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Sports injury physiotherapy

Sports physiotherapy: Give trainers a role in rehab

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Ulrik Larsenputs the case for upskilling personal trainers to take on injury management

Sports Injury Bulletin has long been debating the strengths and weaknesses of the sports physiotherapy profession, and in particular the relative roles of physios and fitness trainers. For me, this is far more than just an academic debate, as it goes to the heart of work I am currently developing, as a sports physio, with the Australian personal trainer industry.

My own thinking is based on five years of extensive involvement with personal trainers and their clients, exposure to the machinations of personal trainer management systems, and work that I have done educating trainers in in-service forums and now in a new in-depth modular course that I have developed, called ‘Rehab Trainer’.

What follows is a SWOT analysis (strengths, weaknesses, threats and opportunities) of the Australian personal trainer industry. I cannot claim that the analysis will hold equally true for other countries, but I suspect there will be many aspects that others will recognise in their own domestic situations. My hope is that this kind of debate, and professional development initiatives such as ‘Rehab Trainer’, will help to push the sports therapy world on into increasingly productive collaboration and satisfactory outcomes for our clients.

Strengths

In Australia the personal trainer industry is booming. There are new gyms popping up all over the place; quality gyms/health clubs are expanding rapidly and positioning themselves for further growth; and educational institutions are consequently enjoying huge demand for their Certificate III and IV personal training graduate courses.

There has clearly been a big increase in the proportion of gym-goers wanting to work with a personal trainer on their fitness programmes. The average user attending a health club seems to view their exercise, and even having a personal trainer, as an integral part of a healthy lifestyle, rather than it being a luxury that they won’t afford.

My own situation in Queensland bears out this trend. I am part of a large multi-disciplinary sports medicine clinic that serves as ‘pit crew’ to a massive gym next door. There, 20 to 30 personal trainers ply their trade around the clock, for 5,000 fitness-seeking mums and dads, plumbers, corporate executives, and even the odd athlete. And everyone seems to win.

These days clients tend to focus as much on maintaining physical health as on having a ‘great’ body. Personal training has become a lot more than your basic machines and exercises; it encompasses a vast selection of outdoor activities, functional exercises, flexibility and core stability regimes, and new equipment designed to push the body in new ways towards its optimal state.

From my perspective as a sports physiotherapist working hard to keep the clients on track with their chosen fitness regimes, the arrangement gives me no end of satisfaction, because the dovetailing of the allied health and the personal trainer professions results in a rapid return to training for injured body parts.

Anecdotally there is no question in my mind that an injured client who belongs to a gym and is a regular exerciser with a personal trainer is much more likely to be motivated in their injury rehab. They are also therefore less likely to become over-dependent on the clinician to give them temporary feel-good treatments.

I am spending a lot more time with clients these days in the gym, watching them do a particular exercise, or discussing with a personal trainer the poor technique or poor movement issues that are intimately connected to the client’s pathology. With a personal trainer on board, the client is much more likely to be encouraged to keep up their training, even in a modified form, until an injured body part becomes functional again.

Weaknesses

Personal trainers, however, increasingly face three challenges in this context of injury, challenges that I believe will require them to evolve in order to hold their own beyond the short term.

Firstly, far too many clients seem to get injured, and with injuries come complications. Some clients bring injuries with them into the gym; these will test the developing relationship between client and trainer at an early stage. Others sustain their injuries through their gym activities, and there seem to be very few who can be trained consistently over many months without getting injured.

My impression is that people do not seem to stay injured for as long as they used to (most injuries I see associated with personal training regimes could not be described as persistent or severe), but it is striking how easily gym goers seem to get injured, particularly in the first few months, as bodies are pushed to their limits, forced to adapt and remodel.

Could it be that as a greater proportion of the population seek out a healthier lifestyle, the newcomers to the gym are more high-risk to start with – people who would in the past never have dreamt of acquiring a regular exercise habit but who are now seeking direction and advice to back up their best efforts? As a personal trainer do you immediately send all your keen new recruits off to a physiotherapist or chiropractor for remedial work, and risk never seeing them again?

Secondly, there is usually an implicit expectation among gym-goers that their minor ongoing injuries are going to get better simply as a result of their getting into a routine, becoming fitter and working with a personal trainer. Put another way, it seems that people increasingly expect personal trainers to be able to sort out their grumpy lower back or niggling knee injury. Are personal trainers aware of this? And are they qualified for this challenge?

Unfortunately the current baseline standard of training for personal trainers makes it truly a gamble as to whether the client’s injury will improve, stay the same or even deteriorate as they get into their new fitness regime.

Many personal trainers are unaware of the key fact that physical training in the context of pain changes everything. Much higher levels of specificity, caution and biomechanical understanding are necessary if the trainer is to have a beneficial rather than a detrimental effect.

Thirdly, while no research has yet confirmed this, it is highly likely that injury plays a part in the drop-out rate of clients from regular gym-going. They get frustrated, lose their exercise momentum, and either stop seeing the personal trainer because they have lost confidence in them, or probably more commonly, stop going to the gym altogether.

Opportunities

Winning client loyalty

With years of experience and continuing advanced professional development, personal trainers become more confident and competent at knowing what to do about injuries. This in turn attracts longer-term loyalty from clients, especially where the trainer has played a positive part in their rehabilitation from injury. Greater client satisfaction is the key to the sustainability of personal training businesses.

This is the direction in which the whole personal training industry needs to move, not just those trainers who opt to specialise more in rehab work. Why? Because the general public are asking for it, and because, I believe, it is the right way to go: it is better that members are steady users of gyms and personal trainers than of allied health services. I know in one sense I am talking myself out of a job!

Greater work satisfaction

To be an active part of helping to free people from pain is rewarding work; much more so than slaving solely to amass money in the bank, or, for that matter, just handing out the latest ‘rehab drill’ without understanding what its purpose is. With new competence will come new confidence in what the trainer is doing with an injured body part.

Alongside greater skill acquisition comes greater intellectual stimulation for the trainer, as they come to understand how injuries are created, what movement patterns need to be corrected, and how to work with referrers.

And personal trainers will be able to help create a virtuous circle. Their training approach will be safer and more geared to injury prevention as they understand the details of which movement patterns predispose to injury.

New skills

Personal trainers must continue to develop their skills of exercise prescription, functional muscle training, postural assessment, and their repertoire of flexibility and fitness modalities. But there is a separate and different stream of knowledge which will up-skill them towards safer training of the injured client. It is a small movement towards the physiotherapy skill-set, but should not alarm physios who know what they are good at (see below ).

Remember that I am not addressing here those trainers who specialise in elite level sports, or those who undertake strength and conditioning work with the kinds of clients who are already reasonable athletes (with very good baselines of strength and coordination).

Rather, my concern is with general personal trainers running their businesses in gyms across the world – specifically they need more of the following skills in order to manage injuries:

* Greater competence and confidence in screening a client’s injury into ‘low injury risk’ or ‘high injury risk’ profiles (through specific questions and tests) for the purpose of knowing the priority and direction of referral.

* Greater knowledge of functional anatomy, injury/pain behaviour, and how patho-mechanics and bad technique create injury. All clinical therapists, from physiotherapists to Alexander technicians, chiropractors, massage therapists and osteopaths, must have some understanding of patho-mechanics, in order to re-educate and retrain clients successfully for long-term recovery. But what about the trainers on the front line? They, as much as any on the allied health spectrum, need a good grounding in how to pick up the often subtle indicators of poor muscle control.

* Enhanced analytical skills to detect poor or pathological movement patterns. While some trainers have a vague sense of this skill, the vast majority hardly even understand the concept, reflecting primarily the priorities of the institutions that educated them. Yet this is the critical observational skill-set, which will ensure that a personal trainer isn’t training their client towards an injury. Without it, they cannot meaningfully contribute to the rehabilitative process of any overuse injury.

* New training principles that are safe and effective in the context of injury. These would emphasise quality of movement for an injured body part as well as performance enhancement.

* How to use these principles (with support from a physiotherapist) to design customised rehab strategies and exercises using equipment readily available in the gym.

Setting clear boundaries

It is paramount that trainers clearly understand the limits of their role and professional abilities. Their credibility and their clients’ wellbeing depend on it.

This is crucial to my belief in the upskilling of trainers. Personal trainers need to know confidently which injuries to refer on (call them ‘high risk profile’ if you like), namely those that should be primarily managed by a physio or other allied health professionals. The rest can be termed ‘low risk profile’ injuries, and while often needing some referral and allied health support, would be primarily managed by the trainer through to an optimal state.

My views are pretty clear on this: unless a personal trainer has achieved certain higher levels of Chek certification, or done other postgraduate courses that qualify them to do so (and these need to be scrutinised very carefully), they should not be dabbling at all in ‘diagnostics’ or tonic/postural muscle activation for injured body parts.

Any seasoned clinician will appreciate the depth of knowledge and experience that a physiotherapist must acquire to be successful in diagnosing a labral tear or re-educating a dysfunctional transversus abdominis muscle. So these skills should remain the sole domain of the physiotherapist (as well as the litany of treatment modalities useful in promoting healing around a pathological structure).

Threats

For trainers, the problem of injury is not just about improving their own education and their clients’ standard of service; it runs a lot deeper.

In the short term, the biggest concern is the alarmingly high rate of fallout of trainers from the industry. In the Australian context, two leading industry professionals have confirmed for me the same drop-out figure of about 60% within the first 18 months of qualification. Remarkably, this is occurring at a time when demand for personal trainers is hugely outstripping supply, and even relatively inexperienced trainers can make a good living from the job. We need research into why these drop-out rates are so high, but there is every possibility that a few too many injured clients not showing up for training gradually takes its toll.

In the medium term, litigation is on the increase. It is not hard to see how a personal trainer who is careless or unaware can suddenly find themselves having to consult a lawyer for defence against an injured client. Yet there is no doubt that much training work still focuses on pushing through ‘the pain barrier’ to get results. Few trainers would be able to mount a credible defence using that approach these days. Moreover, the wider health profession will never contemplate making formal referrals or treating as partners an industry that cannot defend its basic professional competence against legal challenge.

In the long term, the worst case scenario is that the very viability of the personal training industry may be at stake. Gyms and trainers are riding a great wave of public approval and enthusiasm in Australia at the moment, as people chase lifestyle and health improvements. But a spate of high-profile injuries could very quickly shift the public mood. A backlash would inevitably cause a drop-off in client numbers for personal trainers and leave a wonderful industry struggling to recover from mass public scepticism.

Sports injury physiotherapy

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