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Sarah Bolitho explains why special populations are not as niche as they once were, and how fitness professionals should welcome this opportunity to have a positive impact on the health of the nation.

Traditionally, individuals with a medical or mental health condition, a disability or those defined as ‘older adults’ were referred to as ‘special populations’, and many fitness professionals did not target these groups as it required a specialist qualification to work with them.

However, as it is estimated that in the UK over 15 million people have at least one long-term condition, over 14 million have a disability, one in four will experience a mental health condition over the course of a year and nearly 12 million people are over 65 years old, it is clear that these are no longer the special populations but are becoming the norm. This means that, as a fitness professional, whether you work as a personal trainer, gym or group exercise instructor or in other disciplines, you are likely to encounter these ‘not-so-special’ clients in your everyday work.

Long-term conditions are here to stay

So, what is the definition of long-term conditions, also referred to as chronic conditions or diseases? A long-term condition, or LTC, is a health condition that needs to be managed on an ongoing basis and includes those for which there is no cure1. Common examples of LTCs include musculoskeletal conditions such as osteoarthritis, rheumatoid arthritis or osteoporosis; cancer; cardiovascular diseases such as hypertension or high cholesterol; chronic fatigue conditions; diabetes and obesity; digestive disorders; epilepsy; mental health conditions; neurological conditions, including multiple sclerosis and Parkinson’s disease; and respiratory disorders such as COPD and asthma – to name a few!

LTCs are estimated to affect up to 26% of the population of the UK and, according to the Health Survey for England 20192, 43% of those surveyed reported having at least one long-standing condition or illness. Of the respondents, 24% reported having two or more LTCs and 20% reported three or more. The 2020 Chief Medical Officer report3 reports that only 55% of 45-54 year olds and 50% of 55-64 year olds have no LTCs, meaning that a substantial number of those in mid- and late-adulthood have one or more conditions and, in some cases, up to five co-morbid conditions. These may be referred to as co-morbidity, which is having two co-existing conditions, or multi-morbidity, which is the presence of multiple chronic or long-term conditions. Additionally, instructors working with teenage clients need to be aware that 15% of 11-15 year olds are reported to have an LTC.

Furthermore, it is estimated3 that, while current life expectancy is 80 years for men and 83 for women, 20.4% and 23.2% respectively of our later years are spent in poor health. As poor health doesn’t suddenly appear at a specific age but is cumulative, this adds further motivation for optimising health in early, mid and late adult life. (You may also like to check out the health survey information for Scotland4 and Wales5.)

Consequently, many individuals who work with personal trainers, attend classes or are gym members may have an LTC, so fitness professionals need to have the knowledge, understanding and skills to work with these clients safely and effectively on an ongoing basis. Additionally, we must be aware that, as well as new clients who present with one or more long-term conditions, existing clients may be diagnosed with one during the time we are working with them. Therefore, knowing how to provide safe and effective exercise or activity for your clients, or knowing how to signpost them to a more appropriate instructor if necessary, is now an essential skill in our roles.

Start with safe

Although many long-term conditions are more prevalent in older adults, they can occur at any age. As the signs, symptoms and impact on an individual can vary, it is recommended that robust screening is conducted, not only for potential new clients but also for existing clients who should be re-screened on a regular basis to identify any new conditions that are diagnosed and any deterioration in symptoms. Risk stratification6,7 also needs to be considered to ensure that a client is within the scope of your qualification and experience (and insurance!). If your screening protocols and risk stratification identify that a client’s long-term condition, or combination of conditions, affects them to a moderate or severe extent, they may need to be referred on to an appropriately qualified exercise specialist.

However, the symptoms and impact of LTCs on many clients, particularly in the early stages, may be mild and they may want to improve their fitness or functional ability so they can maintain their current health, slow down any potential decline or continue to perform their activities of daily life for as long as possible. And this is where we come in!

The Public Health England (PHE) guidance Health Matters: Physical Activity – Prevention and Management of Long-term Conditions8 estimates that the adults in England who live with an LTC are twice as likely to be physically inactive, despite evidence showing that regular activity is beneficial in both preventing and managing many of the common LTCs. Other benefits include promoting musculoskeletal health, maintaining or improving physical function and independence, social inclusion, weight management and reducing inequalities for people with LTCs.

The PHE guidance also refers to the physical activity continuum, which categorises activity into subsets, including:

  • active living
  • active travel
  • active recreation
  • active sport (informal and competitive).

As fitness professionals, we are in a strong position to give advice and support on how to adopt or improve on many, if not all, of these subsets and, with the underpinning knowledge of the common LTCs, we can offer a safe and effective activity experience to our clients.

Recognise risk

A recent consensus statement from the British Journal of Sports Medicine9 considered the benefits and risks of physical activity for those living with LTCs and summarised that, while there are risks associated with physical activity or exercise, they are outweighed by the benefits. However, there is no ‘one size fits all’ method or a simple algorithm – a client-centred approach is advised and the proposed exercise must be tailored to the client’s need and abilities. This includes considering what, if any, supervision is required, and understanding the client from a symptom and functional perspective, not just according to the clinical pathophysiology of the condition.

A breakdown of the research is shown in Figure 1 below and, for a full summary of the results10, visit

While appropriate activity is recommended by many organisations, efficient screening is essential to determine the starting point of any activity programme, to identify risk and to ascertain the level of supervision required. Effective screening will also identify if referral or deferral is necessary. The PAR-Q+ 2021 ( is the recommended tool to use when screening clients, as it will identify those for whom clearance may be needed. Note that, due to data protection/GDPR regulations, you will need to give the individual a letter to take to their GP to gain clearance, examples of which can be found in the two toolkits mentioned below.

Always remember, if in doubt about a client’s suitability for activity or exercise, check it out!

Figure 1: A breakdown of the research

Ensure effectiveness

The chief medical officers11 (CMO) in the UK and the World Health Organization12 recommend that all adults with a long-term condition participate in regular physical activity. The CMO guidance also states that some activity is better than none and that it is never too late to start – an important message to get across to potential clients of all ages, particularly older ones.

A report from the National Institute for Health Research13 into multi-morbidity (having more than one LTC) identified that physical activity and strong social networks reduce the risk of having multiple LTCs. We also know that group activities are beneficial for mental health and social inclusion, with one report by Kanamori et al stating that, ‘Although exercising alone and exercising with others both have health benefits, increased frequency of exercise with others has important health benefits regardless of the total frequency of exercise’14. This means that opportunities to exercise with others should be provided where possible, whether it is large- or small-group activity, indoor or outdoor classes or by including group-based warm-up and cool-downs or time to socialise afterwards when running gym-based sessions.

Getting FITTer

As stated above, both the CMO and WHO recommend activity for individuals with LTCs, subject to screening. A summary of the Frequency, Intensity, Time and Type (FITT) recommendations is shown in the table below; however, the guidance states that all adults should start to be active at a frequency, intensity and duration that is within their abilities and increase gradually. Progression should focus on increasing frequency, then duration and finally intensity, if appropriate.

Condition-specific recommendations and guidelines should always be consulted and followed, particularly if there is more than one condition present or if the guidelines conflict. Current guidelines are discussed in the relevant qualifications and are available from the American College of Sport Medicine (ACSM)15.

  Aerobic Muscular strength endurance Other
F 5-7 days a week Twice a week Three or more times a week
I Moderate or vigorous Moderate or greater Moderate or greater
T 150-300 minutes of moderate or 75-150 minutes of vigorous activity No guidance; however, CMO recommendations include starting with one set of 8-12 reps and increasing as tolerated or necessary No guidance other than recommendations that this is included in activity provision
T Any large muscle group cardiovascular activity Whole-body approach involving all major muscle groups Varied multi-component activity focusing on balance, function and strengthening

Make it long term!

Our aim as fitness professionals working with LTCs is not to create clients for life. It is to give clients the skills and confidence to become independently active and improve their quality of life – and, as a bonus, they may be able to manage their LTCs more effectively. To achieve this, we need to educate our clients not only on the benefits of activity but also on how to build activity into everyday life to increase the benefits and promote sustainability.

Get qualified

If you are going to work with clients with one or more long-term conditions on a regular basis, you do need to hold an appropriate qualification. Previously, exercise referral qualifications, the current version of which is the Level 3 Diploma in Exercise Referral, focused on specific conditions, with a bias towards instructors working in, or planning to work in, formal exercise referral schemes. However, many instructors did not want to work on a formal scheme but wanted to be able to start or continue to work with clients with diagnosed medical conditions. Many found that, even with this qualification, they were unable to set up their own referral pathway due to existing referral schemes being in place. This meant that many personal trainers and fitness instructors without this qualification felt unable to help new or existing clients with mild or moderate long-term conditions. Many were also reluctant to undertake the qualification, as they had no intention of working within a formal scheme.

While the current Level 3 Diploma in Personal Training includes brief information on several of the more common LTCs, this is not comprehensive, so this is where the new Level 3 Diploma in Supporting Clients with Long Term Conditions is recommended. This qualification gives more in-depth information and guidance for a wider range of long-term conditions, together with clear information on when and how to signpost clients who are outside the scope of the Level 3 instructor. It is designed to provide the knowledge and skills required to be able to support clients living with a range of one or more LTCs by helping them to lead healthier and more active lives so they can manage their symptoms. It covers effective behaviour-change techniques, lifestyle advice and safe and effective exercise prescription for individuals with LTCs, so is ideal for all PTs and group exercise instructors to develop their careers and widen their client base.

Whichever qualification you choose, ensure that it is on the Regulated Qualifications Framework ( and offered by an Awarding Organisation approved centre. Be advised that the Level 3 Diploma in Exercise Referral is being withdrawn from the qualification framework in September 2022.

Working with healthcare professionals

Any fitness professional who wants to work with clients with LTCs outside a formal exercise referral scheme will need to collaborate with healthcare professionals at some stage, both to have a clear pathway for advice and information and as a potential source of referrals. While this is possible, it can be difficult to set up and requires a high level of professionalism and accountability, so a clear structure for all administration and communication from the start is recommended. There are two key sources that provide guidance on this: the Sport England Evaluation Framework16 and the Exercise Referral Toolkit17. The Sport England Evaluation Framework helps with design, implementation and evaluation, and sets out clear steps and procedures to follow when setting up a sport or physical activity project, and the Exercise Referral Toolkit gives more specific guidance for setting up an exercise referral scheme.


These ‘not-so-special’ populations are likely to grow in future years, as long-term conditions are here to stay. Fitness professionals should be embracing this opportunity to not only grow and develop their careers but also to have a positive impact on the health and wellbeing of their clients, and on the health of the nation overall.

This previously featured in the Fitpro digital magazine.

Author Bio:

Sarah Bolitho is a Fitness Career Mentor and uses her 30-years industry experience as an instructor, tutor/assessor, IV/EV, and course writer to support new and experienced fitness professionals in developing their careers. She is the author of six books in the ‘Complete Guide to…’ series, has worked for/run, large and small training organisations, written for magazines and been on radio as a leading authority so is ideally placed to support instructors in their career development.


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  17. Exercise Referral Toolkit


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