Part II of Ulrik Larsen’s ground-breaking approach to rehab for advanced fitness instructors
Last month, in the first of this two-part article (SIB70, May 2007) we looked at why personal trainers and fitness instructors need to take responsibility for their clients’ injuries. Currently there is a significant gap between the role of fitness trainers and that of the various therapeutic disciplines. The fitness trainer expects to take charge of a healthy individual with their body in full working order. But in real life most people acquire injuries, at home, work, play or in the gym, and often these travel with them over the years, unattended and sometimes triggering a sequence of adverse consequences which end up causing them chronic pain and restrictions.
It is all too common for the fitness profes- sional to find that their new client comes with niggling injuries, or, even worse, starts to acquire these soon into their new fitness regime. And the trainer has no idea of how to handle this situation, leading to a down- ward spiral for their relationship with their client and, in the longer term, a decline in public confidence in exercise professionals.
In a new approach that has been piloted and successfully taught to personal trainers in Australia, we can begin to close the gap, to bring together the valuable work of trainers and sports therapists, to ensure we keep our clients fit and healthy. The ‘rehab trainer’ approach does not try to turn the trainer into a mini physiotherapist, but gives guidance and tools to trainers to be able to decide whether, when and how to manage their clients’ injuries, alone or in partnership with sports therapists.
Last month we began to look in more detail at how to conduct an injury assessment, in particular how to grade clients’ injuries into ‘high-risk’ or ‘low-risk’. Below we look in greater detail at how to assess or screenthe injury and then engage with the rehab process, using the appropriate support of physiotherapists, and managing the client’s injury through to an optimal stage.
Pain is the enemy
Pain is the outright enemy of client and trainer alike, and needs a clear plan of action to deal with it. As explained last month, to send the client away just because they reveal they have an injury is folly; and to ignore pain is simply irresponsible.
In our model of injury management, the trainer needs a three-stage plan of attack, stages 1 and 2 being concerned with assessment, based on information gathering from the client and stage 3 being the formulation of a management and rehab plan, in consultation with the client and, where appropriate, other professionals.
Stage 1: Getting to know the battlefield
The battlefield is the context in which the injury has happened. The trainer sets the scene by finding out as much background as possible of relevance to the client’s current injury.
First, the trainer must make sure the client knows they are taking the discussion seriously. That means finding an appropriately private, quiet room to talk and carry out assessment tests. The client should be forewarned that their next session would be at least in part taken up by the injury assess- ment, to enable trainer and client together to decide how to proceed. The trainer should take notes during the discussion.
The trainer is exploring the context of the injury, and therefore needs to gather infor- mation about the circumstances and history of the client’s injury, but also any more general medical background that may not already have been captured during the initial screening preparatory to the start of training.
* Where is the current injury?
* Is it mild or significant?
* Has the client had this injury before?
* Have they had any severe previous injuries?
* Do they have any injury or pain concerns with any area of their body?
* Have they had any major illnesses or medical issues at any stage in their life?
* Have they had any significant operations, and if so, when?
* Is any GP or other therapist currently involved with this injury?
The context of the injury also requires the trainer to know about other aspects of their client’s life, so again, if this information has not already been given during previous screening, the trainer will want to know details such as:
* Are they right or left-handed?
* What sport do they do or have they done in the past, and at what kind of level?
* Have they had children?
* What is their current occupation?
* What is their current exercise habit and how has it been in the past?
Such questions enable the trainer to identify any factors that might have contributed to the onset of the current injury. They also help greatly to establish rapport and trust between trainer and client.
Stage 2: Getting to know the enemy
An essential part of winning a war is to know as much as you can about the enemy (the pain), so this stage of investigation focuses on finding out as much as possible about the injury/pain and how it is likely to affect the client’s training. There are three key ques- tions to consider:
Q1: how did the pain/injury start?
Simply put, we want to know whether the injury is:
Did it start with a particular event (acute), develop slowly over time (‘gradual onset’), or has it simply been around for a long time with no real start date? Textbooks would like us to label an injury as ‘chronic’ if it has been around for more than six months.
To complicate matters, combinations of the above categories are common. Take this example:
An acute knee injury was sustained on the soccer field five years ago. It took three months before it was OK to play again, but there has been residual chronic pain ever since. Lately the training load has increased and the pain is getting worse.
To be thorough we’d have to call this an acute injury that settled to a mild chronic state, finally morphing into an overuse problem!
A more common presentation would be an overuse injury that developed through work or training, which never gets severe enough to prevent training but becomes chronic and starts causing a ripple effect of other overuse injuries as the body tries to compensate.
Q2: how does the pain behave?
Another way to put this question is to ask: ‘What aggravates it?’, or ‘What settles it right down?’ The trainer needs to know whether it is bench press or crunches or boxing or Swiss ball exercises that upset the area, in order to amend the training routine accordingly.
In reality this is easier said than done, because any one session will cover many different exercises and it won’t always be apparent which one(s) caused problems. So this comes down to the experience of the trainer in understanding how each of the various exercises places a particular type of load on specific joints.
Moreover, it may not be anything in the gym or training schedule that is aggravating the pain: prolonged sitting at work may be the biggest culprit, from a poor position or simply from extended periods of relative immobility.
The pain may be inflammatory; ie chemically-mediated from the pathology. In this case, the area will react very quickly if a certain movement, position or load is causing aggra- vation.
However, if the pain is mechanical, the area will tend to warm up well, and pain will probably disappear during exercise, but the after effects will be felt the next day. The knee may feel great during the squat, but does it hurt going up and down stairs the next day?
One of the biggest contributors to pain in the gym is ‘patho-mechanics’: established poor habits of movement that neither the trainer nor the client will have much control over without putting in place a myriad of rehab techniques, such as effective and specific warm-up/stretching to improve joint position and neuro-muscular control before exercise. The wrong exercise prescription will unnecessarily overload an injured body part because the client has not got sufficient muscle control/strength in that area.
Training error – too much loading with too little recovery – either in a single session or over a few weeks, could be the key. The simple act of training too far into fatigue too often will create and aggravate injuries.
Q3: can we train through it yet?
This highly practical question gets to the heart of what the trainer and their client most need to know. The ‘rehab trainer’ approach provides fitness instructors with a simple ‘toolkit’ of four questions and four assessment tests to enable them to make the all-important classification of their client’s injury/pain as:
* high risk
* low risk.
The questions and tests vary depending on the area of injury, with the body being split into three zones: upper limb, lower limb and spine.
Developed from my own lengthy experience in the physiotherapy setting, the four ‘red flag’ questions and tests are designed to flag up pathological and structural concerns that suggest the injury is likely to get worse with training (ie, subjecting the area to movement and loading).
The four questions focus on neural symp- toms, the severity of the pain, potential instability, and cautions specific to the body zone being assessed. The four tests examine reduced range of movement, isometric muscle strength, spinal screening and, again, cautions specific to the body zone being assessed. If the trainer elicits two or more ‘positive’ responses to these eight questions and tests, the injury will be classified ‘high risk’.
In developing this particular form of risk assessment, my aim has been to ensure that it doesn’t overstate the ‘high risk’ category, thereby catastrophising virtually every injury into needing immediate physiotherapy. Yet at the same time it does not pass over injuries that masquerade as insignificant. So, for example, if the question about severity of pain is positive, then another question or test will probably also be positive, leading to a classification of ‘high risk’.
Stage 3: Getting to know the likely outcome
Having worked out what level of risk they are dealing with, the trainer needs to discuss and agree a plan of action with their client. The first priority is to ensure the client under- stands the severity of their problem and therefore how it relates to their ongoing training aims. So the trainer needs to explain the difference between a ‘pathological’ injury and a ‘functional’ one, and where the current injury fits on this scale (see box, above).
Clients may well look to the fitness instructor to help them find a physio or other therapist. Whether this is the case or not, the trainer will need to be in contact with the chosen therapist, to provide diagnostic information and also to consult them about any essential training adaptations and the likely time frame for healing the pathology.
Once this is clear, the trainer and client can set about reviewing and redefining their fitness goals. The skill of the trainer here is to negotiate with their client a set of goals that is both realistic and also positive, to keep the client’s motivation strong in the face of the injury setback, while not setting everyone up for disappointment down the line because goals were pitched too high.
The trainer must then plan their strategy for meeting the revised goals, taking into account the injury, and discussing with their client how best to speed the return to full health and fitness.
Summary of action plan for low- risk injuries
1 Analyse the movement of the area, looking for patho-mechanics: poor body position, technique or biomechanics. In particular, during the first few sessions, the trainer should monitor closely the quality of movement and any tightness or mild discomfort in the affected area as the client performs their exercises. Any exercises that cause pain should become ‘goal’ exercises, to be worked towards and eventually executed pain-free (see below).
2. Select a ‘critical path’ exercise based on the ‘goal’ exercise. This is a stepping stone exercise that the trainer must decide upon/devise, which gives the client a clear sense that they are working towards what they want to do. The critical path exercise is an important opportunity to retrain pathomechanics. In a few instances the trainer may need to declare a certain exercise ‘impossible’ to aim for, for instance with a repeatedly anteriorly dislocating shoulder, the shoulder press (even if it causes no pain) is simply not an option.
3. Incorporate loosening/mobilising tech- niquesto improve joint position prior to loading an affected area. For instance, the client should stretch the pec minor muscle to allow good scapular retraction during chest press, and prevent downward rotation of the scapula during the top of the press movement.
4 Devise rehab drills to warm up poor components of a movement and activate inhibited stabiliser muscles. For instance, the trainer should get the client to practise pure scapular protraction/retraction prior to doing the chest press, in order to greatly improve safety and performance of the exercise.
5.In the event that pain persists despite the instructor’s best efforts at rehab training, decide what support is needed(eg, physio, massage therapy, podiatry), and ensure proper liaison with whichever professional is involved.
Summary of action plan for high- risk injuries
1. Refer the client as soon as possibleto a physio or other similar professional. It is important to give as much supporting infor- mation as possible.
It is the job of the health professional to clarify the diagnosis and nature of injury, and to treat and very closely manage how and when the training of the client’s injured body part takes place. The trainer’s job is to ensure that no movement with load is taken through the affected joint: this is what we mean by training ‘around’ the area (see below). Although It is always possible that the health professional may require training to be suspended altogether for a period, in prac- tice this should be a rare occurrence, because it is amazing what can be done in a pool.
Until the injury is declared ‘functional’, the health professional has primary respon- sibility and the trainer will need to establish a decent working rapport, consulting with and seeking advice from the physio.
2. Train around the injured partuntil the ther- apist declares the injury to have reached a functional state. It is the trainer’s job to keep their client’s training habit on track during their rehab period. But in order for the instructor to continue to train their client, they will have to apply their knowledge, expe- rience and motivational skills to keep the revised training programme on target, varied, safe, effective and fun.
3. Gradually incorporate more rehab skills. As the status of the injury becomes increas- ingly functional, the trainer will need to adjust their programming again. This process, if nothing else, keeps life interesting and the brain cells firing.
For reasons I have explained previously in Sports Injury Bulletin, it is essential that the fitness industry is able to rise to the chal- lenge of dealing with injury and pain among its clients. For individual trainers this should come as a welcome challenge: a chance to enhance their skills, take a more creative and individualised approach to their work and to raise public respect for their profession. The approach being pioneered by Rehab Trainer charts a safe and effective way of joining up the gap that currently exists between therapeutic professionals and fitness trainers, which should threaten none and indeed work to the advantage of all concerned.