It’s time advanced fitness instructors took some responsibility for managing clients’ injuries, Ulrik Larsen argues. Here’s how
Ask any personal trainer what they hate most about training clients and they will probably say ‘injuries’. It is understandable why this should be: an injury represents a stumbling block that can derail a client from achieving their sporting or fitness goals. Most of the time the trainer can only share the client’s frustration as they walk through the minefield of ‘Does this exercise hurt? Does that stretch hurt?’, because they simply lack the competence and confidence to know how best to help manage the injury.
I have previously explored in Sports Injury Bulletin(SIB62, Sept 2006) the implications of poor injury management for the personal trainer and fitness instruction industry. Here is a brief summary of why this widespread problem matters:
* Short term: the very high incidence of failure of personal trainer businesses (in Australia the figure is 60% within 18 months of start-up) is, I believe, partly attributable to the prevalence of injuries among clients. This helps to create a lack of public confidence in the profession.
* Medium term: litigation and its attendant publicity, when a client sues a trainer for incompetence (real or perceived), it can strike a critical blow both to that trainer’s business and more widely to the profession in a particular locality or city.
* Long term: the cumulative effect of inadequate professionalism, high profile court cases and media reports will, I believe, undermine the viability of the personal training industry.
The law of thirds
When clients who are carrying injuries sign up for personal training, in my experience one of three things tends to happen:
* One third of injuries will simply resolve: given training and time, the client’s improved fitness and conditioning will contribute to the resolution of the injury. Everyone is happy and the trainer can pursue the client’s fitness goals without worry.
* One third of injuries will plateau: these injuries will either fail fully to resolve (improved fitness may help reduce symp- toms but will not cure the underlying problem), or, if already chronic, they will simply persist, unchanged in nature or intensity by the training. Some otherwise healthy and fit clients (and none are more guilty of this than personal trainers themselves) will carry around niggling injuries for years, content in the knowledge that it isn’t getting any worse and that the limitations imposed by the injury do not trouble them too much. Many clients, while not happy about their ongoing injury, will choose to put up with it, having briefed their trainer about their pain and limitations.
* One third of injuries will get worse: it may happen gradually or suddenly, but in general the worsening of the injury will be down to the trainer’s lack of awareness, overloading the injured body part in such a way that it progresses to the next level of pain and dysfunction. Or it may be that the lifestyle of the client so aggravates the injury that training now becomes a contributory factor. These injuries are the dangerous ones that haunt personal trainers, threaten their businesses, and reduce the membership numbers of the gyms they work in.
Back to the physio?
So is it simply a matter of every personal trainer having a good physiotherapist or two in their contacts book to sort out the injuries as they come along? In my experience with trainers, when it comes to referring injured clients to physiotherapists, they tend to take an ‘all or nothing’ approach.
‘Refer all injuries…’
Some personal trainers, too nervous even to entertain the notion of training a client with an injury, refer all clients immediately for treatment and don’t want to see them for a month or three, until they are fully recovered. The obvious downside of taking this approach is a loss of training income and the risk that the client, once declared fit again, will never return – either because they have lost momentum or, worse, because they have lost confidence in a trainer who is linked in their mind with the onset of injury but not its resolution.
‘Train through the pain…’
Other trainers take the opposite approach, going into denial about their clients’ pain, and urging them to train on in the hope that the pain will spontaneously disappear or (less irrationally but not necessarily correctly) will be sorted out with muscle strengthening around an affected joint. These trainers are at risk of alienating their clients emotionally, because the client will feel they are not being listened to and cared for. That alienation may well result in litigation at some point and even if it doesn’t get that far, these unhappy clients are at high risk of dropping out or going elsewhere.
A better way: injury assessment
Primary goal: to weed out those injuries that will get worse through training.
It is not the job of the trainer to know what their client’s injury is. But it is essential that they are able to rate the ‘risk profile’ of an injury in terms of the potential effect that training will have on it. An accurate injury assessment should tell them immediately which injuries they need to be worried about and which they can carefully train through.
Secondary goal: to make the client feel cared for, and that their injury is not being neglected.
This level of care is very important to help the trainer build a good rapport with their client. Moreover, the trainer will be able to put together a picture of the client’s history of major injuries and where they have occurred.
If done right, initial injury screening also gives some objective markers for reassess- ment at a later point in time, after some treatment has taken place. This reinforces the message to the client that the trainer is helping to take care of their injured body part and not simply ignoring or forgetting about it.
Finally the screening can help the trainer advise their client on whether they need an immediate referral to a physio, or whether it is possible to train safely for a while, learning how the injury behaves under load.
Most fitness instructors and personal trainers have two procedures in place to screen for injury that may be adversely affected by exercise:
* a standard health questionnaire (in several countries this is known as the PAR-Q or ‘physical activity readiness questionnaire’) which attempts to reveal injuries past and current
* some kind of postural screening, conducted by trainers with greatly varying levels of competence and given greatly varying levels of significance.
In reality, clients often gloss over problems in answering their PAR-Q forms, perhaps citing only their worst or most recent injuries or operations, maybe forgetting an injury altogether, or selectively mentioning only those things they believe to be ‘relevant’. Some clients, overly keen to get started, will undoubtedly omit some injury details, fearing that if they admit them it will stall their precious momentum. After all, how could a 10-year-old niggling shoulder twinge be of any relevance?
As for a postural assessment, a standing assessment will, in theory, pick up some relevant details, but let’s be honest, are they useful for assessing whether or not the body- part in question will get worse with training? After all, who doesn’t have bad posture when they first turn up for exercise? And anyway, when is bad posture too bad? The postural assessment process is just too subjective for the vast majority of trainers, and is not reliably reproducible as a way of determining progress down the line.
I believe standing postural assessments are only of value for trainers who have had a good few years’ experience – and even then they are a poor predictor of injury severity. While poor static posture can be a reason- able predictor of poor movement quality and control, it’s just impossible to tell without doing a further assessment of patho- mechanics (poor movement biomechanics), how in reality the associated injury will fare under load.
In short, neither current screening method addresses adequately the primary goal of initial assessment as stated above: to weed out injuries that will be exacerbated by training. For this, we need a different assessment strategy.
A new screening approach
All injuries are located somewhere on a spectrum ranging from ‘pathological’ at one end to ‘optimal’ at the other – where the injury to the body part has been 100% resolved. Midway between the two extremes is the point physiotherapists refer to as ‘functional’, and this is the point at which the trainer can resume charge of training an injured area.
A pathological injury is one in which some or all of the following may be present:
* significant pain
* swelling, inflammation or instability
* stability (tonic/local) muscles are inhibited as a result of the pain
* movement is limited.
Sometimes the injury will be obvious, but not always. The purpose of the injury assessment, of course, is to pick up the ones in ‘hiding’. All pathological injuries are high- risk to train, so the only way a trainer can operate is to work around them as intelli- gently as possible. The care and rehabilitation of injuries in this state lies with a qualified professional therapist (physio, osteopath, sports physician etc).
A functional injury has:
* much better range of movement
* less severe and frequent pain
* minimal, if any, swelling
* much improved muscular stability and movement control.
At this point, the injured part may be trained with care, with strong emphasis on appropriately progressed loading and attainment of good biomechanics. The trainer is now primarily responsible, even though the client should still be receiving physiotherapy treatment to guide them through to an optimal state.
An optimal body part moves well: neuromuscular coordination has been retrained, proprioception is good, range of physiological and accessory movement is good, and strength/flexibility/durability can be developed safely.
What injury assessment is NOT
It is not diagnosis
Most trainers are quite relieved that they are not expected to figure out what exactly has gone wrong with their client, or which structure is injured. Rather, the task is simply to categorise the injury into a ‘risk profile’. So let’s be quite clear about it, fitness instructors and personal trainers should not be attempting to dabble in injury diagnostics: this is what physiotherapists spend four years learning about at university, and several more years getting to be halfway good at. A trainer who casually declares that their client’s niggly shoulder is down to a ‘rotator cuff problem’ risks looking ignorant when the physio diagnoses the injury as a nerve root irritation from the neck.
So the role of injury assessment is to provide a simple ‘quick screen’, for the purpose of deciding what impact an injured body part will have on the client achieving their stated fitness goals. It is an easy way to encourage the trainer to make a prompt decision (for which, by the way, the client will rightly hold them accountable) concerning what to do about their client’s injury.
The assessment can be carried out even if the client is already being treated for the injury. In this instance, it is important to contact the clinician before the next training session, to discuss diagnostics, dos and don’ts, and to agree on the best strategy to achieve a complete recovery.
It is not trying to predict future injury
To take a body part that is not in pain and predict whether it will in the future become painful is another ‘black art’ that requires many years of experience. While some trainers (particularly those working with regular sportspeople as conditioning coaches) will be involved with specific injury minimisation strategies, most will take a more broad-brush ‘whole body’ approach to their clients’ fitness needs. The initial injury assessment should focus therefore on existing problems, rather than future ones. Once the client is injury-free and the trainer is more familiar with their partic- ular strengths and weaknesses, a more individualised ‘prehabilitation’ strategy can be developed if that’s what is needed.
It is not rocket science
The questions and tests that comprise an injury assessment are not difficult. Done properly, the process takes a few minutes, and leaves the trainer very clear about which path they will take with the injury. Every injury will either be ‘high risk’ or ‘low risk’.
Category I: Low risk
Train through the injury
If the injury falls into this category the trainer can decide to train through the injury with secondary support from a physiotherapist (or other relevant clinician). The trainer assumes primary responsibility for the body part and the injury. The trainer’s skills of movement analysis, stretching, safe training technique, correct exercise prescription and rehab drills are the right tools to guide a client’s progress from functional injury towards an optimal state of injury resolution.
Category II: High risk
Train around the injury
If the injury falls into this category the job of the trainer is to explain to their client that this injury could hijack their fitness goals unless they take it seriously. They must visit a good physiotherapist urgently, who will diagnose the injury, begin treatment and set a critical path from the patho- logical state towards a functional state. In this situation the physio has primary responsibility until the injury again becomes functional/low risk.
In the second part of this article, we will look in detail at the injury assessment protocol, describing the steps that must be taken to ensure that trainers can rate every injury accurately into the appropriate risk category.