Why should you, as a trainer, use the clinical approach to evaluate your patient?
MAI-LINH DOVAN M. Sc., CAT(C)
Original article available here
As most of you probably know by now, I come from a rehab background. I studied Athletic Therapy at Concordia University in Montreal. Although I did do quite a bit of clinical work with athletes as well as with the general population, I was always more of a gym rat. One thing I have always been good at is assimilating information and figuring out how I can apply it to suit my needs. After all, tools are useful but methods are indispensable, and in my opinion, it’s actually the application that serves the tools best.
In my own practice, I have always tried to incorporate what I could from the clinical aspect. Note that I am in no way implying that you should assume a role that is clinical per se. What I mean is that there are foundational concepts of clinical assessment and intervention that can translate quite well to the trainer’s approach. Ultimately, this is what we all (should) want: to grow and fine-tune our practice so that we can provide clients with the best of ourselves. And I say: “the best of ourselves” because I think it is important to recognize that nor we, nor our own approach, will meet all client needs. For more on this, click on this link: De-Narcissize your Practice article.
IMPORTANT NOTE: Remember to refer out if you are dealing with something outside of your scope of practice. As a trainer, you are a movement specialist, not a clinician. I am simply saying that there are clinical concepts that you can apply to your approach while remaining WITHIN your scope of practice.
Here are 3 fairly general rehabilitation concepts that you can apply/adapt to your practice:
With the exception of an acute traumatic injury, the area of complaint is often not the area where dysfunction originates, but the area where dysfunction has caused a breakdown. As a simple example, think of shoulder pain, which is not always due to dysfunction of the shoulder (ie. glenohumeral) joint itself.
In a clinical setting, we are taught to clear the joint above and below the area of complaint. If these joints are symptom-free, we can be more confident that we are actually narrowing in on the right area. (I’ve simplified the concept, but you get the drift).
As an adaptation to an in-gym practice, think more region(s) above and region(s) below, because while the clinical practice can be quite local, you will likely need a more exhaustive approach when working in a coach/trainer function.
Let’s take our simple shoulder example to make this clearer from a practical standpoint:
Scenario: Client presents with limited ROM in overhead movements, currently symptom-free.
Region “below” – Clear the T-spine: is there excessive kyphosis? This may disrupt scapular function and limit overhead ROM. Clear the hips: Is there a posterior pelvic tilt? If so, external obliques and rectus abdominis may be facilitated and concentrically oriented and cause the spine to flex slightly and up the kinetic chain that goes!
Region “above” – Clear the scapulothoracic joint: Can they access and control scapular retraction? Inability to retract the scapula without upper trapezius substitution (shrugging the shoulders) is typically an indication of sub-optimal scapular function. An improperly positioned scapula may lead to altered shoulder ROM. Clear the cervical spine: Does the head protrude forward? The deep cervical flexors tend to be weak and I have found that exercises that target these, and in turn release the extensors, also tend to relieve the upper traps and down the kinetic chain that goes!
Isometrics are a fantastic tool, and not just for rehab. Christian Thibaudeau has written great work the use of isometrics as an efficient tool for increasing muscle mass and building strength. The use of isometrics as a corrective tool to strengthen weaknesses at specific portions of a lift is common place. Even further, using them to strengthen various points throughout the range of motion is an excellent injury prevention strategy.
What’s more, slow affords thinking time. You think better when you’re not moving. Don’t you slow down when you text while walking? (In most instances, you do, my Masters’ literature review was on this very topic…). So, it’s no surprise that isometrics trigger efficient results, as they produce a better mind-muscle connection.
In the clinical setting, we often use isometrics in the early stages of rehabilitation when we have reason to limit movement at the joint, but want to maintain muscular activity. This can translate directly into a training scenario:
Client presents with non-specific LBP exacerbated by repetitive forward flexion. Do they need to “take time off until the episode subsides”? Tell me you answered NO. Using isometrics will limit trunk movement and typically also break the pain-spasm cycle, so they will LOSE LESS MOVEMENT over time. Remember that mobilisation is key to limiting loss of function, you just need to know how to adapt to temporary limitations. There are so many isometric variations to choose from: isometric lunges, glute bridge holds, plank and side planks, chair, and here’s one I really like, the modified Copenhagen hip adduction exercise:
Simple, yet effective!
“It takes 500 hours to invoke a motor pattern before it becomes unconscious. It takes 25-30 thousand reps to break a bad motor pattern.” – Buddy Morris
As trainers, we’re not strangers to frequency. Remember learning the FITT principle?! LOL… But seriously, we know that if a stressor is applied frequently enough (the stressor in question being training where we’re concerned), the body will be forced to adapt. This is Hans Seyle’s general adaptation syndrome.
Practice is essential for learning to take place, and typically, frequent short periods of practice will yield more learning than longer, less frequent sessions. So if you’re trying to “fix” something, it’s not enough for a client to see you once, twice, or even 3 times per week one on one. If you want to generate an adaptation, frequency is key, otherwise, you’re just generating a response, and a response is but a temporary change. In simple (almost layman’s) terms, if they’re “tight” here, if they’re “weak” here, if they’re “disconnected” here, they need to be hitting whatever correctives you’re giving them to target these dysfunctions EVERY DAY. Low threshold, re-patterning, muscle connection, mobilisation, activation…that stuff needs to be done AT LEAST as often as whatever it is they are doing that has led to dysfunction, and typically, that’s potentially what they are doing every waking hour of their day.
So 1) make clients accountable and 2) give them homework.
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