Chapter 21 Clients with Orthopedic, Injury and Rehabilitation Concerns NSCA’s Essentials

Introduction The personal training profession has been gaining more acceptance and with that it allows for more flexibility and opportunity in training individuals with injury orthopedic dysfunctions A personal trainer’s unique knowledge and experience provides a unique perspective to helping these types of clients

Introduction This chapter, while informative, is not to provide the reader with rehabilitation protocols or replace medical professional’s advice It is designed to explain the physiological events that accompany orthopedic-related injury and disease processes Ultimately it is information to be used in conjunction with healthcare/medical providers to facilitate communication

Injury Classification Several ways to classify injuries such as type of injury (sudden or gradual) and tissue damaged. Macrotrauma: sudden, specific episode of overload injury to a given tissue Microtrauma: overuse injury (over a long period of time), repeated stress on body…many overuse injuries are due to too little recovery time, poor technique, training surfaces, but not necessarily repeated physical activity.

Tissue Healing Following Injury General Phases of Tissue Healing Inflammation Phase During injury blood flow increases along with capillary permeability causing edema This also causes a decrease in joint mobility and tissue function Increased pain associated as well with increased nerve fiber stimulation

Tissue Healing Following Injury Inflammation Typically last two to three days following acute injury, but can last longer (5-7 days) Goal during this phase is to prepare for new tissue formation during subsequent phase of healing RICE (rest, ice compression and elevation) are primary treatment No exercise during inflammation phase

Tissue Healing Following Injury Repair Phase Three to five days following acute injury and may last 7 days up to two months Allows for replacement of tissues that are not viable following injury or surgery Damaged tissue is regenerated (scar tissue) and new capillaries and vessels form in the area and collagen fibers are randomly laid down for a framework.

Tissue Healing Following Injury Repair Phase Goals is to prevent excessive muscle atrophy and joint degeneration of injured area Also avoid disruption of newly formed collagen fibers Introduce low level stresses on the body Specific exercises should be used during repair phase only after consultation with client’s physician or physical therapist Isometric exercise allows strength gains to occur, but the intensity is low enough to not disrupt the collagen fibers.

Tissue Healing Following Injury Remodeling Phase Can last two to four months or ≥ 1 year Weakened tissue formed during repair phase is not becoming strengthened Collagen fiber production has significantly decreased Mainly work on increasing function and structure of area…optimizing tissue function Eventually add more stress on the injured area

Orthopedic Concerns and the Personal Trainer Personal trainers should have an awareness of different types of orthopedic injuries and types of exercise strategies for them Indication: activity that will benefit the client Contra-indication: an activity or practice that is inadvisable or prohibited because of given injury Precaution: an activity that may be performed under supervision of qualified personal trainers and according to client limitations and symptom reproduction. It is not your job to determine movement or exercise restrictions…rather it is to identify and abide by appropriate contraindications and precautions Must communicate with the client’s physical therapist or physician

Orthopedic Concerns and the Personal Trainer It is not feasible for a personal trainer to know all the injuries, but being familiar with general information is important See table 21.1 (pg. 537) for common injuries to muscles, tendons, bones and joints

Low Back Low back pain means a lot of things Disc dysfunction, muscle strain, lumbar spine stenosis, etc.) Different types are treated differently Aim of this section is to provide appropriate movements and understand inappropriate movements

Low Back Movement and Exercise Guidelines Hypomobility (tight muscle: stretch it) and hypermobility (weak muscle: strengthen it) are not uncommon. Balance work is recommended Responds well to stabilization exercise, posture corrections, and flexibility exercises. A proper flexibility and mobility assessment should be conducted. If the client has a considerable history of low back pain or a low back injury or experience an increase of symptoms, or if the personal trainer is unclear about the condition or status, a consult with the medical providers is warranted.

Low Back Lumbar Disc Injury When a lumbar disc herniates part of the nucleus pulposus makes its way through the outer annulus fibrosis, resulting in inflammation This irritation then irritates the spinal nerve roots Client may feel: Pain in back Lower extremity pain, abnormal sensation and weakness Excessive flexion may be a big contributor to this Seek treatment from a physician if this happens!

Low Back Movement and Exercise Guidelines (table 21.3, pg. 543) No lumbar flexion exercises Use extension exercises Resistance training contraindication are full sit ups Resistance training precautions include squatting, rowing movements and deadlift Aerobic exercise contraindications include bicycle riding (possible increased flexion with forward lean) Contraindicated flexibility include hamstring stretches (lumbar flexion) Precautions for stretching include gluteal, hip adductor and upper back stretches

Muscle Strain Tears to muscle fibers An overuse muscle strain may require client to improve proper posture and movement patterns Retraining muscles to function in their intended manner will enable them to work more efficiently, thereby decreasing the abnormal stress the affected muscles experience.

Movement Exercise Guidelines Restrictions highly dependent on the muscle that is strained Once therapist or physician have pinpointed muscle that has been strained then one should avoid all exercises that rely on that area

Spondylolysis and Spondylolisthesis Spondylolysis: defect or fracture in the lumbar vertebrae (pars interarticularis region) Spondylolithesis: possible progression of spondylolysis, a forward slippage of one vertebral body on another Commonly occur following lumbar extension injuries or in persons participating in activities that require lumber extension (divers, football linemen, etc.) Clients with this usually describe low back pain and lower extremity pain, muscle weakness, etc.

Spondylolysis and Spondylolisthesis Movement and Exercise Guidelines Focus on strengthening muscle surrounding the spine Avoid exercises that involve lumbar extension Many abdominal exercises are fine (crunches, and exercises for the obliques and transverse abdominis are good) Walking and other forms of standing cardiovascular exercise are not considered contraindicated if client does have back pain after 8-10 minutes with standing cardio, then keep it at that duration and increase when tolerance is built up