Written by: Kevin Cann
Corrective exercise is all the buzz in the fitness industry. With the fitness industry focusing more on movement rather than muscles, there has been a lot of grey area between what requires physical therapy and what requires a personal trainer.
Shirley Sahrmann has shown us that pain is typically a result of movement impairment. If we fix the movement impairment we should help alleviate the pain. The problem is if there is pain, this is not a problem for a strength coach. Pain changes movement. In fact, when pain is present our motor firing becomes inconsistent and unpredictable. This means that we can have someone with back pain perform hip hinging, it can look good to us, but each rep may be different due to what is going on the inside. Our nervous system is coordinating this movement differently every time.
When there is pain, as a strength coach you should be referring out. We do not possess the tools to help those in pain. Now, I understand due to insurance reasons this can be difficult and oftentimes people are released from physical therapy before they are ready. Also, I understand as a coach or personal trainer you need to make money to be able to afford food and rent. Most trainers are only paid when they complete sessions, so referring everyone in pain out to a physical therapist may not be the greatest business solution.
I truly believe that always doing right by your client is the best way to conduct business. If someone truly needs to be in physical therapy, you will always be better referring them out instead of trying to play the role of really bad physical therapist. They will go to physical therapy and come back to you once they are capable because they will trust you. They will also tell their friends how great you are and that can lead to even more business.
Oftentimes coaches and trainers will take that client recovering from an injury or in pain and just attempt to avoid anything that causes pain. This is part of what needs to happen for us as strength coaches, but carrying on with business as usual is not in the best interest of that same client. You need to have a system in place to be able to properly filter these clients to the right people and also to know what you can and cannot do.
There are many assessment protocols out there. Some examples are the Functional Movement Screen (FMS) by Gray Cook, the Physical Competency Assessment (PCA) by Kevin Giles, and Kelly Starrett has some good stuff in his Supple Leopard book. All of these have their pros and cons and you need to figure out what is best for your clients and what data you need to collect.
When I was sitting down and thinking about how to assess my clients to better help me do my job I had a bit of an epiphany. My job title is strength coach. My job is to get people stronger. When people get stronger they tend to feel a lot better, have better body composition, and they gain confidence in themselves.
I believe there is no better way to get strong than to squat, press, and deadlift. I need an assessment that tells me whether clients are capable of performing these movements and I also need to be able to see where they are upon the spectrum of these movements. Not everyone that is pain free will just come in and throw a bar on their back and squat.
Due to this, the assessment I use is a combination of the FMS, PCA, and Kelly Starrett. For the most part the FMS is looking for pain and asymmetries during unloaded movements and in primitive patterns. This is a great starting point. If we are unable to perform primitive patterns how can we be expected to perform more complex ones?
From there I like to add some increased stability and load to the movements. For example, the active straight leg raise (ASLR) is a test in the FMS where you lay on your back and raise one leg as high as you can with your knee straight. We are looking for roughly 70 degrees of hip flexion in this test. Laying on your back does not require you to stabilize your spine as the floor does it for you. If someone gets a passing score on this test, I want to know if they can perform a Cook hip lift (a hip lift with hip flexion past 90 degrees on one side. I compare height side to side to the bilateral version). I also want to know if they can touch their toes and perform a single leg deadlift. This continually increases stability requirements and load.
By increasing stability requirements and load, I can see where upon the spectrum each client falls. If the ASLR is an asymmetry or not a passing score, I will apply a corrective strategy to it. I will re-assess to assure that the corrective worked and then I will retest the others to see how they changed. Maybe now they can touch their toes, but the Cook hip lift and single leg deadlift are poor. I will apply corrective strategies to the Cook hip lift and then retest each.
Often times these corrections can happen quick, within minutes. The goal is to make them aware of positions and take that learning experience with them to the next exercise. Once this assessment is completed, the warmup can be made up of those correctives that allow them to fix the asymmetries and advance out of the primitive patterns and into the fun stuff. From here it is putting it all together into squats, deadlifts, and presses with good coaching and the appropriate progressions.
Now, what if I find pain? If I find pain in one of the loaded movements, but not a more primitive pattern I will just regress the exercise, coach them into proper positions, come back to it when appropriate and see if it is better. I will try to give them some coaching points to see if it helps the pain. If they have pain during the FMS, I will refer them out, but I will still coach them.
We will just stay away from that pattern until it is fixed by the appropriate professional. We can still work along the spectrum of the other patterns. Chances are there are non-painful patterns that are also dysfunctional. Fixing these patterns will help alleviate some of their symptoms and they will feel better without putting them in any risk of further injury.
If you are a strength coach I encourage you to checkout some of the references above and either use them exclusively, or develop a system that can help you identify where corrective exercise is appropriate and when a referral is necessary. This assessment can also allow you to keep clients while they work on their painful patterns with a qualified professional. In fact, their recovery time will be much faster if they work with a strength coach on non-painful patterns and a physical therapist on the painful ones.
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