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

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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!

15. 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

16. 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.

17. 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

18. 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.

19. 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