All professional coaches and fitness trainers should take responsibility for injury management.
It has been argued that best practice for the fitness industry is that all levels of exercise professionals need to take responsibility for their clients’ niggling injuries.
That is not to say that they cannot work as part of a “rehab-team” that would include primarily a Physiotherapist, but secondarily perhaps a Remedial Massage Therapist, Chiropractor, Osteopath, Acupuncturist or even GP.
However, there is currently such a significant gap between the role of exercise professional and that of the various therapeutic disciplines which makes it hard for the two industries to work effectively together.
Improving injury management for clients
Getting exercise and therapeutic professionals in sync can only help the client as they strive towards health and fitness.
The newly educated Personal Trainer expects to take charge of a healthy individual with their body in full working order. In reality of course, it is all too common to find that their new client comes with niggling injuries, or even worse starts to acquire these soon into their new fitness regime.
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. And the trainer generally has little or no idea of how to handle this situation, leading to a downward spiral for their relationship with their client.
The skills they learnt in Cert IV do not help them to know what to do in this situation.
For example, the commonly performed Postural Assessment holds little practical value when a client asks what should be done with their current injury such as a painful ankle or even shoulder – its value is perhaps mainly for prevention.
In a new approach that has been piloted and successfully taught to personal trainers in Australia and the UK, we can begin to close the gap between the fitness and allied health industries to ensure we keep our clients fit and healthy on their journey towards fitness.
The Rehab Trainer approach does not try to turn the trainer into a quasi-physiotherapist, but suggests a radical and new model based that 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 allied health professionals.
Pain is the enemy
Let’s be clear: pain is the outright enemy of client and trainer alike, and needs a clear plan of action to deal with it. The solution is not simply to send the client away just because they reveal they have an injury – this is folly; and to ignore pain is simply irresponsible.
Three Stage Plan for injury management
In this model of injury management, the trainer needs a three-stage plan of attack to draw up a management and rehab plan in consultation with the client and, where appropriate, other professionals.
- Step 1 – Understanding the whole picture of the client’s body and injury history
- Step 2 – Asking four critical questions to understand the pain specifically
- Step 3 – Predict approximately and discuss with the client how the pain will resolve and training implications.
STEP 1: GETTING TO KNOW THE PLAYING FIELD (The Client’s Body and History)
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 any assessment tests if possible. The client should be forewarned that their next session would be at least in part taken up by the injury assessment, 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 information 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. For example:
• 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 other area of their body?
• Have they had any major illnesses or medical issues at any stage in their life?
• Have they had any signifi cant 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.
STEP 2: GETTING TO KNOW THE COMPETITION (The Pain)
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 four key questions to consider:
Q1. Where exactly is the pain or problem?
Important here to record the basics of what the client is reporting is going on for them – is it only pain, or also pins and needles, or a feeling of instability or weakness? The Rehab Trainer Record Pad (given out on the Essentials course) allows the Trainer to easily record what the client is telling them onto a “Body Chart”.
Q2: How did the pain / injury start?
What is its exact history? 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 aches and pains ever since. Lately the training load has increased and the pain is again returning and gradually 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 on-going overuse injury!
A more common presentation would be an 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.
Q3: 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 PT 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; i.e. chemically-mediated from the pathology.
In this case, the area will react very quickly if a certain movement, position or load is causing aggravation. This type of pain is likely to be more severe, constant, and be categorized as “high risk” to train with.
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 possibly 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?
Q4: 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 Risk Assessment Laminated Cards (part of the Rehab Trainer “toolkit”) of four questions and four assessment tests to enable them to accurately screen the client’s injury as
• High risk, or
• 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.
The Rehab Trainer Risk Assessment Screen requires four “red flag questions” be answered, and four “red flag tests” be carried out, that are designed to flag up pathological and structural concerns that suggest the injury is likely to get worse with training (i.e. subjecting the area to movement and loading).
The four questions focus on neural symptoms, 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, the aim has been to ensure that it doesn’t overstate the “high risk” category, thereby catastrophizing virtually every injury into needing immediate physiotherapy.
Yet at the same time it does not pass over injuries that masquerade as insignificant, 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”.
STEP 3: GETTING TO KNOW THE LIKELY OUTCOME (How Long Will The Game Play Out…)
Having worked out what level of risk they are dealing with, the trainer needs to discuss and agree on a plan of action with their client.
The first priority is to ensure the client understands the severity of their problem and consequently 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 fi ts on this scale.
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, who will provide diagnostic information and also 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 set-back, 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.
Injury management – in conclusion
For the sake of the general public, it is essential that the fitness industry is able to rise to the challenge of dealing with niggling injury that arises as part of the training process.
For individual trainers this should come as a welcome challenge: a chance to enhance their skills, take a more creative and individualized approach to their profession and to develop more meaningful relationships with their clients.