Strengths and Weaknesses of the

Australian Personal Trainer Industry

from a Sports Physiotherapist's

perspective

(as written for the Sports Injury Bulletin 2006)

In recent months Sports Injury Bulletin has been debating the strengths and weaknesses of the physiotherapy profession, and in particular the relative roles of physios and fitness trainers. For me, this is far more than just an academic debate, as it goes to the heart of work I am currently developing, as a sports physio, with the Australian personal trainer industry.

My own thinking is based on five years of extensive involvement with personal trainers and their clients, exposure to the machinations of personal trainer  management systems, and work that I have done educating trainers in in-service forums and now in a new in-depth modular course that I have developed, called "Rehab Trainer".  

What follows is a SWOT analysis (strengths, weaknesses, threats and opportunities) of the Australian personal trainer industry. I cannot claim that the analysis will hold equally true for other countries, but I suspect there will be many aspects that others will recognise in their own domestic situations. My hope is that this kind of debate and professional development initiatives such as "Rehab Trainer" will help to push the sports therapy world on into increasingly productive collaboration and satisfactory outcomes for our clients. 

• Greater competence and confidence in screening a client's injury into "low injury risk" or "high injury risk" profiles (through specific questions and tests) for the purpose of knowing the priority and direction of referral.
• Greater knowledge of functional anatomy, injury/pain behaviour, and how patho-mechanics and bad technique create injury. All clinical therapists, from physiotherapists to Alexander technicians, chiropracters, massage therapists and osteopaths, must have some understanding of patho-mechanics, in order to re-educate and retrain clients successfully for long-term recovery. But what about the trainers on the front line? They, as much as any on the allied health spectrum, need a good grounding in how to pick up the often subtle indicators of poor muscle control.
• Enhanced analytical skills to detect poor or pathological movement patterns. While some trainers have a vague sense of this skill, the vast majority hardly even understand the concept, reflecting primarily the priorities of the institutions that educated them. Yet this is the critical observational skill-set, which will ensure that a personal trainer isn't training their client towards an injury. Without it, they cannot meaningfully contribute to the rehabilitative process of any overuse injury.
• New training principles that are safe and effective in the context of injury. These would emphasise quality of movement for an injured body part as well as performance enhancement.
• How to use these principles (with support from a physiotherapist) to design customised rehab strategies and exercises using equipment readily available in the gym.
  

Setting clear boundaries
It is paramount that trainers clearly understand the limits of their role and professional abilities. Their credibility and their clients' wellbeing depend on it.

This is crucial to my belief in the upskilling of trainers. Personal trainers need to know confidently which  injuries to refer on (call them "high risk profile" if you like), namely those that should be primarily managed by a  physio or other allied health professionals. The rest can be termed "low risk profile" injuries, and while often needing some referral and allied health support, would be primarily managed by the trainer   through to an optimal state.

My views are pretty clear on this: unless a personal trainer has achieved certain higher levels of Chek certification, or done other postgraduate courses that qualify them to do so (and these need to be scrutinised very carefully),  they should not be dabbling at all in "diagnostics" or tonic/postural muscle activation for injured body parts.

Any seasoned clinician will appreciate the depth of knowledge and experience that a physiotherapist must acquire to be successful in diagnosing a labral tear or re-educating a dysfunctional transversus abdominis muscle. So these skills should remain the sole domain of the physiotherapist (as well as the litany of treatment modalities useful in promoting healing around a pathological structure).

Threats
For trainers, the problem of injury is not just about  improving their own education and their clients' standard of service; it runs a lot deeper.:

In the short term, the biggest concern is the alarmingly high rate of fallout of trainers from the industry. In the Australian context, two leading industry professionals have confirmed for me the same drop-out figure of about 60% within the first 18 months of qualification. Remarkably, this is occurring at a time when demand for personal trainers is hugely outstripping supply, and even relatively inexperienced trainers can make a good living from the job. We need research into why these drop-out rates are so high, but there is every possibility that a few too many injured clients not showing up for training gradually takes its toll.

In the medium term, litigation is on the increase. It is not hard to see how a personal trainer who is careless or unaware can suddenly find themselves having to consult a lawyer for defence against an injured client. Yet there is no doubt that much training work still focuses on pushing through "the pain barrier" to get results. Few trainers would be able to mount a credible defence using that approach these days. Moreover, the wider health profession will never contemplate making formal referrals or treating as partners an industry that cannot defend its basic professional competence against legal challenge.

In the long term the worst case scenario is that the very viability of the personal training industry may be at stake. Gyms and trainers are riding a great wave of public approval and enthusiasm in Australia at the moment, as people chase lifestyle and health improvements. But a spate of high-profile injuries could very quickly shift the public mood. A backlash would inevitably cause a drop off in client numbers for personal trainers and leave a wonderful industry struggling to recover from mass public scepticism.

“The Flat Bench Press:

    the good, the bad and the solution”

PART 1 (OF 3)

By Ulrik Larsen APA Sports Physiotherapist

Among those who keep up with sports science research, the standard flat bench press(FBP) is fast becoming the black sheep of gym exercises – and for good reason: it is widely reported as being the most common cause of shoulder injuries in the gym.  Yet despite the growing recognition of this risk, the flat bench press remains very popular with personal trainers and strength and conditioning coaches. It is time for a serious reappraisal….does it really need to be outlawed?

There is no doubt that the flat bench press is an extremely good way to grow a  big chest – hence its abiding popularity among many gym-goers! (This also has a lot to do with the extra levels of effort generated and hormone production that occurs when a 100kg weight is precariously balanced above your neck... there is nothing like a little fear to boost a person’s motivation!)

The same levels of pectoral growth cannot be achieved with standing cable presses, or single arm dumbbell presses on swiss balls, even though biomechanically they are profoundly safer, as they spread the load across numerous body parts. So, rather than try to outlaw an exercise that is likely to remain extremely popular because it delivers what so many people want in the gym, let us look at how to overcome its dangers with some intelligent modification.

So What’s the big problem with Bench Press?

i. The bench

 The high levels of injury associated with the FBP are primarily caused by the bench itself, and it effect on the movement of the shoulder joint.  It is relatively common to find that you or your client will experience shoulder pain with the FBP, but none if they are doing normal prone push-ups.  This is because the effect of most benches is to severely restrict the movement of the scapula (also called the “socket”, or the shoulder blades), thereby artificially exaggerating the movement of the gleno-humeral (main shoulder) joint.  It is possible to find very narrow benches, but these carry the real risk of the client falling off sideways during the exercise, especially when fatigue sets in. In addition one occasionally finds a unique type of bench that has notches cut out of it for the scapula to retract, however these are surprisingly rare in gyms.

 As the bench restricts the movement of the scapula, at the shoulder joint the “ball” is forced to move to the end of its range in the “socket”.  The scapula is unable to retract on the latter part of the down phase as the elbow moves past the point of the shoulder (the humerus is therefore horizontally hyper-extending); and is unable to protract with the latter part of the up phase as the elbow moves to the ceiling (the humerus is therefore horizontally hyper-flexing).

Ideal movement of the scapula is primarily achieved by the under-rated serratus anterior muscle working concentrically on the push phase to produce protraction, and eccentrically on the return phase to produce controlled retraction. Excellent drills have been developed and are available from the Rehab Trainer course (and other excellent sources) for the training and activation of this key shoulder stabilizing muscle.

So, in the FBP, rather than the scapula and humerus moving synergistically (together), a kind of “lurching” takes place, in which the point of the shoulder flicks in the opposite direction to the point of the elbow. This is catastrophic for all the fragile structures in the glen-humeral joint.

iii. Excessive humeral head movement

 The effect of the repeated lurching movement at the humeral head is to over-load the external rotators of the rotator cuff (infraspinatus, teres minor, and supraspinatus), causing them gradually to become tighter and tighter in response. The first sign of this is the reduced ability of the client to reach up behind their back, as if to do up a bra or scratch their back: this indicates a decrease in internal rotation flexibility as the external rotators become too tight.

The internal rotator cuff muscle (subscapularis), in contrast, becomes gradually biomechanically disadvantaged, inhibited and weakened.  This imbalance between external and internal rotators in the injured shoulder, resulting in inhibition of the subscapularis, is well supported in the research literature (see end of article).

Crucially at the bottom of the press movement, where the elbow is behind the level of the bench, the head of humerus lurches forward and the tendon of subscapularis (as it rises from the armpit at the front of the shoulder) is unable to exert its counter-balancing and stabilizing force.  The scapula needs to be able to retract sufficiently at this point to give subscapularis better biomechanical force to prevent the destructive anterior shear of the humeral head.

iv.  The bar

A related, if less severe, biomechanical challenge with FBP is the use of the weighted bar. There is good reason to believe that the restricted capacity for supination and pronation of the wrist/elbow joint complex during the exercise leads to altered muscle recruitment patterns around the shoulder complex. 

Take, for example, the top of the press movement. A ‘free’ dumbbell-weighted hand that is ‘free’ to move how it wants because there is no bar to block it will ideally slightly supinate to enhance external rotation of the gleno-humeral joint and scapular protraction. With the bar, the forearm is kept in relative pronation and the humerus is kept in internal rotation, increasing the risk of subacromial impingement. 

“The Flat Bench Press: the good, the bad and the solution”

PART 2 (OF 3)

By Ulrik Larsen APA Sports Physiotherapist

Poor Biomechanics = Poor results

In our previous article we discussed how the progressive tightness at the back of the shoulder socket leads to the head of humerus being nudged anteriorly and superiorly (forwards and up) into the socket during the press movement. This anterior shear creates overload of the long head of biceps tendon as it crosses the front of the shoulder, and the superior shear creates compression of the supraspinatus tendon under the acromion.   Compression and shear forces gradually worsen and pain, inevitably, results.

Typically the top, lateral or anterior aspects of the shoulder will begin to ache after training, or the next day, perhaps during warm-up, under heavy loads, or with fatigue. The pain may emanate from inflamed tendon structures, or from the labrum (cartilaginous rim of the socket) or subacromial bursa, or up-regulated neural structures… In the end, the precise diagnosis matters less than an understanding of the mechanism that has caused the pain.

Alongside pain, muscular development will be inhibited and distorted. Pec minor will begin to dominate the press movement over pec major, preventing the chest from developing as it should.  The gleno-humeral lurching will ensure that the pec major does not have a strong base from which to operate, again preventing its normal development.  Instead the shoulders just become rounded, possibly with a tendency to develop the anterior deltoids and triceps over pec major.

Poor Biomechanics = Poor Technique

In my opinion every therapist, strength coach and personal trainer should know how to activate or enhance the protraction and retraction movements of the scapula, in order to prevent rotator cuff overload and shoulder pain.

Get it right: good push-pull biomechanical technique always requires sufficient movement of the scapula with the humerus.  This notion may well be at odds with some schools of thought among trainers and strength coaches, where the emphasis is on “locking back” the scapula at all times, as a sign of good scapular control. 

While there may be an argument for this ‘locking back’ early in the training regime of a client with very poor muscular development and body awareness, all the research and anecdotal evidence strongly suggests that the scapulae should not be locked if one wants to protect the fragile structures of the gleno-humeral joint and develop the muscles of the shoulder optimally. 

Rather the scapula must move synergistically with the arm, so the rotator cuff doesn’t have to over-work. As soon as the client grows in their awareness, the PT must begin to teach them how to move the shoulder and the arm together or injury will result.  This is easily done with cable push machines, single arm dumbbell chest press or even the simple push-up.

It is my strong contention that the majority of rotator cuff problems that develop in the gym are due to poor scapular movement during push-pull exercise, not due to weakness of the rotator cuff per se.  Standard “turn-out, “turn-in” exercises for the rotator cuff are of no real and immediate help for most of these situations, as the client will simply go back to their poor technique and continue to overload the cuff tendon.

In summary, the most common cause of rotator cuff injuries in the gym is excessive and uncontrolled gleno-humeral movement due to partly to insufficient scapular movement and control. Too much ‘ball- lurching’ takes place, with insufficient ‘socket-sliding on the ribs’.

In the next and last article on Bench Press two solutions will be proposed to solve these two critical biomechanical problems during bench press – the pool noodle will enhance scapular movement during the exercise, and rubber tubing will stabilize the ball in the socket. Look for the article in the next magazine to learn how you can use them with your clients. They are two solutions that are simple to apply by the PT and form a small part of the Rehab Trainer Tool Kit for the shoulder.

“The Flat Bench Press:

the good, the bad and NOW FINALLY....the solution”

PART 3 (OF 3)

By Ulrik Larsen APA Sports Physiotherapist

How to modify the bench press to improve biomechanics

The following two approaches will allow a therapist or trainer to start the process of correcting bad mechanics and enforcing good movement patterns without the need to ban the bench press from the client’s exercise repertoire.  The first physically alters the bench to give the client a chance to use their scapula; the second gives movement feedback to challenge the client to isolate and activate key muscles.

Pool noodle

These are standard easy-to-buy long cylindrical foam floats, widely used in aqua aerobics classes. You will need one that is 100mm or less in diameter and ideally with some “give” in it. A half-circular foam roller will do the same job; a full one is too high.  The noodle needs to run the length of the client’s spine, so that head to pelvis can lie on it during the exercise .  If the noodle sits too high off the bench, it makes it too unstable to perform the exercise safely; if it is too soft (eg, a hollow-core pool noodle) it will not act as a stimulus to change the movement of the scapula.

The client lies supine as normal, with the noodle placed longitudinally under the length of the spine (including the head and pelvis) on the bench.  Give them a set or two using just the bar to get used to the feel of it.  Then gradually add weight, taking care not to allow the bar to fall sideways.

During this simple modification of the bench press, the scapulae will be able to protract and retract, which the therapist or trainer should encourage. Cues such as:  “Open your chest” as the elbow travels beneath the level of the bench can be excellent.  As the scapulae retract to their limit, the elbows should not descend any further, thus preventing even the slightest ‘lurching’.

On the latter part of the push-up phase, the client may bring their scapulae somewhat further around the rib cage (protraction), but care must be taken to not allow shrugging of the shoulders (over-activity of upper trapezius and levator scapulae) or flexion of the trunk.  Pure protraction of the scapulae without downward rotation is invaluable for good serratus anterior development, and minimises dominance of pec minor over the pec major muscles.

Pool noodle longitudinally along the spine and head

to allow scapular protraction and retraction

(soft foam roller depicted in picture close enough to pool noodle).

Be clear about it: this is not a temporary measure to “retrain” pathomechanics after which the client simply returns to the standard bench press: they should ALWAYS perform the exercise with this modification.

Rubber tubing

Acquire some low-resistance therapeutic rubber tubing (be sure to use the round hollow core tubing, not stretchy elastic bands sheets – for this purpose they are no good. You will only need stronger resistance tubing if you are working with an extremely strong client, but start with red tubing for the average strength client..  Make a loop at either end so the client can hold on.

Set up the client to perform the bench press (with the pool noodle as well), using a low weight on the bar. Ask the client to hold on to each end of the tubing at the loop handles, or alternatively fix the ends of the tubing to the ends of the bar outside the weight plates. The therapist / trainer then stands at the head-end of the bench, holding the middle of the tubing.

.

Rubber tubing set up for L arm enhanced gleno-humeral stability.

As the client performs their bench press, gradually increase the pulling force on the tubing, creating additional ‘torque’ (rotary force) around the shoulder.  Be careful not to pull the client’s line of push out of alignment (the forearms should remain vertical). It should be easy for the client to resist the force and continue their bench press.

The pulling force of the tubing is towards external rotation of the client’s gleno-humeral joint, so as the client resists, they have to activate their internal rotators. And because they are resisting a constant force through the movement, they are more likely to recruit  the deep internal-rotation stabiliser subscapularis in preference to the “mover” muscles such as teres major and latissimus dorsi.  This extra level of activation of subscapularis braces the anterior aspect of the gleno-humeral joint, preventing it from lurching forward and upwards in the socket. 

In my experience, this activation mechanism is frequently extremely effective in removing pain from pressing movements.  Many shoulders will feel “different” in a way that equates to feeling more ‘safe’ and ‘strong’ in the shoulder when it is under load.

Now all you have to do is get into the gym and try it on yourself to see how it feels!

1. “Recruitment Patterns of the Scapular Rotator Muscles in Freestyle Swimmers with Subacromial Impingement” D. Wadsworth and J Bullock-Saxton, University of Queensland, Brisbane, Australia
2. “Dynamic EMG Analysis of the shoulder muscles during rotational and scapular strengthening exercises”  Post M, Morrey BG, Hawkins RS (eds) Surgery of the Shoulder, St Louis CV Mosby 1990
3. “Intramuscular EMG of the subscapularis.” MP Kapada, A Cole, ME Wotten, P McCan, M Reid, G Mulford, E April, L Bigliani; Orthopaedic Engineering and Research Center, Helen Hayes Hosp, New York.
4. “Subscapularis muscle activity during selected rehabilitation exercises” Decker MJ, Tokish JM, Ellis HB, Torry MR, Hawkins RJ; Steadman-Hawkins Sports Medicine Foundation, Vail, Colorado, USA
5. “Functional Stability of the Glenohumeral Joint”, Sally Hess; Dept of Physiotherapy, University of Queensland, Qld Australia
6. “Relative Balance of Serratus Anterior and Upper Trapezius Muscle activity During Push-up Exercises”; Ludewig PM, Hoff MS, Osowski EE, Meschke SA, Rundquist PJ;  Program of Physical Therapy, Uni of Minnesota, Minnesota