One on One
Personal Training
Post-Bariatric Surgery
Patients: Exercise
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Recommendations
Paul Sorace, MS, ACSM RCEP, CSCS*D1 and Tom LaFontaine, PhD, ACSM RCEP, CSCS, NSCA-CPT2
1
Hackensack University Medical Center, Hackensack, New Jersey; and 2Optimus: The Center for Health, Owner,
PREVENT Consulting Services, LLC, Columbia, Missouri
Paul Sorace, MS, ACSM RCEP,
CSCS*D
Column Editor
SUMMARY
PERSONAL TRAINING FOR POST-
BARIATRIC SURGERY PATIENTS
REQUIRES SPECIAL CONSIDERA-
TIONS AND EXERCISE PROGRAM
MODIFICATIONS. THIS COLUMN
DISCUSSES GENERAL EXERCISE
TESTING AND TRAINING RECOM-
MENDATIONS TO PROMOTE SAFE
AND EFFECTIVE EXERCISE FOR
POST-BARIATRIC SURGERY
PATIENTS.
INTRODUCTION
espite an increase in the num-
D ber of bariatric surgeries being
performed in the United States
and around the world, there are no
specific exercise recommendations at
the present time (7). Therefore, there
Copyright Ó National Strength and Conditioning Association
is a need for more research to help
establish exercise guidelines for post-
bariatric surgery (PBS) patients. Exer-
cise recommendations presented in
this column are the result of a combi-
nation of the professional experience of
the authors, recommendations from
bariatric surgeons, and established
guidelines for overweight/obese per-
sons. The Special Populations column
discusses overweight and obesity sta-
tistics, the types and basics of bariatric
surgeries, the risks and benefits of these
surgeries, and the importance of exer-
cise for PBS patients.
EXERCISE TESTING
The personal trainer should obtain
medical clearance from the client’s
surgeon or primary physician before
exercise testing and training. This is
particularly prudent because the PBS
patient likely has several obesity-related
diseases including hypertension, car-
diovascular disease, diabetes, dyslipi-
demia, and osteoarthritis. As a result,
they may be taking a number of medica-
tions (1). Also, there may be certain
exercise restrictions (see the Exercise
Considerations and Safety Precautions
for more specific information).
Ideally, the PBS patient will have had
a physician-supervised exercise test
before starting an exercise program.
The personal trainer can use the results
and physician interpretation to design
the initial program (e.g., exercise heart
Strength and Conditioning Journal | www.nsca-lift.org
rate and rating of perceived exertion
[RPE]). In the absence of an exercise
test, a 6-minute walk test also can be an
effective test that many PBS patients
can perform (4). Variables including
distance walked (in meters), exercise
and recovery heart rate, and RPE can be
used to assess the PBS patient. Retesting
at a later time is important to show
progress. Reference equations are avail-
able for the 6-minute walk test (3).
Men ¼ ð7:57 3 height ½cm
Þ
ð5:02 3 ageÞ
ð1:76 3 weight ½kg
Þ
309 m
Women ¼ ð2:11 3 height ½cm
Þ
ð2:29 3 weight ½kg
Þ
ð5:78 3 ageÞ þ 667 m;
where cm = centimeters; kg = kilo-
grams; m = meters.
These reference equations may be used
to calculate the percent predicted
6-minute walk distance for adults per-
forming the test for the first time, when
using the standardized protocol (3).
A 6-minute walk test protocol is
explained below:
Six-minute walk test
 The test is performed on a track or in
a measured corridor.
101
One on One
 A practice walk should be conducted
to familiarize the PBS patient with
the test.
 The client is told to walk as fast as
possible covering as much distance
as possible.
 The client is allowed to set the pace
and rest as needed.
 Encouragement should be given (e.g.,
‘‘you are doing great’’) regularly.
 The total distance walked in meters
and the number of rest stops are
recorded.
 Heart rate is recorded before, during
(minutes 2, 4, and 6), and after the
test (minutes 2 and 4 of recovery);
blood pressure is measured before
and immediately after the test; RPE
is recorded during the test at minutes
2, 4, and 6.
 Any symptoms experienced by clients
during the walk (e.g., angina, dyspnea,
dizziness, fatigue) are recorded.
Muscle strength and endurance tests
initially may be contraindicated be-
cause resistance training (RT) is typi-
cally contraindicated in the early
weeks/months after surgery. There-
fore, large muscle strength testing is
not recommended. However, a maxi-
mal hand grip dynamometer test is
a simple test that may be administered
to PBS patients to measure initial
strength levels at the start of an exercise
program. Reference values for hand grip
tests have been developed (9). Retesting
to show strength improvements over
time is important and should be
performed. When the PBS patient is
cleared for RT, larger muscle strength
tests may be administered, such as the
bench press and leg press (1).
The standard sit and reach test,
commonly used to assess flexibility in
the hamstrings and low back, may not
be appropriate for PBS patients. Many
PBS patients can have difficulty getting
down to the floor and back up because
of their large size. The personal trainer
should use good judgment in deter-
mining whether or not to use this
assessment.
A modified back saver sit and reach
test on the floor or on a bench may
be administered (6). Although this
102 VOLUME 32 | NUMBER 3 | JUNE 2010
information can be useful for exercise
prescription, initiating stretching for
the major muscles without a flexibility
assessment is reasonable. Other
simple flexibility tests may be admin-
istered on clearance from the bariatric
surgeon (5).
EXERCISE TRAINING
Exercise, with or without caloric re-
striction, can promote overall body fat
loss with a greater reduction in the
abdominal area more effectively than
diet alone (11).
This, considering exercise is one of the
most important factors for mainte-
nance of weight loss (1,2,11), empha-
sizes the importance of regular physical
activity for PBS patients.
Without specific exercise guidelines for
PBS patients, guidelines for over-
weight/obese persons should be followed
(1,2). Aerobic exercise is, perhaps, the
key component of the program for PBS
patients (1,2,11). Resistance training
should compliment the aerobic com-
ponent and be included once the PBS
client is medically cleared. Resistance
exercise can increase muscular strength
and endurance, promoting increased
lifestyle physical activity. Resistance
training does not seem to enhance
weight loss but may increase fat-free
mass, may increase loss of fat mass, and
is associated with reductions in health
risk (2). Any increased fat-free mass (i.e.,
muscle) will enhance metabolic rate,
thus assisting in greater weight loss.
Cardioresistance training (CRT) is an
effective form of RT for achieving both
cardiorespiratory fitness and strength
improvements. Cardioresistance train-
ing involves combining aerobic exer-
cise and RT in an interval format.
For example, a CRT program might
include 5 minutes of cycling, followed
by 4–5 RT exercises for the lower
body, 5 minutes of treadmill walking,
followed by 4–5 RT exercises for the
upper body, and so on. As the PBS
patient progresses, the volume and
intensity of the RT program needs to
be increased, if greater gains in mus-
cular fitness are desired (8).
The Table shows a summary of exer-
cise recommendations for PBS patients.
EXERCISE CONSIDERATIONS AND
SAFETY PRECAUTIONS
Most bariatric surgeons wait 6–8 weeks
after surgery before they medically
clear PBS patients to perform RT.
Regarding abdominal exercises such
as a crunch, many bariatric surgeons
will recommend waiting 3–6 months
after surgery. Other core exercises (e.g.,
alternating prone arm/leg raises) can
be performed sooner. It is the experi-
ence of the authors that this is a ‘‘gray’’
area. Therefore, it is optimal that the
PBS patient and personal trainer re-
ceive specific clearance/recommenda-
tions from the surgeon.
If bariatric surgery was performed as
an open procedure (one large incision
during gastric bypass surgery), healing
and recovery time will be longer, thus
increasing the time frame before PBS
patients can safely perform RT and
abdominal exercises.
Excess body fat and a limited ability
to consume fluids are factors that
can cause overheating during exercise
in PBS patients. Exercising in a cool
climate-controlled environment is
ideal initially. Sipping small amounts
of water frequently is recommended.
As time passes after the surgery, the
PBS patient will be able to consume
larger amounts of fluids. Lap band
patients may be limited to sipping
small amounts of fluid again after a
band adjustment.
Because of a large body size, some PBS
patients may not fit comfortably on
many aerobic and resistance machines.
Free weights are often a good alterna-
tive to machines when selectorized
machines are not appropriate. If the
PBS patient is at or beyond the weight
limit on a treadmill, the belt can ‘‘drag’’
or stop altogether. Use of an indoor or
outdoor track, if available and weather
permitting, is a good alternative. Re-
cumbent bikes are often a good choice
because of the large seat.
SUMMARY
Bariatric surgery is a weight loss
option that currently, overweight/
 Table
Exercise recommendations for postbariatric surgery patients

Aerobic training
Frequency: 5–7 d/wk; PBS patients may need to start at a lower frequency
Intensity: Moderate to vigorous (40–75% heart rate reserve); PBS patients should gradually progress to more vigorous
intensities, as tolerated
Duration: 30–60 min; an initial goal should be to achieve 150 min/wk, gradually increasing to 250–300 min/wk; duration goals
can be accomplished in one exercise bout or through multiple bouts (e.g., 10 min, 3 times).
Modes: Large muscle group activities; examples include walking, cycling, swimming, and other modes (e.g., elliptical training)
Resistance training
Frequency: 2–3 d/wk; allow for at least 48 h between sessions; frequency can vary depending on the RT program design (e.g.,
total body, upper/lower body)
Intensity/loads: 60–80%; 1 repetition maximum
Exercises: 8–10 exercises for the major muscle groups; multijoint exercises should be emphasized
Sets: 2–4 sets/major muscle group; the total sets/muscle group can be from one exercise or multiple exercises
Reps: 8–12 reps; 10–15 reps for older adults (.50 years of age)
Rest intervals: Approximately 1 minute; this time frame may vary according to muscle groups used and client recovery
Progression: Increase resistance by approximately 2.5–5%; once the goal reps and sets can be achieved, a minimum of 2
consecutive sessions; the increase will vary depending on training experience and muscle groups used. A gradual
progression to the use of heavier loads (e.g., 80% 1 repetition maximum) should be encouraged to stimulate greater gains in
muscle hypertrophy
Modes: Free weights, selectorized machines, elastic tubes/band, and bodyweight; equipment selection is based on the client’s
ability, experience, body size, comfort, and preference
Flexibility training
Frequency: At least 2–3 d/wk; can be performed daily
Type: Static, dynamic, or PNF
Muscles: All major muscle-tendon groups
Duration: 15–60 s; PNF can use a 6-second contraction, then a 10- to 30-s stretch
Warm-up and cool down
All exercise sessions should start and end with a warm-up and cool down. This can consist of 5–10 min of light (low intensity)
aerobic activity; stretching may follow the aerobic components of the warm-up and cool down
These guidelines may need modifying according to the individual’s needs and abilities.

Reps = Repetitions; PNF = proprioceptive neuromuscular facilitation.

Information modified from American College of Sports Medicine (1), Donnelly et al. (2), and Wallace and Ray (11).

obese individuals are choosing in
an attempt to gain control of their
bodyweight and live a healthier
and better quality of life. However,
lifestyle intervention is needed for
long-term success with weight loss
and living healthier. Along with
proper and healthy eating habits,
stress management, and social sup-
port, regular exercise, and physical
activity are essential for long-term
success after bariatric surgery.
The personal trainer’s role with
PBS patients is critically important.
As a result, the personal trainer
should realize the responsibility
he/she has and embrace their role
with enthusiasm.
Paul Sorace is a clinical exercise
physiologist at Hackensack University
Medical Center and an instructor for the
American Academy of Personal Training.

Strength and Conditioning Journal | www.nsca-lift.org 103

One on One
Tom LaFontaine is director of
Optimus: The Center for Health in
Columbia and owner of a personal
health consulting business, PREVENT
Consulting Services, LLC.
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104 VOLUME 32 | NUMBER 3 | JUNE 2010
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