the removal of a significant amount of breast tissue; however, GACMS involves more than the treatment for breast cancer and usually includes chest contouring and nipple repositioning (Mayo Clinic, n.d.). Nipple repositioning, usually in the form of nipple grafts, needs adequate time to heal. If exercise or 32 excessive chest movement occurs too soon, there is a possibility of nipple stretching which can be a detriment to nipple graft survival. To conclude, breast cancer rehabilitation may not seamlessly translate to proper GACMS rehabilitation. The most important point is that patients listen to their doctors' recommendations. Lastly, throughout the research for this project, all resources stated that it was safe to start exercising after the six-week initial recovery period. However, one resource was found stating conflicting information. The Gender Confirmation Center (n.d.) has recently revised their recovery protocol by announcing that individuals should avoid lifting their arms higher than shoulder height for three months post-operation. Minimizing scarring is a very important factor for many people who receive GACMS, and these recommendations for limited shoulder ROM are to prevent the scars from stretching or widening (Gender Confirmation Center, n.d.). Limiting shoulder ROM for that length of time has the potential to create a host of other functional limitations, especially for older individuals or people with previous shoulder injuries. Given these points, research needs to be done on the impact of exercise on GACMS scars, to better understand the ideal time to commence an exercise program. Conclusion The transgender and gender queer community face physical activity barriers that stem from historical discrimination and stigma, and these barriers can be exacerbated by gender dysphoria, gendered language and gendered exercise facilities. Many genderqueer individuals receive GACMS to mitigate gender dysphoria or align their physical bodies with their gender identity, or both. GACMS is a life-saving and necessary intervention for genderqueer individuals; however, there is a lack of research on the functional outcomes post-surgery and a lack of healthcare knowledge on GACMS rehabilitation protocols. The primary goal of this 33 project was to fill this gap and create an exercise plan that is specific to GACMS rehabilitation, which could be used by healthcare professionals or GACMS patients themselves. By supporting individuals throughout the recovery process, exercise and rehabilitation programs can help improve overall health and well-being and enhance the positive effects of gender affirming top surgery. Ethical Considerations There are various ethical considerations that need to be considered for people wanting to start an exercise program after GACMS. This exercise program is meant to be a generalized exercise program for individuals that have received GACMS, but the previously mentioned scar care management needs to be heavily considered. There are various methods of surgery and locations of scars following GACMS and both need to be examined when developing a training program. To lessen the potential risks of the exercise program, scar care should be prioritized to make sure clients do not experience unnecessary pain or discomfort. Additionally, open communication with the client regarding pain levels will aid in the collaborative effort to adjust the program as needed and mitigate negative effects of training. For these reasons, a generalized exercise approach may not be the best option for this demographic. Another ethical consideration is the individual experience with GACMS and an associated exercise program may be different due to ethnicity, race, socioeconomic status, and gender identity. Again, having a generalized exercise program may not take these things into consideration, but having a healthcare provider that is taking steps to address these disparities and be sensitive to these differences will be a massive help to increase inclusivity and ensure safety of the client. Providing things like education and resources that are tailored to each person's specific needs would also help promote inclusion and equity of the exercise program. 34 By attending to these ethical considerations, exercise programs for GACMS can promote safe, effective, and compassionate care for all genderqueer individuals. A thorough assessment of previous medical history, exercise experience, lifestyle habits, and barriers to exercise can help mitigate some of the risks mentioned above. However, not all people can afford to have this type of assessment or have access to facilities with these services. In these cases, individuals completing this exercise program should proceed with caution and do so at their own risk. Application to KINE Field and Future Directions This project has highlighted some of the major gaps in transgender and genderqueer research. This type of research is on the rise, however there is currently no research on functional outcomes and exercise protocol after GACMS. There are also no standardized rehabilitation programs that are developed by credible sources; the rehabilitation information is vague or nonexistent. With an increase in genderqueer individuals receiving GACMS it is essential that healthcare professionals such as kinesiologists, physiotherapists and personal trainers are involved in the recovery process and have the knowledge to safely and effectively deliver exercise information to this population. This exercise program provides an invaluable tool for GACMS recovery that can be utilized by healthcare professionals or clients themselves. With that being said, all people working in a health-related field should be aware of more than just the training aspects of an exercise program but should also provide a safe environment free from discrimination, to allow the client to feel safe and be themselves. This includes engaging in education that is specific to transgender care, proper pronoun usage and open dialogue that encourages self-discovery and self-identification. 35 Lastly, the topic of transgender and genderqueer health cannot be discussed without mentioning the state of transgender rights in North America. There is a massive anti-transgender movement currently taking place and it is gaining traction largely due to the American political climate. 417 anti-LGBTQ bills have been introduced since the start of 2023 and sadly, most of them are targeting transgender youth, by taking away gender affirming healthcare and removing LGBTQ information from public-school curriculums (Choi, 2023). The anti-transgender movement has also gained a lot of traction in sports media because American lawmakers have been attempting to ban transgender people from athletics since 2020 (Strangio & Arkles, 2023). The anti-transgender rhetoric is spreading misinformation and extremely harmful language for the genderqueer community. Transgender lives are at risk, and it is now more important than ever to create positive dialogue around transgender and genderqueer healthcare. This exercise program not only provides a necessary tool for genderqueer individuals, but it provides positive information that will help the field of kinesiology provide better care for transgender patients. 36 Appendix A Glossary of Terms Bisexual “A person emotionally, romantically or sexually attracted to more than one sex, gender or gender identity though not necessarily simultaneously, in the same way or to the same degree. Sometimes used interchangeably with pansexual.” (Human Rights Campaign, n.d. Glossary section) Cis-gender “A term used to describe a person whose gender identity aligns with those typically associated with the sex assigned to them at birth.” (Human Rights Campaign, n.d. Glossary section) Gay “A person who is emotionally, romantically or sexually attracted to members of the same gender. Men, women and non-binary people may use this term to describe themselves.” (Human Rights Campaign, n.d. Glossary section) Gender diverse/gender non-conforming “A broad term referring to people who do not behave in a way that conforms to the traditional expectations of their gender, or whose gender expression does not fit neatly into a category. While many also identify as transgender, not all gender non-conforming people do.” (Human Rights Campaign, n.d. Glossary section) Gender Identity “One’s innermost concept of self as male, female, a blend of both or neither – how individuals perceive themselves and what they call themselves. One's gender identity can be the same or different from their sex assigned at birth.” (Human Rights Campaign, n.d. Glossary section) Gender queer “Genderqueer people typically reject notions of static categories of gender and embrace a fluidity of gender identity and often, though not always, sexual orientation. People who identify as "genderqueer" may see themselves as being both male and female, neither male nor female or as falling completely outside these categories.” (Human Rights Campaign, n.d. Glossary section) Lesbian “A woman who is emotionally, romantically or sexually attracted to other women. Women and non-binary people may use this term to describe themselves.” (Human Rights Campaign, n.d. Glossary section) Non-binary “An adjective describing a person who does not identify exclusively as a man or a woman. Non-binary people may identify as being both a man and a woman, somewhere in between, or as falling completely outside these categories. While many also identify as transgender, not all nonbinary people do. Non-binary can also be used as an umbrella term 37 encompassing identities such as agender, bigender, genderqueer or gender-fluid.” (Human Rights Campaign, n.d. Glossary section) Plus (+) “A sign to recognize the limitless sexual orientations and gender identities used by members of our community.” (Human Rights Campaign, n.d. Glossary section) Queer “A term people often use to express a spectrum of identities and orientations that are counter to the mainstream. Queer is often used as a catch-all to include many people, including those who do not identify as exclusively straight and/or folks who have non-binary or genderexpansive identities. This term was previously used as a slur, but has been reclaimed by many parts of the LGBTQ+ movement.” (Human Rights Campaign, n.d. Glossary section) Sexual orientation “An inherent or immutable enduring emotional, romantic or sexual attraction to other people. Note: an individual’s sexual orientation is independent of their gender identity.” (Human Rights Campaign, n.d. Glossary section) Transgender “An umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. Being transgender does not imply any specific sexual orientation. Therefore, transgender people may identify as straight, gay, lesbian, bisexual, etc.” (Human Rights Campaign, n.d. Glossary section) Two-Spirit (2S) “A term used within some Indigenous communities, encompassing sexual, gender, cultural, and/or spiritual identity. This umbrella term was created in the English language to reflect complex Indigenous understandings of gender and sexuality and the long history of sexual and gender diversity in Indigenous cultures. This term may refer to cross, multiple, and/or non-binary gender roles; non-heterosexual identities; and a range of cultural identities, roles, and practices embodied by Two-Spirit peoples.” (Trans Care BC, n.d. Glossary section) Note: Glossary of terms amended from the Human Rights Campaign https://www.hrc.org/resources/glossary-of-terms and Trans Care BC http://www.phsa.ca/transcarebc/gender-basics-education/terms-concepts/glossary#undefined 38 Appendix B Survey Questions and Results Question 1: What was your experience navigating the healthcare system while inquiring/preparing for GACMS? (positive/negative/neutral?) Answers: P1: Neutral P2: Neutral P3: positive P4: neutral Question 2: Did you experience any adverse reactions or complications after surgery? Answers: P1: I fainted a couple days post-op and was scared that I had maybe done damage to healing, I hadn't but I couldn't reach anyone for about a week in order to get confirmation and didn't get seen for another 4-5 weeks after that call. P2: Yes, slightly above average fluid build up in the surgery site, as well as major complications with the JP drains P3: infected nipple graft, stretch marks, poor posture from post-op binder P4: yes Questions 3: Were you given any pre-surgery recommendations for exercise? If yes, what were they? Answers: P1: I remember being told that it would be recommended to stay healthy pre-surgery but there was no direct instructions P2: No, just told to continue exercising as normal P3: to lose weight, if possible. from my own research, people recommended building chest/upper body muscles to help the surgeon with more natural scar/nipple graft placement P4: no Question 4: Were you given any recovery/rehabilitation information for immediate post surgery? (initial 6weeks) What was it? Answers: P1: Initial 6 weeks I was told to do basically nothing, try not to lift arms and try to limit all movement 39 P2: I was told to heavily limit the movement of my arms for the first 2 weeks, and begin to introduce some movement in the arms/upper body (not exercise) after 2 weeks P3: no raising my arms above my head for at least 4 weeks, no lifting more than 5 lbs P4: yes-bending over and rotating arms at shoulders in increasingly larger circles clockwise and counter-clockwise Question 5: After the initial 6-week recovery time, were you given any information about proper exercise technique or rehabilitation? Answers: P1: I had my final check up about 5-6 week post surgery and was just told that I could go back to everyday life but was not given any specific rehabilitation information P2: I was not. I was told I could return to normal exercise- despite that I probably actually needed extra time due to the amount of fluid build up and the JP drain complications P3: no P4: no Question 6: What (if any) exercises were given by your surgeon or doctor post surgery? (rehabilitation/postural/strength) Answers: P1: None by surgeon or doctor. P2: None P3: only to massage my chest/scars to break up the scar tissue P4: lol Question 7: Were you given any resources on how to properly progress through movements post surgery? Answers: P1: No I was not P2: None P3: no P4: no Question 8: Were you given any contacts or resources for physiotherapy or personal training post-surgery? Answers: P1: No I was not P2: None 40 P3: no P4: no Question 9: Do you have any suggestions for how the healthcare system could improve GACMS recovery? Answers: P1: I felt I was left with very little information or resources after my surgery, in fact when I tried to contact my surgeon about a week post-op I was informed he had gone on vacation and would not be back for another 4 weeks. I think having more resources on trans friendly clinics, nurses or physical therapy would be super beneficial. P2: Better and more hands on after care. It is hard to know wether you are actually doing more bad then good to your body when you begin exercising after the 6 weeks is up. The numbness in my chest lasted for over 6 months, leaving my unaware when I had strained my pectoral/chest muscles or stretched scar tissue. I even accidentally stretched one of my nipples in the 7-8th week after surgery. P3: a lot of the top surgery process was done through transcare bc and i don't remember seeing anything about post-surgery exercise recommendations anywhere on their website or mentioned at all during the process, aside from mentioning that one would have to wait at least 6 weeks to heal before heavy lifting. i'd love to see more info out there to help folks with their posture postsurgery since a lot of pre-op people hunch to hide their chest, and during surgery recovery the stitches and compression vest enforce bad posture as well. P4: Giving patients information on how to recover post-surgically for their body. The only information is online for us and that can be dangerous. 41 Appendix C Informed Consent and Liability Release 42 43 Appendix D Physical Activity Readiness Questionnaire Note: Full version available at http://eparmedx.com/?page_id=79 44 Appendix E New Client Intake Form 45 46 Note: amended from CSEP-PATH (2019) 47 Appendix F Fillable Assessment Forms Treadmill Walking Test Age: 50% HRmax: Stage 1 1min: 2min: 3min: 4min: Speed After 4min: Steady State HR: Aerobic Assessment: Treadmill Walking Test HRmax: Calculation: = 0.85 x [208 - (0.7 x age)] 70% HRmax: 85% HRmax: Stage 2 Extra Time 5min: 9min: 6min: 10min: 7min: 11min: 8min: 12min: VO2max Calculation: Estimated VO2max (ml · kg-1·min-1) = 15.1 + (21.8 × speed mph) − (0.327 × SSHR bpm) − (0.263 × speed mph × age) + (0.00504 × SSHR bpm × age) + (5.98 for males) Note: Amended from CSEP-PATH (2019) Fillable Functional Assessment Form Assessments: Functional Assessment Notes Lateral View Posterior View Static Posture Shoulder Flexion/Extension R Side L Side Segmental Intervertebral Motion Flexion Extension Common Breakdowns: - Excessive thoracic kyphosis - Rounded shoulders - Winged scapula - Anterior/posterior hip tilt - Forward head position - Elevated shoulders - Rib cage flare - Lack of movement 48 Seated Rotation Test Overhead Squat Single leg balance Single Leg Squat R Side L Side **See below for full assessment form R Side L Side R Side L Side Plank Seated Chest Press Machine R Side L Side Cable Row R Side L Side Double Leg Lowering Test - Unable to move tspine separate from hips - Flat feet + knee valgus - Unable to complete without support - Hip hike/drop - Knee valgus/varus - Torso rotation - Raised butt - Arched low back - Head sagging forward - Shoulder blades retracted (lack shoulder stability) - Shoulder elevation - Low back arch - Head migrates forward - Shoulder elevation - Low back arch - Head migrates forward - Low back unable to stay on the ground 49 Sorensen Erector Spinae Test Sit and Reach Test Sagittal View Head - Hips excessively tucked under Overhead Squat Assessment Notes Common Breakdowns - Forward head position Shoulders - Excessive internal rotation Spine - Excessive thoracic kyphosis - Excessive lumbar lordosis Hips - Excessive anterior/posterior tilt Knees - locked out Posterior/Frontal View Notes Common Breakdowns Head - Lateral tilt Shoulders - Shoulders elevated or shrugging 50 Spine - Spine scoliosis Hips - Hips tilted to one side Knees - valgus or varus knee movement Feet - Flat feet or excessive arch 51 Appendix G Post-Surgery Recommendation Hand-Out 52 Appendix H Macrocycle and Mesocycles GACMS Recovery - Macrocycle Yearly Training Plan/Macrocycle Level Phase Jan Feb Initial Recovery Stabilization + Movement Strength Endurance Hypertrophy Rehab • ½ Strength 4 Power 5 1 Year: 2023 Mar ½ Apr May Jun • Jul Aug • 2 Sept • Oct • • • • • Note: ½ indicated half of the month spent in allocated phase. GACMS Recovery – Mesocycle 1 (Stabilization and Movement) Phase 1 (6 weeks) Day 1-2 2-4 4-6 M T WT F S S M T W T F S S M T Aerobic X X X X X X W X T F S S X X X Resistance X X X X X X X X X Flexibility X X X X XX X X X X X X X Mind-Body X X X X X X X GACMS Recovery – Mesocycle 2 (Strength Endurance) Phase 2 (4 weeks) Weeks Day Aerobic 1-2 M T X W T X 2-4 F S Dec • • 3 Weeks Nov S X M T X W T X F S S X 53 Resistance X X X X Flexibility X X X X Mind-Body X X X X X X X X X X GACMS Recovery – Mesocycle 3 (Hypertrophy) Phase 3 (4 weeks) Weeks Day 1-2 M Aerobic T W 2-4 T X F S S M T W X X T F S X X Resistance X X X X X X X X Flexibility X X X X X X X X Mind-Body X X X X S X X GACMS Recovery – Mesocycle 4 (Strength) Phase 3 (4 weeks) Weeks Day 1-2 M T Aerobic T F S X X Flexibility X X X X X S M X X Resistance Mind-Body W 2-4 T T F S X X X X X X X X X X X X W X X S X X X X GACMS Recovery – Mesocycle 5 (Power) Phase 3 (4 weeks) Weeks Day 1-2 M T W T 2-4 F S S M T W T F S S 54 Aerobic/anaerobic Resistance X X Flexibility X X Mind-Body X X X X X X X X X X X X X X X X X X X X X X X X X 55 Appendix I The following exercise program contains the information for the stabilization and movement phase. There are three workouts (upper body, lower body, and full body) for each 2-week section within the 6-week microcycle. Each exercise is hyperlinked to a video of the movement as well as notes describing important queues and the reasoning behind each exercise. The sets and reps change each week and intensity increases throughout the phase. Flexibility and mind-body exercises can be found as the cool-down portion of the exercise routine and cardiorespiratory training can be found at the end of the program and an example client logbook can be found in the last table. Phase 1 (Stabilization and Movement) Microcycle Exercise Sets Week 1-2 Day 1 – Upper Body Reps Intensity Notes (RPE or %) Prep: A1: Cat/cow 1 18-20 1-3 RPE 1 18-20 1-3 RPE 1 6-8/side 1-3 RPE A2: Thoracic Extension on Foam Roller A3: Lying TSpine Rotation A4: Seated 1 18-20 Shoulder Retraction and Depression Resistance, Technique, Balance, Core B1: Supine W1 1 15 Drawing-In (Bracing W2 2 12 Technique) B2: W1 1 15 Quadruped W2 2 12 Drawing-In (Bracing Technique) W1 1 30sec hold 1-3 RPE 2-4 RPE 2-4 RPE n/a Reasoning Breath in during cat and out during cow. Don’t let rib cage flare up Spine mobility, specifically working into extension Thoracic mobility (extension) Keep knees directly stacked over each other N/A Thoracic mobility (rotation) Keep spine neutral (don’t arch or round low back) Keep spine neutral (don’t arch or round low back) Core engagement and bracing practice Scapular movement Improve strength of muscles around the shoulder blade Core engagement and bracing practice Static balance 56 B3: Single Leg Balance W2 2 40sec hold C1: Prone Swimmers W1 W2 1 2 15 12 2-4 RPE C2: Plank W1 W2 1 2 20sec hold 30sec hold 3-4 RPE C3: Shoulder CARs W1 W2 1 2 8/side 6/side 1-3 RPE D1: Wall Slides W1 W2 1 2 20 18 D2: Wall Angels W1 W2 1 2 Cool Down/Flexibility: E1: Childs 1 Pose E2: Standing 1 Chest Stretch E3: Overhead 1 Reach with Side Bend E4: Seated 1 Neck Stretch Use a chair or wall as support if needed Don’t shrug shoulders, keep them away from your ears Tuck hips under and squeeze the glutes. Go from knees if needed Create tension through the body and don’t move anything but the shoulder joint -Shoulder mobility -Trapezius, rhomboid, rotator cuff strength 2-4 RPE Keep core engaged 20 18 2-4 RPE Keep low back and head against the wall -Shoulder mobility -Strength for muscles surrounding the scapula Shoulder blade retraction and strengthening of scapular muscles 60s hold 1-3 RPE N/A Flexibility 60s hold/side 60s hold/side 1-3 RPE N/A Flexibility 1-3 RPE N/A Flexibility 60s hold/side 1-3 RPE N/A Flexibility Week 1-2 Day 2 – Lower Body Reps Intensity Notes (RPE or %) Exercise Sets Prep: A1: Rocking Quadrupeds W1 1 20 1-3 RPE Keep spine neutral W2 W1 2 1 18 20 1-3 RPE Try to keep movement in the A2: Pelvic Tilts Core strength Shoulder joint ROM Reasoning Thoracic and hip mobility while maintaining lumbar stability 57 A3: Half Kneeling Hip Flexor Stretch (with rotation) A4: Hip 90/90 Holds W2 2 18 W1 1 20/side W2 2 18/side W1 W2 1 2 60s/side 45s/side Resistance, Technique, Balance, Core B1: Glute W1 1 20 Bridge W2 2 18 hips, not the spine Improve hip mobility and pelvic tilt control Thoracic rotation and hip flexor stretch 1-3 RPE N/A 1-3 RPE Ease into these holds, use hand support if needed Hip mobility (glutes, piriformis, psoas, hip flexors, hip abductors, and adductors) 3-4 RPE Keep hips tucked under and rib cage down -Bilateral hip hinge -Glute and hamstring strength -Core stability -Unilateral squat -Lower body strength and stability B2: Split Squat (bodyweight) W1 W2 1 2 20/side 18/side 3-4 RPE Use chair or wall as balance support if needed C1: Squat (bodyweight) W1 W2 1 2 20 18 3-4 RPE Brace core before each rep C2: Hip 90/90 Switches W1 W2 1 2 20 18 1-3 RPE Lean back onto hands if needed D1: Hip Hinge Practice W1 W2 1 2 20 18 2-4 RPE -Bilateral hip hinge -Core bracing and hinging practice 20/side 3-4 RPE Feet hip width apart, keep spine neutral and brace before each rep Move arms opposite to leg position D2: Staggered W1 1 Stance to Single Leg W2 2 Balance Cool Down/Flexibility: E1: Seated 1 Hamstring Stretch E2: Half 1 Kneeling Hip Flexor Stretch (hold) E3: Supine 1 Figure Four Hip Stretch E4: Standing 1 Calf Stretch 18/side -Bilateral squat -Lower body strength -Active rest -Hip mobility -Balance and single leg stability -Glute activation -Coordination 60s/side 1-3 RPE N/A Flexibility 60s/side 1-3 RPE N/A Flexibility 60s/side 1-3 RPE N/A Flexibility 60s/side 1-3 RPE N/A Flexibility 58 Exercise Prep: A1: Cat/Cow Week 1-2 Day 3 – Full Body Reps Intensity Notes (RPE or %) Sets W1 W2 1 2 20 18 1-3 RPE Breath in during cat and out during cow A2: Quadruped Scapular Pushups W1 1 20 1-3 RPE W2 2 18 Don’t flex or extend the spine of bend the elbows A3: Supine Drawing-In (Bracing Technique) A4: Adductor Rock Backs W1 1 15 1-3 RPE W2 2 12 W1 W2 1 2 15/side 12/side Keep spine neutral (don’t arch or round low back) Keep spine neutral Resistance, Technique, Balance, Core B1: Deadbug W1 1 20 (marching W2 2 18 only) B2: Birddog (individual arm/leg movement) W1 1 20 W2 2 18 C1: Step Up to Single Leg Hold W1 1 20/side W2 2 18/side C2: Half Kneeling Medicine Ball Chop W1 1 20/side W2 2 18/side 1-3 RPE 3-4 RPE Keep low back pressing into the floor 3-4 RPE Do not extend lumbar spine or lift head/neck up 3-4 RPE -Use balance aid if needed -Don’t let knee cave in -Slight bend in elbows -Focus on movement from the trunk not the shoulder joint 3-4 RPE Reasoning Spine mobility, specifically working into extension -Scapular retraction and protraction under load -Scapular strength and stability Core engagement and bracing practice Thoracic and hip mobility while maintaining lumbar stability -Core strength and stability -Maintain spine stability during limb movement -Core strength and stability -Maintain spine stability during limb movement -Balance -Single leg strength and stability Rotational movement and strength 59 D1: Push-Up W1 W2 1 2 20 18 3-4 RPE Keep elbows pointed in a reverse direction (not out to the side) Don’t shrug shoulders Create tension through the body and don’t move anything but the shoulder joint Upper body strength (push) D2: TRX Row W1 W2 W1 W2 1 2 1 2 20 18 8/side 6/side 3-4 RPE 60s 1-3 RPE N/A Flexibility 60s/side 1-3 RPE N/A Flexibility 60s/side 1-3 RPE N/A Flexibility 60s/side 1-3 RPE N/A Flexibility Mind-Body Practice F1: Box 1 Breathing 1-2min 1 RPE N/A Physiological and cognitive benefits Exercise Week Sets Week 3-4 Day 1 – Upper Body Reps Intensity Notes (RPE or %) Prep: A1: Cat/cow W3 2 16 W4 3 15 W3 2 16 W4 3 15 W3 2 W4 3 16 (8/side) 16 (8/side) D3: Shoulder CARs Cool Down/Flexibility: E1: Box 1 Shoulder Stretch E2: Standing 1 Chest Stretch E3: Standing 1 Hamstring Stretch E4: Standing 1 Quad Stretch A2: Thoracic Extension on Foam Roller A3: Quadruped Thoracic Rotation 1-3 RPE 1-3 RPE Breath in during cat and out during cow 1-3 RPE Keep rib cage down. 1-3 RPE N/A Upper body strength (pull) -Shoulder joint ROM -Active rest Reasoning -Spine mobility, specifically working into extension -Thoracic mobility (extension) -Thoracic mobility (rotation) 60 B1: Supine Drawing-In (Bracing Technique) B2: Wall Angels W3 2 16 W4 3 15 W3 W4 2 3 16 15 Resistance, Technique, Balance, Core C1: Plank W3 2 35s hold 2-4 RPE Keep spine neutral (don’t arch or round low back). Core engagement and bracing practice 2-4 RPE Keep low back and head against the wall. Shoulder blade retraction and strengthening of scapular muscles 4-5 RPE Tuck hips under and squeeze the glutes. Go from your knees if needed. Focus on extension through the upper back. Keep feet on the floor. Use balance aid if needed. Core strength. Don’t shrug shoulders. Keep elbows pointed in a reverse direction (not out to the side). Upper body strength (pull). Upper body strength (push). Start light. Try to fully extend your elbows and get the dumbbells directly overhead. Walk heal toe heal toe. Keep arms slightly away from body. Upper body strength (push). Create tension through the body and don’t move anything but the shoulder joint. Shoulder joint ROM. W4 3 30s hold C2: T-Spine Lifts W3 W4 2 3 16 15 4-5 RPE C3: Single Leg Balance With Reach W3 2 2-4 RPE W4 3 16 (8/side) 16 (8/side) D1: TRX Row W3 W4 W3 W4 2 3 2 3 16 15 16 15 4-5 RPE E1: Seated Dumbbell Shoulder Press W3 W4 2 3 16 15 4-5 RPE E2: Farmers Carry W3 W4 2 3 40s 35s 4-5 RPE 6-8/side 1-3 RPE D2: Push-Ups Cool Down/Flexibility: F1: Shoulder 1 CARs 4-5 RPE Strengthening spine extensor muscles. Specifically in the thoracic region. Maintaining center of gravity with limb movement. Strength and conditioning. Specifically grip and core strength. 61 F2: Standing Chest Stretch 1 1-3 RPE N/A. Flexibility. 1 60s hold/sid e 12-15 each directio n F3: Scapula CARs 1-3 RPE Shoulder girdle ROM. 1 60s hold 1-3 RPE Create tension through the body and don’t move anything but the shoulder blades. N/A. F4: Seated Neck Stretch Week 3-4 Day 2 – Lower Body Reps Intensity Notes (RPE or %) Flexibility. Exercise Sets Prep: A1: Rocking Quadrupeds W3 W4 2 3 16 15 1-3 RPE Keep spine neutral A2: Half Kneeling Hip Flexor Stretch (with rotation) W3 W4 2 3 16 15 1-3 RPE N/A A3: Hip 90/90 Holds W3 W4 2 3 16 15 1-3 RPE Ease into these holds, use hand support if needed. Hip mobility. B1: Hip CARs W3 W4 2 3 16 15 3-4 RPE Hip ROM and mobility. B2: Pelvic Tilts W3 W4 2 3 16 15 1-3 RPE No movement anywhere but the hip joint. Keep pelvis level with the ground. Try to keep movement in the hips, not the spine. B3: Quadruped Knees Off Hold W3 2 16 3-4 RPE W4 3 15 Knees one inch off the ground. Imagine squeezing the ground between hands and feet, creating tension. Core strength and stability 4-5 RPE Keep hips tucked under and rib cage Unilateral hip hinge. Glute and Resistance, Technique, Balance, Core C1: Glute W3 2 16 Bridge With W4 3 15 Reasoning Thoracic and hip mobility while maintaining lumbar stability. Thoracic rotation and hip flexor stretch Improve hip mobility and pelvic tilt control. 62 Single Leg Hold C2: Reverse Lunge (bodyweight) W3 W4 2 3 16/leg 15/leg 4-5 RPE D1: Goblet Squat W3 W4 2 3 16 15 4-5 RPE (5456%) D2: Hip 90/90 Switches W3 W4 2 3 16 15 1-3 RPE E1: Kettlebell Deadlift W3 W4 2 3 16 15 4-5 RPE (5456%) E2: Single Leg W3 2 Medicine Ball W4 3 Chop Cool Down/Flexibility: F1: Banded 1 Hamstring Stretch F2: Half 1 Kneeling Hip Flexor Stretch (hold) F3: Supine 1 Spinal Twist 16/side 15/side 4-5 RPE F4: Standing Calf Stretch 60s hold/side 1 down. Try to not let hips drop when leg is lifted. Lower the back knee as close as possible to the ground. Use balance aid if needed. hamstring strength. Core stability Brace core before each rep. Keep DB close to body. Lean back onto hands if needed. Loaded bilateral squat. Lower body strength. Active rest. Hip mobility. Keep spine neutral. Brace before each rep. N/A. Loaded bilateral hip hinge. Lower body strength. Balance and rotational strength. Unilateral squat. Lower body strength and stability. 60s hold/side 1-3 RPE N/A. Flexibility. 60s hold/side 1-3 RPE N/A. Flexibility. 60s hold/side 1-3 RPE N/A. Flexibility. N/A. Flexibility. Week 3-4 Day 3 – Full Body Reps Intensity Notes (RPE or %) Reasoning 1-3 RPE Exercise Sets Prep: A1: Adductor Rock Backs W3 W4 2 3 16 15 1-3 RPE Keep spine neutral. Thoracic and hip mobility while maintaining lumbar stability. W3 2 16 1-3 RPE N/A. Spine mobility. 63 A2: Seated Spinal Flexion/Extens ion W4 3 15 B1: Quadruped Scapular Pushups W3 W4 2 3 16 15 2-3 RPE Don’t flex or extend the spine of bend the elbows. B2: Wall Slides W3 W4 2 3 16 15 2-4 RPE Keep core engaged. B3: Glute Band Walk W3 W4 2 3 16/side 15/side 2-4 RPE Keep knee over ankle. Try to not lean from side to side. Resistance, Technique, Balance, Core C1: Deadbug W3 2 16 W4 3 15 4-5 RPE Keep low back pressing into the floor. C2: Birddog W3 W4 2 3 16 15 4-5 RPE Do not extend lumbar spine or lift head/neck up. C3: Suitcase March W3 W4 2 3 16 15 4-5 RPE Try to not lean side to side while switching feet. D1: Single Leg Squat (to bench) D2: Paloff Press W3 W4 2 3 16 15 4-5 RPE W3 W4 2 3 16 15 4-5 RPE Control on the way down. Don’t let knee cave in. Don’t let shoulders shrug. 2 3 16 15 4-5 RPE (5456%) Don’t let Upper body strength shoulders shrug or (pull). Thoracic knee cave in. rotation. 2 3 16 15 4-5 RPE (5456%) Keep hips facing forward. Don’t let the trailing leg hip open up. E1: Staggered W3 Stance Single W4 Arm Cable Row E2: Staggered W3 Stance W4 Kettlebell Deadlift Cool Down/Flexibility: Scapular retraction and protraction under load. Scapular strength and stability. Shoulder mobility. Strength for muscles surrounding the scapula. Glute activation and strength. Core strength and stability. Maintain spine stability during limb movement. Core strength and stability. Maintain spine stability during limb movement. Balance. Grip and core strength. Unilateral squat. Lower body strength. Balance. Anti-rotation drill. Core strength Unilateral hip hinge. Lower body strength. 64 F1: Box Shoulder Stretch F2: Standing Chest Stretch F3: Shoulder CARs 1 60s hold 1-3 RPE N/A. Flexibility. 1 60s hold/side 6-8/side 1-3 RPE N/A. Flexibility. 1-3 RPE Shoulder joint ROM. F4: Standing Quad Stretch Mind-Body F1: Box Breathing 1 60s hold/side Create tension through the body and don’t move anything but the shoulder joint. N/A. 1 3-5min N/A Physiological and cognitive benefits Exercise Prep: A1: Cat/cow 1 Sets 1-3 RPE 1 RPE Flexibility. Week 5-6 Day 1 – Upper Body Reps Intensity Notes (RPE or %) Reasoning W5 W6 3 3 14 12 1-3 RPE Breath in during cat and out during cow. Spine mobility, specifically working into extension. A2: Half Kneeling Thoracic Rotation Against Wall A3: Shoulder CARs W5 W6 3 3 14/side 12/side 1-3 RPE N/A. Thoracic mobility (rotation). W5 W6 3 3 6-8/side 6-8/side 2-3 RPE Create tension through the body and don’t move anything but the shoulder joint. Shoulder joint ROM. B1: Scapular Push-ups (from toes) W5 W6 3 3 14 12 3-5 RPE Don’t bend at the elbow joint. Don’t let low back arch. B1: Deadbug W5 W6 3 3 14/side 12/side 3-5 RPE Keep low back pressing into the floor. Scapular retraction and protraction under load. Scapular strength and stability. Core strength and stability. Maintain spine stability during limb movement. W5 3 14 3-5 RPE 65 B2: Banded Pull-aparts W6 3 12 Resistance, Technique, Balance, Core W5 3 14 C1: Push-Up W6 3 12 4-6 RPE Elbows slightly bent. Keep shoulder blades down and back. Upper body prep. Strengthening shoulder retractors. Keep elbows pointed in a reverse direction (not out to the side). Don’t shrug shoulders, keep them away from your ears. See progressions in the video. Use feet support if needed. Upper body strength (push). C2: Shoulder Swimmers W5 W6 3 3 14 12 3-5 RPE C3: Dead Hang W5 W6 3 3 15s 20s 5-6 RPE D1: TRX Row W5 W6 W5 W6 3 3 3 3 14 12 14 12 5-6 RPE Don’t shrug shoulders. Upper body strength (pull). 5-6 RPE N/A. Core strength. Upper body strength. Shoulder mobility. W5 W6 3 3 14/side 12/side 5-6 RPE (5860%) Unilateral upper body push. Shoulder strength. W5 W6 3 3 30s/side 40s/side 5-6 RPE Keep rib cage down. Aim for full ROM overhead. Try not to lean to one side. Walk heel toe heel toe. Create tension through the body and don’t move anything but the shoulder joint. N/A. Shoulder joint ROM. Create tension through the body and don’t move anything but the shoulder blades. Shoulder girdle ROM. D2: Plank to Down Dog E1: Half kneeling Dumbbell Shoulder Press E2: Suitcase Carry Cool Down/Flexibility: F1: Shoulder 1 CARs F2: Standing Chest Stretch F3: Scapula CARs 6-8/side 1-3 RPE 1 60s/side 1-3 RPE 1 12-14 per direction 1-3 RPE Shoulder mobility. Trapezius, rhomboid, rotator cuff strength. Grip strength. Overhead mobility. Core and grip strength. Flexibility. 66 F4: Standing Triceps Stretch Exercise Prep: A1: Hip CARs 1 60s/side 1-3 RPE N/A. Flexibility. Sets Week 5-6 Day 2 – Lower Body Reps Intensity Notes (RPE or %) Reasoning No movement anywhere but the hip joint. Keep pelvis level with the ground. N/A. Hip ROM and mobility. W5 W6 3 3 14 12 2-3 RPE A2: World's Greatest Stretch W5 W6 3 3 14 12 1-3 RPE A3: Hip 90/90 Switches W5 W6 3 3 14 12 1-3 RPE Lean back onto hands if needed. Active rest. Hip mobility. B1: Glute Bridge W5 W6 3 3 14 12 2-4 RPE Keep hips tucked under and rib cage down B2: Birddog W5 W6 3 3 14 12 2-4 RPE Do not extend lumbar spine or lift head/neck up. Bilateral hip hinge. Glute and hamstring strength. Core stability. Core strength and stability. Maintain spine stability during limb movement. Resistance, Technique, Balance, Core C1: Glute W5 3 14 Bridge (from W6 3 12 bench) 5-6 RPE Keep hips tucked under and rib cage down. C2: Walking Lunge W5 W6 3 3 14 12 5-6 RPE (5860%) Don’t let front knee cave in. D1: Goblet Squat W5 W6 3 3 14 12 5-6 RPE (5860%) D2: Staggered Stance Kettlebell Deadlift W5 W6 3 3 14 12 5-6 RPE (5860%) Brace core before each rep. Keep DB close to body. Keep hips facing forward. Don’t let the trailing leg hip open up. W5 3 14 5-6 RPE Movement prep and mobility. Bilateral hip hinge. Glute and hamstring strength. Core stability Unilateral squat. Lower body strength. Loaded bilateral squat. Lower body strength. Unilateral hip hinge. Lower body strength. 67 E1: Lateral Lunge W6 3 12 E2: Single Leg Medicine Ball Chop W5 W6 3 3 14 12 Cool Down/Flexibility: F1: Banded 1 Hamstring Stretch F2: Standing 1 Quad Stretch F3: Supine 1 Spinal Twist F4: Standing 1 Calf Stretch Mind-Body F1: Box 1 Breathing 5-6 RPE Sit back into hip and try to not let your knee come over your toes. Slight bend in elbows. Focus on movement from the trunk not the shoulder joint. Unilateral squat. Frontal plane. Lower body strength. Rotational movement and strength. 60s/side 1-3 RPE N/A. Flexibility. 60s/side 1-3 RPE N/A. Flexibility. 60s/side 1-3 RPE N/A. Flexibility. N/A. Flexibility. N/A Physiological and cognitive benefits 60s/side 6-8min 1-3 RPE 1 RPE Week 5-6 Day 3 – Full Body Reps Intensity Notes Reasoning 3 3 14/side 12/side 1-3 RPE Keep spine neutral. Thoracic and hip mobility while maintaining lumbar stability. W5 W6 3 3 14 12 1-3 RPE N/A. Spine mobility. W5 W6 3 3 14/side 12/side 1-3 RPE Keep back straight. Hamstring dynamic flexibility. W5 W6 3 3 20s 30s 4-5 RPE Knees one inch off the ground. Imagine squeezing the ground between hands Core strength and stability. Exercise Prep: A1: Adductor Rock Backs Sets W5 W6 A2: Seated Spinal Flexion/Extens ion A3: Walking Hamstring Sweep B1: Quadruped Knees Off Hold 68 B2: T-Spine Lifts W5 W6 3 3 14 12 4-5 RPE B3: Glute Band Walk W5 W6 3 3 14/side 12/side 4-5 RPE Resistance, Technique, Balance, Core C1: Deadbug W5 3 14/side W6 3 12/side C2: Birddog W5 3 14/side W6 3 12/side and feet, creating tension. Focus on extension through the upper back. Keep feet on the floor. Keep knee over ankle. Try to not lean from side to side. Strengthening spine extensor muscles. Specifically in the thoracic region. Glute activation and strength. 5-6 RPE 5-6 RPE Do not extend lumbar spine or lift head/neck up. Core strength and stability. Maintain spine stability during limb movement. Shoulder strength and stability. C3: Overhead Carry W5 W6 3 3 30s/side 40s/side 5-6 RPE Keep ribcage down. Try to get full arm extension overhead. D1: Single Leg Squat (to Bench) W5 W6 3 3 14/side 12/side 5-6 RPE D2: Cable rotation W5 W6 3 3 14/side 12/side 5-6 RPE Control on the way down. Don’t let knee cave in. Elbows slightly bent. Create movement using your trunk, not the shoulder joint. Unilateral squat. Lower body strength. Balance. Rotational strength. E1: Staggered Stance to Single Leg Hold with Single Arm Cable Row E2: Side Plank W5 W6 3 3 14/side 12/side 5-6 RPE N/A. Unilateral upper body pull. Upper body strength. Balance. W5 W6 3 3 20s/side 30s/side 5-6 RPE Keep feet, hips and shoulders Core strength. 69 in line. Use appropriate progression in the video Cool Down/Flexibility: F1: Half 1 Kneeling Lat Stretch F2: Standing 1 Chest Stretch F3: Shoulder 1 CARs F4: Seated Hamstring Stretch 1 60s/side 1-3 RPE N/A. Flexibility. 60s/side 1-3 RPE N/A. Flexibility. 6-8/side 1-3 RPE Create tension through the body and don’t move anything but the shoulder joint. N/A. Shoulder joint ROM. 60s/side 1-3 RPE Cardiorespiratory Training Intensity Time Weeks 1-2 Light to moderate (3-5 20min RPE) Weeks 3-4 Light to moderate (3-5 30min RPE) Moderate to vigorous 18min (4-6 RPE) Weeks 5-6 Moderate (4-5 RPE) 35min Moderate to vigorous 18min (4-6 RPE) Frequency 3x/week 2x/week 1x/week 2x/week 2x/week Type Walking or cycling Walking or cycling Brisk walk, jog, or cycling Walking or cycling Brisk walk, jog, or cycling Client Logbook Example Week 1-2 Day 1 – Upper Body Rate on a Scale of 1-5 (worst to best) Sleep Quality 1 2 3 4 Energy Level Muscle Soreness Stress Level Mood Flexibility. 5 1 1 2 2 3 3 4 4 5 5 1 1 2 2 3 3 4 4 5 5 70 Exercise Sets Reps Intensity (RPE or %) Prep: A1: Cat/cow 1 18-20 1-3 RPE 1 18-20 1-3 RPE 1 6-8/side 1-3 RPE A2: Thoracic Extension on Foam Roller A3: Lying TSpine Rotation A4: Seated 1 18-20 1-3 RPE Shoulder Retraction and Depression Resistance, Technique, Balance, Core B1: Supine W1 1 15 2-4 RPE Drawing-In (Bracing W2 2 12 Technique) B2: Quadruped W1 1 15 2-4 RPE Drawing-In W2 2 12 (Bracing Technique) B3: Single Leg Balance W1 1 W2 2 Working weights/notes Queues Breath in during cat and out during cow. Don’t let rib cage flare up Keep knees directly stacked over each other N/A Keep spine neutral (don’t arch or round low back) Keep spine neutral (don’t arch or round low back) 30sec hold 40sec hold n/a Use a chair or wall as support if needed Don’t shrug shoulders, keep them away from your ears Tuck hips under and squeeze the glutes. Go from knees if needed Create tension through the body and don’t move anything but the shoulder joint C1: Prone Swimmers W1 1 W2 2 15 12 2-4 RPE C2: Plank W1 1 20sec hold 30sec hold 8/side 6/side 3-4 RPE 20 18 20 18 2-4 RPE Keep core engaged 2-4 RPE Keep low back and head against the wall 60s hold 1-3 RPE N/A W2 2 C3: Shoulder CARs D1: Wall Slides W1 1 W2 2 W1 1 W2 2 D2: Wall W1 1 Angels W2 2 Cool Down/Flexibility: E1: Childs 1 Pose 1-3 RPE 71 E2: Standing Chest Stretch E3: Overhead Reach with Side Bend E4: Seated Neck Stretch 1 1 1 60s hold/side 60s hold/side 1-3 RPE N/A 1-3 RPE N/A 60s hold/side 1-3 RPE N/A 72 References Agarwal, C. A., Scheefer, M. 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