"When in doubt, refer out"

I've already discussed the problem of when is a physical issue simple weakness, and when genuine dysfunction requiring medical treatment. Over on Dean Somerset's blog, an American physiotherapist writes, 

"I can say almost universally, if a client comes in complaining of back pain and has not been evaluated by a physician or physical therapist, you should not train them."

This would require us to turn away about 5 in 10 new clients, of whom only 1 would actually go to a medical professional of some kind, the other 4 wander off and either find another trainer or not train at all, and of the remaining 5 clients, those presenting with no lower back pain, 4 of them would be turned away from sessions by us at some point in the next three months. That is, half of all new clients present reporting some sort of lower back pain in the recent past or present, and nine out of ten will have it at some point. They'll also have hip, knee and shoulder pain at some point. 

But the simple fact is that for many issues the best medicine is movement. 

This does not mean I accept any and all clients. One showed up the other day, a 76yo woman presenting with a history of high blood pressure, a total knee reconstruction 12 months ago, waiting on a second in another 12 months. I referred her to an exercise physiologist, which in Australia is the person who deals with high risk clients. On the other hand, many cases are not so clear, because there is after many years of looking no clear diagnosis and prescription for treatment. 

Many clients will also go medical shopping, getting different advice from different medical professionals, some of whom are ignorant of exercises, and others whose claim to the title "medical professional" is doubtful.

• General practice doctor: "Rest and take anti-inflammatories, don't squat or deadlift, nobody should, those exercises are bad for your knees and back."
• Chiropractor: "Your joints are misaligned, I'm going to manipulate them back into place, this will only last a week so you'll have to come every week at $150 a time."
• General physiotherapist: "You must rest from exercise and do this one exercise I'm showing you, come back in two weeks for a second exercise, that'll be $75."
• Sports physiotherapist: "You'll be alright, just do these stretches and then squat and deadlift."
• Orthopaedic surgeon: "You need immediate surgery. Of course the reinjury rate after this surgery is higher than before it, but I still suggest it. That'll be $8,000." 
• Second chiropractor: "Your sore shoulder is caused by tightness in pecs, which comes about from liver dysfunction. You should visit my friend the naturopath."
• Naturopath: "You are lactose and gluten intolerant."

The client tries each bit of advice for a bit and nothing changes, the pain and hindered movement are still there. 

So the client comes to me as a personal trainer and wants to start exercise, saying, "when I was younger and active I had no problems, I want to be active again, then I will have no problems." My fitness organisation's code of ethics, common sense and legal liability require me to follow all medical advice given to my clients. But what to do when the medical advice is contradictory? 

I have two simple guidelines: 

• Firstly, beginning with the simplest and least loaded version of an exercise, we teach correct movement. 
• Secondly, if it hurts, check technique. If technique is bad, fix it. If technique is good and it still hurts, we'll do something else. 

It's my experience that most medical professionals are excellent at dealing with acute issues, like torn ligaments and so on, and really not much use at dealing with chronic issues, like misaligned sacroiliac joints, patellar maltracking, scoliosis and so on. Of course a chronic issue may become acute, and vice versa. 

One of my clients Tim has loose shoulder joints, this is a chronic issue. He does karate, and keeps dislocating his shoulder doing it, this is now an acute issue, so he's gone for surgery. My client Agatha has patellar maltracking, which is a chronic issue. She did the 100km Oxfam walk, her knees swelled into immobility, it became an acute issue. Rest, ice, compression, elevation, and a week later it's a chronic issue again. We just don't run, we do lots of strength training, and while doing that her knees feel great. 

Another is 157kg and has sore knees and back - his problem is chronic, he has 157kg going through his knees and back, if he drops the weight those back and knee problems will be greatly reduced, but when these flare up in pain we stop what we're doing and do something else. When he did three workouts a week pain flared up every two months, now he does one workout a week pain flares up every two weeks. And so on. 

I feel that acute issues are best dealt with by medical treatment of some kind, chronic issues are best dealt with by correct movement, progressing the technical difficulty and load of the movement over time. The client must always be critically assessing the value of their training, asking, "Do I feel better after a session than I did before it?"