The push towards assessment and corrective exercise is rampant in the training industry. And you know what?
- Most trainers assessing are improperly diagnosing issues.
- Most trainers prescribing corrective exercises don't know enough about what they are correcting to know what exercise to prescribe.
It is irresponsible for you to tell your client that complains of pain that they have X issue, Y impingement, or Z-itis. It's not your job to know about these things; there are professionals who do years of advanced education that specialize in diagnosing and treating movement malfunctions and injuries.
Even then, many physical therapists will tell you that they don't assess correctly 100% of the time. Seeing as how they have at least four more years of specific schooling than most trainers, you are not in the position to diagnose your client because you took a weekend course. (Even if you took the level 2 later on that year.)
This article is a dual effort between my friend Mike Reinold and I. Mike is a top physical therapist having published 50+ journal articles, books, and a prominent website. He has worked with the Boston Red Sox and is currently in private practice in Boston, MA.
Increasingly, trainers are infringing on the roles of the physical therapists. After speaking about the issue, Mike and I decided to write this article to draw the lines so that trainers know how they can provide the best service for their clients. Also, we both feel strongly that there is a great opportunity to collaborate with one another.
We have broken up this piece into two sections. In my section, I speak about the trainers role as I see it. In Mike's, he discusses what physical therapists do and how trainers can best work alongside them to get their clients the best results and encourage cross-referrals.
Enjoy.
-Jon
The Trainers Role - Jonathan Goodman
The Assessment
I don't believe that trainers should be doing assessments for the sole reason that they are rarely done well. I think it's irresponsible and sometimes even edging on malpractice when I hear about the assessments that occur in most gyms across North America.
A weekend or even week long course is not enough for us to tell our client that they are dysfunctional"”and it's definitely not enough for us to tell our client that they have an imbalance that needs corrective exercise. In full disclosure I used to diagnose clients without really knowing what was going on. I had an educated guess, but didn't really know. As I evolved as a trainer, I become more comfortable in saying, "I don't know, but I know who does".
I believe that a trainer's role when it comes to assessment is similar to a general physician. It's our responsibility to educate ourselves enough to be able to identify a problem and know what expert to refer out to.
You may argue that an assessment creates a baseline for measurement and improvement. To this I ask you, what are you measuring? And does it really matter?
Nobody comes into a gym saying that they want to improve their straight leg raise or inline lunge. They might say that they want to improve their posture, but more often than not they don't really know why. They probably believe that an improved posture will reduce pain, which may or may not be true. Point is, posture improvement isn't the goal, pain reduction is"”so you should be measuring and tracking pain, not posture.
Personal training comes with a lot of important responsibilities. We're in charge of our clients well-being, and a lot of the time their health is completely in our hands. If we say that getting an extra two points on an assessment will make them feel better, they will believe it and make it their goal. But don't be confused; their goal is to feel better, not to score a 17. You've just arbitrarily convinced them that, once they achieve a better score, they will feel better.
My assessment was to have the client fill out a medical history questionnaire and get clearance if necessary. If there were no red flags, I watched them move without weights"”squat, deadlift, push, pull, and anything specific they may do for work"”and see whether anything jumps out at me as abnormal. After each "test" I'll ask them if there's any pain.
We Need to be Focusing on Performance
99% of the times, clients want to look better naked and to not be in pain. This is your job and this is your responsibility. If a client can do all of the major movements without pain and with adequate form (keep in mind that regressions may be necessary) then your job is to get them to perform, lose weight, or gain muscle.
If you feel that a client has a movement dysfunction or is in pain, refer them to a professional who specializes in dealing with that. As Mike will talk about in a minute, referring to a physical therapist doesn't mean that you stop training the client for that period of time. With good communication, the clients will be best served working with both of you at the same time working within your professional capacities.
The Physical Therapists Role - Mike Reinold
As a physical therapist, I'll be one of the first people to admit that I truly feel that I have become a better therapist by learning from and collaborating with many great personal trainers and strength coaches. I say that because I fear that there are some physical therapists that do not feel this way. Maybe it is ego, or stubbornness, or maybe even a perceived turf war, but I'm not sure why every therapist doesn't feel the way I do.
In fact, I'm sitting at my desk and looking at all the books, journals, and DVDs that I have in my bookcase. For every physical therapy based resource, I have another that is fitness based.
We are all technically in the same field. Sure, I perform physical therapy and you perform personal training. That is our respective "products" that we provide. However, we both provide the same "commodity" to the general public - we help people attain optimal health and function.
In the broad spectrum of care, I see it as helping people "feel better, move better, and perform better." While I think both physical therapists and personal trainers can help people achieve all three of those goals, there is no doubt in my mind that collaborating will surely provide the best service to our clients.
And isn't that what it is all really about? Helping our clients?
As a physical therapist, I combine my knowledge of anatomy, biomechanics, and injury pathomechanics to properly evaluate and treat injuries and dysfunction. I say "injuries and dysfunction" because I think a common misconception is that you need to either have a blow-out injury or surgery to see a physical therapist. This is not true at all. In fact, physical therapists excel at evaluating, identifying, and correcting dysfunction that can prevent injuries as much as rehabilitate injuries.
Think about the sports medicine model in professional sports today. Gone are the days of retrospective care of injuries. Medical departments in the sports world now consist of a team of multidisciplined physicians, athletic trainers, physical therapists, strength coaches, massage therapists, and other health care professionals. Developing this model is one of the accomplishments I am most proud of in my past experiences working in professional sports.
If the professional sports teams have this model, why don't we?
The majority of people that a personal trainer may encounter could be excellent candidates for physical therapy. But when would I recommend a personal trainer referring a client to a physical therapist? In effort to simply, let's say there are two candidates:
1. Anyone in pain. This doesn't just apply to that new client you just started working with that stated they wanted to exercise again because they have knee or low back pain. That is the obvious physical therapy candidate. This also applies to someone that doesn't have an injury but may experience pain during certain movements or exercises. As a personal trainer, you have two options - work around the pain or refer to a physical therapist for help. Take a step back and think about what is in your client's best interest.
2. Anyone that moves poorly. I know this is a pretty broad statement. I am all for the current trends in personal training to assess movement and develop an individualized program for someone. This may be appropriate for many clients, however the client that doesn't respond to corrective exercise strategies and improve their movement patterns is a perfect candidate for physical therapy. Otherwise, you risk putting strength on top of dysfunction, which often times leads to muscle imbalances, compensatory movement patterns, and eventual injury. Have you ever had that client that just seems to always tweak their back when they start to make strength gains?
Many times, corrective exercises are ineffective because the dysfunction requires a combination of manual therapy and corrective exercise. Many of the common assessment tools that are in place in the personal training world make a great attempt at trying to provide a template to add corrective exercises to a program. This is great, and surely better than nothing, however, we all know that not many people fit into a template.
Referring a client to physical therapy doesn't always mean that you have to stop training your client, either. This is just another example of why collaborating is always best. Rather than stopping the client's workouts, personal trainers and physical therapists can work in tandem to best address the client's needs. I often work side by side with personal trainers collaborating on clients. I handle the dysfunction, they work around it for awhile, then as the client improves, they are ready to roll full steam ahead.
It really is all about collaboration and putting our strengths together. Each time I personally collaborate, I learn something, and that makes me better at what I do. Why do you think Jon and I are collaborating on this article?
To quote Charles Darwin, "Those who learned to collaborate and improvise most effectively have prevailed." As we all continue our own evolution, both as individuals and as a profession as a whole, those that avoid collaboration will not prosper as much as those that do.
Communication
One of the keys to making all of this work is great two-way communication. As a physical therapist, you referring me a patient is no different than a physician. My level of communication to you should be the same as it would be to a doctor. I love to keep personal trainers in the loop with my findings and game plan because I know it will enhance your approach with that client as well.
The reverse is also true. In all honesty, if you have been training a client for a long duration, you probably know more about the client than they do themselves. That is valuable information for me. I want to be armed with every bit of info that I can before I see your client so I can address their goals as best as possible.
For the physical therapists that may be reading this -- pay attention! Find a few personal trainers in your area and get to know them, learn from them, and start to work together. It will be a rewarding experience, I promise.
If you are a personal trainer and do not feel that the physical therapist you send clients to is involving your or respecting your experience, move on. Find a better therapist, they are out there and your clients will thank you.
Here is a partial list of things I would love to know when a personal trainer is referring me a patient:
- What is the client's chief complaint? Is it pain? Dysfunction?
- What do you think is the reason for the chief complaint?
- How long have they had this dysfunction? How did it begin? Was it insidious or was there a mechanism of injury?
- How long has the client been training with you? What are their goals with you (weight loss, strength, performance, etc)?
- How advanced have their fitness level and programs been?
- What other functional limitations have you noticed, even if they seem unrelated to the chief complaint (they may be related!)?
If you have taken any objective measurements or performed any screens, like the FMS, I would love to know this information as well. Systemized screens are great ways for multidisciplined professionals to communicate in a standardized format.
When the Lines Are Clear, We All Benefit - Jonathan Goodman and Mike Reinold
Play to your strengths, and know when to play to others. Physical therapists like Mike are trained in improving movement and reducing pain. Trainers, even those with a degree in exercise science, don't have the requisite schooling and experience to correct movement patterns. Our job is to take pain free clients and provide a service; usually this service is fat loss or muscle gain.
When we identify the boundaries and work together:
- You benefit because you get a relationship with the physical therapist for referrals.
- The physical therapist benefits because they get more work.
- And most of all, the client benefits because they get the best service for them.
I want to take a minute and thank Mike for contributing his time on this piece. His bio is below:
Michael M. Reinold, PT, DPT, SCS, ATC, CSCS is considered a leader in the field of sports medicine, rehabilitation, and performance enhancement. As a physical therapist, athletic trainer, and certified strength and conditioning specialist, Mike uses his background in sport biomechanics, movement quality, and muscles imbalances to specialize in all aspects of human performance. He has worked extensively with a variety of professional athletes with emphasis on the care of throwing injuries in baseball players.
