// Perfect Practice: Personal training people in pain

by Lisa Champion and Anna-Louise Bouvier

In an ideal world, personal trainers wouldn’t have to work with clients in pain. In reality, this rarely occurs.

Clients often come to us with a host of ailments. As personal trainers, we need tools to understand what we can and can’t do for these clients. We must first understand and respect professional boundaries. Thinking trainers then need a structure for assessing clients with pain issues that will be the first building block for great programming.

Finally, they need to think outside the square of traditional exercise prescription models and train clients with new tools to help them overcome pain.

In this article, we take a close look at the elements of professional boundaries and the detective work involved in a good assessment. Next issue, we’ll apply what we’ve learned to some real personal training situations and see how different a personal training session for a client with pain can look!

Respecting professional boundaries

In order to begin training a client with pain issues you must ensure they have been properly diagnosed by a medical practitioner. As a fitness professional, you are not qualified to diagnose and this is where having excellent links with physios and medicos (preferably with strong sports medicine knowledge) will be imperative to the professionalism of your work. The first question you should ask is; ‘have you had a medical diagnosis?’ If they have not seen a medical practitioner, and are unsure of who to see, then you should have the business cards of the professionals you recommend on hand to refer them on.

Medical professionals use the term ‘pathology’ to refer to the origin, nature and course of diseases. Having your client get a proper diagnosis means that you can rule out ‘pathology’ as a cause of their pain. This allows you to then work on the muscular and mechanical elements that may be contributing.

In some cases, clients who have pathology can still benefit from carefully selected exercises. However this must involve collaboration between you and the diagnosing practitioner.

If you do not currently have good relationships with practitioners you can refer to, then work on developing them. Introduce yourself to local physios and medicos who you would like to work with. Offer to give them a few free training sessions so they can get to know you and your work. Have professional business cards and flyers that you can leave with them. Consider having a ‘medical professional’ open day or cocktail party at your centre or studio. If you do refer a client, make sure to write a referral letter explaining what you have done with the client to date and asking for their professional advice as to what should occur next. You will find that this ground work opens up new avenues of communication that will be of great benefit.

Once it is established that your client is free of any sinister pathology you can get to work on helping them overcome pain through exercise. As a personal trainer, you are qualified to teach four of the most important elements that will benefit clients in pain; postural awareness, breathing techniques, specific stretching and strengthening techniques and new daily living strategies.

Trainers who work with people in pain also need the special qualities of being patient, sympathetic and understanding. It is also helpful to have lateral thinking skills to determine what types of exercises would best help clients.

The assessment process

The key to working out which strategies will best help your client with pain is to start with a comprehensive assessment.

The assessment process that we outline here is based on the process that Anna-Louise has developed over many years for her innovative physiotherapy practice called Physiocise (www.physiocise.com.au). In the ten years that Physiocise has been in operation she and her team have assessed thousands of people with pain. As personal trainers we can learn a huge amount from this vast experience.

The first part of the assessment should include the standard health/medical questions. Make sure to cover the elements of cardiovascular risk factors such as heart health, family history, blood pressure, and blood lipids, whether they are taking any prescription or non-prescription medications, if they have diabetes (or a family history of), whether they are on any special diet, whether they smoke and the level of their alcohol use. You then move on to the pain and injury assessment.

Here, you work from the head down asking your client if they have had any pain or injury to the head, neck, shoulders, back, hips, knees, ankles, or feet. This can take some time as you will need to discuss each area where they have had pain. Understanding their pain history can often unlock secrets as to how their body is operating. For example, someone who has had a knee injury that has resulted in a limp can end up with hip or back pain from compensating. It’s essential to review the whole body, not just the area where they are currently hurting.

Your detective work continues as you move on to the accident assessment. Here you simply ask the client if they have had any major accidents in their lifetime. Accidents can leave lasting marks on even the fittest of bodies and again, can lead to compensation patterns that contribute to pain. You then ascertain what types of exercise they are currently doing and the strength of their exercise history.

Here, you can find out all types of interesting factors that may be contributing to their pain. A client with back pain may have switched to a swimming program, but not have the core control to maintain good alignment in the pool.

Someone who has a very strong exercise history and is very good at stiffening and tightening their global muscle system may face greater challenges re-imprinting good low-level control as a foundation for their movement habits.

The next assessment step is the 1-2-3-4 Core Assessment.

In the two part ‘Cutting edge core control‘ article that was featured earlier this year (Winter 2006), we talked about the importance of assessing whether your client is likely to have a ‘core crash.’ The core or LMS (local muscle system) in the body is made up of four parts – the lid, the walls, the spine and the floor. Any factor that affects any part of the core will compromise its integrity and contribute to a possible ‘crash’.

Crashes lead to pain as the LMS loses integrity and the GMS (global muscle system) takes over to try to compensate.

Global muscles working overtime tend to tighten and spasm – a leading contributor to pain.

So you need to ask your client if they have any elements that could be affecting the integrity of their LMS. Here are the four parts of the LMS broken down and a list of the factors which can affect each.

How do you use the 1-2-3-4 Core assessment?

Give your client one point for each area of the core that is compromised. The higher their score out of four, the more likely they will have difficulty ‘switching their core on’. When this is the case, you will have to work on low-grade core control to establish a better brain connection with their LMS.

The assessment process continues with a look into your client’s pre-morbid ligament laxity. You are trying to determine where your client is on the scale between floppy and stiff. Importantly, the questions here relate to what they were like as a child, as often people who are high on the floppy scale stiffen up over time.

Ask your client five simple questions:

• Were you considered quite flexible as a child?
• Could you do the splits as a child?
• Could you do back bends?
• Have you ever been told you were double jointed?
• Do your joints click a lot?

The more questions your client says yes to, the higher they are on the ‘floppy’ scale (see the ‘Cutting edge core control’ article if you need a review of this important concept). Understanding where your client with pain is on this scale will determine what your training sessions look like.

As a general rule of thumb:

• Floppies need CONTROL and STABILITY
• Stretch floppies STRATEGICALLY as over-stretching will de-stabilise them
• Flippies and stiffies may need CONTROL work, but also need STRETCHING to help them find better range.

Next you assess your client’s posture. The postural assessment does not have to be complicated. Simply have a look at whether your client is more of a slumper or a swayback and then assess which leg they like to stand on all the time (we call this the sideways curve). For simplicity’s sake, we use the relationship between the pubic bone and the centre of the sternum to assess posture.

Slumpers end up with their pubic bone in front of their sternum (photo 1). The pubic bone of swaybacks sits behind the centre of their sternum (photo 2). Sideways curvers will tend to stand on the same leg all the time and can normally identify quite easily which is ‘their side’. The model in (photo 3) is a right sideways curver as he stands on his left leg with his right leg bent.

What can you learn from the postural assessment? Heaps!

The postural habits of your client will often be one of the most important clues as to why they have developed pain. Standing and sitting with poor posture all day everyday wreaks havoc with our GMS as muscles fight to maintain some semblance of uprightness. This causes an ‘override’ of the LMS and the GMS works overtime doing a job it wasn’t designed to do. The work of two prominent physiotherapy researchers Dr Peter O’Sullivan and Dr Garry Allison has shown that when the spine is aligned, the LMS is on. This is a simple statement, but very important. As you’ll discover in Part 2 of this article, retraining postural awareness is one of the most important steps in helping people overcome pain.

The final step in the assessment is to do three small tests.

The first is a stability assessment (photo 4).

Have your client sit on a massage table, high stool or table so that their legs do not touch the ground. Ask them to cross their arms, placing their hands on their shoulders. Then, ask them to slowly lift one knee. Watch for any compensations they may have.

Did they lean to one side, did their hips change position, did their upper body move? Repeat to the other side.

The more compensation patterns you see, the less low level core control your client has. It’s important to remember that you can only do this assessment once! Once they know what you are looking for, sporty people who like a goal will stiffen and tighten to try and do it better, which is cheating!

Next, you’ll need to assess if your client is able to maintain a balanced spine position during 300 of forward flexion. To perform this test, place one hand on your client’s abdomen and the other on their back. Ask them to bend forward about 300 and feel whether they can maintain perfect spinal alignment while moving both forward and back to upright.

What are you looking for? Slumpers will often find it very difficult to not ‘slump’ into forward flexion, while swaybacks will tend to ‘stick their butt out’ as they go down and then use an extensor pattern to bring them back up to standing. If your client has difficulty maintaining a neutral spine in this simple exercise, then you can be sure they are using a host of compensation patterns as they move about during the day and, most certainly, when they are exercising.

The final step in the assessment is to look at gluteal activation. Start by assessing whether they are able to activate gluteus maximus (one side at a time) in the ‘Lancelot’ position. Have them kneel down in a 900/900 position as if they are about to be knighted (photo 5).

With their left leg forward, have them imagine they are moving their pubic bone toward their nose by firing their right gluteus maximus – without any change in their spinal alignment. They must not lean back, slump, sway or push through their front leg. In order to feel how well they are able to activate, you’ll have to have your hand on their right buttock. Switch, and assess the other side.

What are you looking for? Often, due to the prevalence of sideways curving, one gluteal muscle will work better than the other. You’ll often find that they have no problems firing the glut on the side that they are used to standing on, but the other feels like a spark plug that has lost its spark. They just won’t be able to get a good, consistent fire out of it.

Imbalances between right and left sides can cause irregularity in the movement of the pelvis and set off a chain of compensation patterns in the body.

The other reason the gluts may not be working well is that your client may have developed a pattern of hamstring domination at the expense of glut activation. One of Sydney’s leading physiotherapy researchers, Dr Barbara Hungerford has shown through her work that people with back pain can develop ‘gluteal amnesia’ and lose the ability to use their gluts as primary movers, over-relying on the hamstrings instead. In Part 2 of this article, you’ll see the strategies we use to help overcome this pattern.

Last, but not least, have a look at how your client’s knees are tracking. Do their knees role in as they walk, lunge or squat? Do they stand with their toes excessively externally rotated? If so, you will have to work on their deeper gluteal muscles, gluteus medius and minumus. As a unit, these muscles are responsible for controlling both the ‘side to side’ movement of your pelvis and the rotation of your leg from the hip. Their role is to control the alignment of the leg relative to the pelvis. While walkingor runnning, they activate to keep your pelvis level and stable as you step onto your leg. If they are weak (‘inny knees’) or over-active (toes turned out) they could be contributing to pain and you’ll have to work with your client to bring them back into balance. Again, we’ll take a look at how to do this in Part 2.

So there you have it - a comprehensive assessment that will give you many clues as to why your client has pain issues. A thorough assessment like this will take between 1 ½ and 2 hours, so be sure to leave plenty of time to work through all the possible clues. Next issue we’ll look at a few case studies to see how you turn what you’ve learned into a personal training session with a difference!

PERFECT PRACTICE™ is based on the framework of the Physiocise program developed by Anna-Louise Bouvier. The terms ‘Floppy’, ‘Re-boot your core’, ‘1234 Core’ used in this article are copyrighted by Anna-Louise Bouvier and should be acknowledged as such, particularly in presentations and written materials. More information on the Physiocise program can be found in Fix Your Back by Anna-Louise Bouvier available from all ABC shops and centres, good book shops or online at www.abc.net.au


Lisa Champion, MSc (ExSc)
Lisa is a multi-talented exercise specialist. In her role as a director of the Australian Fitness Network, she has had a positive influence on the development of the fitness industry in Australia for nearly 20 years. Lisa has shared her expertise and knowledge as an instructor trainer, program developer, convention presenter and author. She works as a personal trainer, teaches pilates and children’s movement classes and inspires equestrian athletes through her book Riding from the Inside Out. With Anna-Louise she is the co-creator of the PERFECT PRACTICE(TM) training system.

Anna-Louise Bouvier, BAppSc (Physio)
Named Australian Fitness Network's 2004 Presenter of the Year, Anna-Louise is an accomplished author and creator of audio resources addressing back pain. The developer of a back specialist program called Physiocise, she runs a private physiotherapy practice and is an injury prevention consultant to the NSW Rugby Union team.