Post Rehabilitation Training Series
Article 1: How injuries occur and Rehab Triangle

By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, C-IASTM

Introduction

The human body is a complex machine that consists of multiple parts engineered to work
and function synergistically. At the helm is the central and peripheral nervous system, which directs traffic in a sense, choreographing gross and precise movements of the musculoskeletal system. The degree of injury that someone sustains is dependent upon the magnitude, duration, and velocity of force-applied force to the body and underlying tissues involved. During an examination of a physical therapy patient, the mechanism of injury (MOI) is one of the most important pieces of information that a physical therapist acquires during the history taking. The mechanism gives the clinician a very strong indication of what tissues and structures may have been injured, how the injuries occurred and the potential severity of these injuries (Macgee et al 2007).

This information assists the physical therapist in treating all musculoskeletal injuries and movement dysfunctions. So how does all of this pertain to the 21^st century fitness professional? The human body breaks down because of injuries, surgeries and movement dysfunctions. Do you understand common injuries, post rehabilitation training, and program design to work with these types of clients? These series of three articles will the foundation science, functional assessments and application science of evidenced based movement science. This will help you, the fitness professional understand that having sound information in foundation science, will help your knowledge and understanding of helping all clients.

How common dysfunctions develop

There are several reasons a dysfunction (pathology) develops. It is important for the personal trainer to thoroughly understand all potential causes of how a dysfunction develops. Familiarizing yourself with these different causes will not only strengthen your knowledge and understanding to help the client, but will also assist in the communicating with other health care professionals as part of the Rehab Triangle. The rehab triangle is the communication between the client, personal trainer and physical therapist.

Do not diagnose or try and ‘figure’ out a client’s problem. If you have a client who has an injury or recently injured  himself or herself, the most prudent thing you can do is to refer to either a physician or physical therapist for help. A fitness professional is not a licensed professional, nor has the same educational level, clinical experience and rigorous training as a physical therapist does. It is important to know your boundaries and operate within it.

Listed below are several common causes on how dysfunctions develop:

1.  Degeneration due to overuse: Degeneration is simply defined as thinning of a tendon

due to micro tears or in essence or the breaking down of  a joint surface.  For example, a

postal worker who repeatedly uses one arm to file mail to one side for many months or even

longer, all of a sudden feel a  twinge in their medial deltoid for no reason. Another example

is a farmer who for years lifted hay a certain way and then starts to experience shoulder pain.                         

Both of these scenarios are examples of strain to a tendon (in this example, most commonly

the supraspinatus). Which most likely is tendonitis and if ignored, eventually progresses to

a tendinopathy.

2. Injury or trauma: There are several mechanisms or causes where tissue can be injured.
Someone who falls from a ladder will have a greater magnitude of force applied to the body, than someone who misjudges a step and falls. The forces can result in tissue overload that result from acceleration or deceleration injuries (i.e. sprains and strains), repetitive stress or overuse (i.e. repetitive stress injury),  compression or crushing (i.e. contusions) or transections (lacerations or surgical incisions). In addition, both static and dynamic movements (i.e. walking, sit to stand, etc.) made by the patient, provide the clinician with insight into the irritability and severity of the injury (Macgee et al 2007).

3. Surgery:

Like cars, Individuals down over time. Clinically, arthritis is common in both men and women, but tends to be more prevalent among those who work as tradesman, carpenters, plumbers, mechanics and similar fields. In these positions, individuals are consistently loading their spine, hips and knees. Whether someone is installing, building, or fixing,  the body receives compressive loads (forces) that stress the joint and surrounding tissues. Over time causes muscles to tighten, joint to break down, and eventually leading the onset of arthritis. The severity of the arthritis is diagnosed by an x-ray. Therefore, an individual’s type of work, lifestyle, injury(s) or all impact one’s daily function.

4. Sedentarism: Research is staggering about the United States and how obese we have become. In the next 2-5 years, the United States will lead the world as the most obese country. The consumption of a diet high in calories consisting of both fats and sugars, and lack of exercise

compounds this problem. This scenario stresses multiple systems such as the cardiovascular, musculoskeletal, neurologic systems. For example, there is a well established body of literature highlighting the relationship between lack of regular physical activity and hypokinetic diseases such as diabetes mellitus, cardiovascular disease and may also predispose and predisposing this individual to diabetes, early osteoarthritis to name a few. It is vital to educate your clients and their children about the importance of a healthy active lifestyle.

5. Systemic pain: Besides those mentioned above, another source of pain is know as “referred” pain. There are three sources of pain that someone may experience. The first is cutaneous pain  (related to the skin). Another is deep somatic pain, which is pain related to the wall of the  body. Lastly, visceral pain, is pain that includes all body organs of the respiratory, digestive, urogenital, endocrine, spleen, heart, etc. Pain is not well localized because innervation of the viscera which is connected via nerve endings.

Various organs such as gallbladder, spleen, appendix and others, have been shown by research to have distinct referral pain patterns. Listed below are some referral pain patterns for your review. However, as stated earlier, you as a fitness professional are not qualified, legally allowed or entitled to make a diagnose. Familiarizing yourself with this knowledge will help you become a better fitness expert, not a physical therapist or physician. When in doubt refer to a qualified heath provider.

Local and referred pain patterns systemic in nature(see below)

•          Gallbladder: Pain that is referred below the right pectoral region/right sub scapular area.

•          Spleen: Pain that is referred to left upper quadrant/shoulder pain.

•          Appendix: Pain that is referred to right lower quadrant along the right inner groin area.

•          Possible MI (myocardial infarction): Chest pain over left pectoral, left inner arm pain

and possible jaw pain. Pain is described as “elephant is sitting on my chest, or“heaviness.” Chest pain can also radiate to the right arm, neck and jaw and may not be reproducible.  Chest pain that resolves with rest immediately after activity should be assessed by a physician.

6. Repetitive stress injury (RSI): are injuries to the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression, or sustained or awkward positions(www.osha.gov). Injuries come in all shapes and sizes, like computers, bicycles or house. Injuries are classified as either acute (0-7 days), subacute (7-21 days), or chronic (21 days post injury or surgery).

Rehab Triangle

Communication

The rehabilitation triangle is the synergistic connection between the client, personal trainer, and physical therapist (PT) I firmly believe that this relationship pseudo exists presently, however, should be more

pronounced. When evaluating a new patient for the first time, PTs are legally by insurance and Medicare standards, are required to contact and send a plan of care to a physician. This not only educates the physician with the thoughts’ of the PT, but how the PT will help the patient and why skilled

physical therapy is needed.  
                 Client 

Physical Therapist            Personal Trainer

A personal trainer and those with advanced training such as a Certified Post Rehabilitation Specialist are not  legally required to do something similar. However, if you receive a new client that comes from a physical therapist, professionally, contact the physical therapist and thank them! Why? Because no one is entitled to anything. If a physical therapist provides a thorough evaluation, personalized treatment that is evidenced  based, accompanied with great customer service, and listens to the patient, what will happen? That patient is going to tell other patients and most likely the physician. This is the cornerstone of word of mouth advertising.

Building relationships

Building relationships with allied health professionals such as physical therapists, massage therapists, chiropractors, physicians, and others is fundamental. This should be the cornerstone of marketing who you are, and how you can help their patients as the fitness professional. A strong referral network, provides greater exposure of your training services, branding and most importantly, how you can help clients achieve their fitness goals.

Marketing

According to the American Marketing Association, Marketing is the processes of creating, communicating, delivering, and exchanging offerings that have value for customers and clients. In other words, marketing is about satisfying the needs and wants of users or customers in a superior way than competitors.

The marketing mix (the 4 Ps)
Within marketing, there are four Ps, often referred to as the marketing mix The traditional marketing mix refers to four broad levels of marketing decision, namely: product, price, place and promotion.

1. Product

·         The product is something that is viewed as capable of satisfying a need or want. In

       other words, it is a bundle of positive attributes that a customer receives. I.e. Personal

       Training Services.

2. Price

·         This refers to the process of setting a price for a product, including discounts. The price is the cost that a consumer pays for a product--monetary or not.  I.e. Cost of a group or training sessions vs. the cost of one training session.

3. Place

·         This refers to how the product gets to the customer; the distribution channels used

such as wholesalers and retailers.  Helping customers to access products or services in a convenient manner. I.e. Conducting training at a gym or health club vs. at a clients home.

4. Promotion

·         This includes all traditional aspects of marketing communications; advertising, sales promotion

       including promotional avenues(print, radio, television) public relations, personal selling, product

       placement, branded entertainment, event marketing, trade shows and exhibitions.

Direct vs. Indirect Marketing
Direct marketing: Direct marketing think of it as an attempt to ask a customer to buy. Examples of direct marketing can be:

–Contacting physical therapists, physicians, chiropractors, massage therapists informing  
   them about who you are, and how you can help their patients. Be specific.
– In-person sales calls
– Print, radio or television advertisements
– Telephone sales calls
– Email advertisement campaigns
– Direct mail flyer or sales letters
– Promotedor paid advertising on social media(Facebook, LinkedIn, Instagram, Twitter)
– Creating videos about you, client testimonials using YouTube and other video platforms,
    and placing these on your website.
– A website informs potential clients about your educational background, qualifications,   
   experiences and skillset.

Indirect marketing: Is an approach to grow customer loyalty. Indirect marketing can be found in many forms:

– Offering an in-house presentation on a specific topic you are going to teach. Inviting
 members and outside members charging a nominal fee.
–Ne articles and press
– Useful blog posts
– Social media fan pages
– Product placements
– Word-of-mouth
– Referrals
– Online reviews

Summary:
Injuries are inevitable.  It is paramount to ensure that fitness professionals are qualified, skilled and representing themselves as professionals in this industry. The landscape of providing fitness services is changing drastically. The avenues for marketing and providing services have never been more robust and the ability to reach many markets is rapidly expanding with advancing technology.

A fitness professional who takes the time to advance their skill set with continued education or by obtaining specialty certifications, who develops professional relationships and delivers quality services informs prospect consumers and other professionals (e.g., physicians, PT, chiropractors) of their level of dedication, training and service quality. This, coupled with leveraging the marketing strategies described above, will help you experience success in this industry.

REFERENCES

Magee, D, et al, 2007, Scientific Foundations and Principles of Practice in Musculoskeletal Rehabilitation, Saunders, pp. 5-10, 25-32.