Avoid Tunnel Vision

Many times, I will see a client who complains of knee pain.  During my initial assessment, I will check the knee strength and range of motion.  I will perform special tests to detect deficits with the ACL, PCL, Collateral Ligaments, Menisci, etc.  I will compare the "good" knee to the "bad" one with the prior tests and measures.  That would be considered a "FAIR" assessment.  But to provide a "GOOD" assessment, I must perform a 'peripheral joint scan' checking at least one joint above and one joint below the "problem" area to truly pinpoint the problem.  The knee pain could be caused by some biomechanical problem at the ankle such as over pronation due to tight gastrocnemius, tight soleus or restricted subtalar joint.  It could also be caused by weak hip musculature, particularly the posterior gluteus medius.  You may not pick up on these other areas as being potential causes until 2 or 3 sessions have gone by.  But the point is, do not have tunnel vision.  If your client attends 2 weeks of sessions, and there has been no change in the symptoms, that is your cue to look elsewhere as a possible cause.  Check one joint above and one joint below the knee.  You can usually detect signs of deficiency in these other joints while simply observing your client's posture, gait and stepping activities.  So always pay close attention to your client's movements, especially as they transition from one exercise or position to the next.  You will be surprised at what you see, as it may be the cause of their main complaint.

Proof That Your Client is Progressing

When dealing with a client (or patient) who has been experiencing chronic pain, particularly lower back pain, they often become discouraged at the somewhat slow progress when working towards their goals.  The first thing you want to do is the obvious...make sure they are doing what they are supposed to be doing when they are not working with you (They should be compliant with a home exercise program on a daily basis).  So that you can make educated observations on your client's progress, you should begin with a detailed initial assessment with Objective and Subjective information.  Each session, you should be writing notes not only on what exercises your client is performing, but range of motion and strength measurements, observations on quality of movement, and quantity of work performed before rest is required (Endurance or Activity Tolerance).  This is the information that you will need to show the client many times to carry them along, minimizing discouragement and depression.  So many times, I am working with a client recovering from lower back pain and I hear "my pain has not changed at all since we started."  I explain that this is common.  As they make progress in their rehab sessions, they are able to perform more work outside of the clinic.  More work outside of the clinic is just like performing more exercise or new exercise in the gym.  This causes an increase in soreness.  When I look through the chronological notes with the client/patient, my explanation usually sounds like this..."When we first started, you felt 5/10 (pain score 5 on a scale from 0-10) when getting out of bed in the morning and were unable to perform any additional activities throughout the day without the pain increasing to a 7 out of 10 on the pain scale.  Now, you are exercising daily, cleaning your house, you have returned to work and your pain level is 5 out of 10.  That's progress!!!"  Progress is not a 'black or white' situation.  It is usually slow and steady.  Explain this to your clients and open their eyes to what other details they need to be focused on in order to truly assess their own progress.  Take their minds off "pain, pain, pain," and show them the other aspects which they have made improvements in.  Your clients are looking to you for support and guidance.  They are trusting you with their health and wellness.  Give them as much information on their progress as you can.  Don't just spit out a bunch of weight and rep numbers to show them that they have improved. That information does not mean much in terms of overall functional abilities.  Keep detailed records.  Many times, clients are selective in what they remember, especially when they are  not progressing as quickly as they would like to.  Show them they are not wasting their time.

Organize Your Sessions For Efficiency

When studying to be a Physical Therapist, my practical exams were not just based on my techniques, but the order in which I performed them.  For example, when evaluating or treating a patient with lower back pain, there are certain Special Tests I would like to do in order to help diagnose my patient's condition.  Some of these tests are performed standing, others in sitting, a few with the patient on his/her back, side or stomach.  The last thing a client with back pain is going to want to do is to constantly change positions from one side to the other, sitting to standing to sitting again, etc... So in our practical exams, we had to not only know how to perform the tests, but had to strategically minimize our patient's transitions from one position to the next, minimizing their pain.  You want your patient/client to return for treatment, not leave thinking they are in more pain now than they were before they came to you.  This takes some planning.  In the personal training realm, you may not have clients that are in such acute pain, but many of them are not in the best physical shape and do have difficulty transitioning from one position to the next.  With that in mind, think through each session.  Customize it not only in terms of what exercises you will have your client do, but in which order they will do them.  Try to group as many supine exercises, sitting exercises, standing exercises, etc.. together.  You do not want them to be exhausted before they even attempt the exercise, because they had such a hard time getting into position to do that exercise.  Simple organization will help your sessions run smoothly and efficiently.

"The Good Go To Heaven, The Bad Go To Hell"

When working with a client status post hip, knee or ankle surgery, we must ensure that they will be safe when they are moving around in their home.  Many people have stairs that they will need to navigate to enter or exit their home or to move from one floor to the next.  Initially, they may have too much pain when fully weight-bearing on the surgical leg.  So we use the saying "The Good Go To Heaven, and The Bad Go To Hell" in order to explain that the "good" or stronger leg goes up first upon ascending the stairs, while the "Bad" or weaker leg goes down first, upon descending the stairs.  Basically, the stronger leg is in control of the body weight completely when ascending as well as descending the stairs.  It does the work of controlling the body safely up and down while the weaker, surgical leg goes along for the ride.  Many patients/clients receive home care treatments immediately following their surgery and may receive therapy for up to 2 months.  I have seen these patients many times towards the end of their 2 months, and when I ask them to show me how they climb stairs, they continue to perform the task with "The Good Go To Heaven, and The Bad Go To Hell" strategy.  I think many times, as therapists, we get so caught up in educating a patient to perform this task the safest way possible, that we never progress them to the next step.  As therapists, it should be our goal to get our patient/client as close to their prior activity level as safely possible.  There is nothing wrong with being safe, and advising our patients to perform stair-climbing this way.  However, when they no longer have us by their side, what happens if they accidentally forget and try to go up or down the stairs using the weaker leg to control their body weight?  They never practiced the technique this way while we were with them because we were so intent on doing it the "safest way."  We actually limited their functional improvment by 'protecting' them so much.  In general, the #1 most important thing is to be safe.  But we also want to challenge, progress and move forward.  If your patient/client independently climbs stairs using the "Good go, Bad go" rule, begin strengthening the surgical leg in the same manner so that they are symmetrical, safe and confident if they ever need to use it (Do this as long as their doctor allows full weight bearing on the surgical leg, of course).  Remember, if they didn't have to think about it before, you do not want them to have to think about it now.  Do not fall into the routine of doing the same treatment day in and day out.  Challenge your patient/client and take them to the next level.

Osteoporosis: Wolff's Law

As defined in Wikipedia, Wolff's law is a theory developed by the German Anatomist/Surgeon Julius Wolff (1836–1902) in the 19th century that states that bone in a healthy person or animal will adapt to the loads it is placed under.^[1] If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading. The internal architecture of the trabeculae undergoes adaptive changes, followed by secondary changes to the external cortical portion of the bone,^[2] perhaps becoming thicker as a result. The converse is true as well: if the loading on a bone decreases, the bone will become weaker due to turnover, it is less metabolically costly to maintain and there is no stimulus for continued remodeling that is required to maintain bone mass.<sup>[3(See Wikipedia Wolff's Law)

Basically, this means that resistive training will help to "strengthen" and improve bone density.  Therefore, if you have a client with the diagonsis of osteoporosis, you need to incorporate strength training, especially in  upright functional positions in order to assist the recovery from, as well as reduce their chance of fractures.  See prior postings for exercises that should be avoided with client's who have osteoporosis.  So if your client with osteoporosis seems hesitant to train with you, now you can explain the benefits to them.</sup>

Osteoporosis & Posture

Osteoporosis, or loss of bone density, may lead to "brittle bones" and fractures, particularly in the spine, hips, and pelvis.  When the vertebrae are affected, 'wedging' of the anterior portion of the spinal bones may occur, which leads to a flexed or kyphotic posture.  With a rounded trunk, you will also see protracted shoulders, and a forward head posture, with excessive capital (head) extension.  Just by observing someone, you will have multiple treatment ideas. 

First and most importantly is to correct their posture by stretching the short, tight muscles and strengthening the stretched out weaker muscles.  Lets start at the head and neck.  With a forward head posture, you will have weak capital (head) flexors, and tight capital extensors.  To counteract this, teach your client chin tucks.  This will stretch the tight suboccipitals while strengthening the capital/head flexors.  It will also realign your ear with your acromion on both sides. 
Now for the shoulders and Scapulae.  We need to stretch our pectorals which have been tightened due to the constant protraction of the shoulders.  The posterior muscles have been stretched out and are weak due to this protracted posture, so you will need to work the retractors such as the rhomboids, rear delts and middle traps..."Bring those shoulders back!"

Most likely there will be a flat lower back, with loss of the lordotic curve.  Pelvic tilts are helpful to reintroduce flexibility and motion to this region.  you will also want to incorporate core stability training to your client, progressing from static to dynamic postures.  Focus on glute training with bridges and glute sets, as the glutes assist in lower back stabilization. 

Integrating the above techniques into each of your client's sessions will help them to correct their current posture, prevent any future injuries and impove their overall results, as it enhances efficiency of all movement.  Once you have corrected posture, then you can move into body mechanics and training movement patterns.