I love working with senior clients. We work on getting up from the ground, going from a sitting to standing position, picking things up from the floor and pushing and pulling movements. However, almost all of my clients have some sort of arthritis, tendonitis, bursitis, etc. My question is, should I not continue with moves like this if they feel "a little achy" in the back, hip, knee, shoulder, even though these are things they have to do every day? I know I'm not the only trainer struggling to find the balance between helping them to be strong and independent versus causing injury. Any insight you could share would be a big help.
Most of the chronic aches and pains older clients experience are related to arthritis. Although the term arthritis literally means joint inflammation, arthritis really refers to a group of more than 100 rheumatic diseases and conditions that can cause pain, stiffness and swelling in the joints. Osteoarthritis (OA), previously known as "degenerative joint disease," results from wear and tear and affects 21 million people (almost every second adult over the age of 65). Initially, osteoarthritis is non inflammatory and its onset is subtle and gradual, usually involving one or only a few joints. The joints most often affected are the knee, hip and hand. Pain is the earliest symptom, usually made worse by repetitive use. The risk factors of OA include advancing age, joint trauma and obesity.
Low back pain, another type of chronic pain, is also a common affliction in our society. It may be related to damage to or aging of one or more discs, muscular problems, arthritis of the spine, problems with tendons or ligaments in and around the spine or malpositioning of vertebrae. The pain can vary from severe and long term to mild and short lived. It will resolve within a few weeks for most people. A typical response to experiencing back pain is to take it easy - either staying in bed or at least stopping any activity that is at all strenuous. While this approach is understandable and may even be recommended in the short term, when done for more than a day or two it can actually undermine healing. Instead, active forms of exercise are almost always necessary to rehabilitate the spine and to help prevent future back pain. You can minimize problems with back pain for your clients with exercises that make the muscles of the back, stomach, hips and thighs strong and flexible.
"Years ago, people who were in pain were told to rest," says Edward Laskowski, M.D., a physical medicine and rehabilitation specialist and co-director of the Sports Medicine Center at Mayo Clinic, Rochester, Minnesota. "But now we know the exact opposite is true. When you rest, you become deconditioned, which may actually contribute to chronic pain."
Regular exercise is an all-around weapon in the fight against chronic pain and can:
- Prompt the body to release endorphins, which are the body’s natural pain relievers and help to alleviate anxiety and depression.
- Help build strength. The stronger the muscles, the more force and load that will be taken off bones and cartilage.
- Increase flexibility to allow joints to move through a full range of motion, which can decrease aches and pains.
- Improve sleep quality by lowering stress hormones, resulting in better sleep.
- Boost energy levels, giving a person more energy to cope with chronic pain.
- Help maintain a healthy weight, which will reduce stress on the joints (weight loss is another way to improve chronic pain).
- Enhance mood and contribute to an overall sense of well being.
It’s not a bad thing (actually, it is a very smart thing!) to be concerned about hurting a person who has chronic pain when you are designing an exercise program for them. But, unless the pain is “protective pain,” a well designed program will be very beneficial for seniors. With that said, working with people recovering from injuries, surgery, chronic diseases or undergoing medical rehabilitation demands advanced training. The inexperienced personal trainer (even with a degree) and/or certified personal trainer without advanced training is not in a position to safely work with at-risk clients and could be vulnerable to costly legal action. And even if you are qualified to work with these clients, you need to make certain they do not have conditions that need the attention of a physician or other specialist. You also need to verify the person has been “released” or cleared for exercise if he or she has been under the care of a medical professional.
Given the flood of at-risk older clients in the fitness setting, trainers must utilize suitable pre-activity screening methods to identify members who may need medical clearance and/or medically supervised programs or may need to see a trainer with more advanced skills. Studies have shown that more than 25 percent of all clubs surveyed do not complete pre-activity screenings. It is not clear the percentage of personal trainers working independently that do not perform adequate screening prior to working with a new client. Proper screening of a new client is essential in deciding if there are conditions that need to be assessed by a therapist or physician prior to exercise.
The general exercise guidelines for a client who has no significant chronic pain or one with pain that has been released from therapy and is in a stable phase are much the same as for all older adults. In general:
- Aerobic exercise. For physical conditioning, start slowly at a safe point for your client’s current abilities. Over several months, work up to a regular routine of working out for 20 to 30 minutes, three to five times a week. Low-impact exercise such as biking, the elliptical and walking are often good choices, and swimming may be especially effective for those with joint disease.
- Strength training. Start with a resistance that allows your client to perform 12 to 15 repetitions and try to work major muscle groups in the upper body, lower body and core.
- Stretching. Increasing flexibility can be a helpful component of pain relief. Prescribe a consistent stretching routine. Gentle stretching exercises like yoga or body movement exercises such as Pilates are good choices as well.
- A good rule of thumb for clients who have chronic aches and pains is to have them keep a journal of what they are feeling and when they are feeling it. If you notice patterns or particular aches after certain types of exercise-- and after two weeks there is no improvement-- then you should recommend that the client see a physical therapist, orthopedic doctor or other health professional if they have not done so previously. As you already know, a small amount of muscle soreness one or two days after exercise is normal. Another rule of thumb is to discontinue or modify any exercise that causes pain or increases an already existing pain for more than two hours after the exercise.
Your clients, especially those with arthritis, need to be taught to distinguish between the different “types” of pain. We sometimes distinguish pain as “bad pain” versus “good pain.” A better description might be “pain” versus “soreness.”
Good pain or soreness is felt in the muscle, not in the joint. It stops within a few minutes after exercise ends. There is less soreness associated with each subsequent exercise session. Normally, soreness is what we all experience to some extent when we exercise.
Bad pain occurs in or near the joint, continues to hurt after exercise is complete, and does not improve with future sessions. It might even worsen with time. This usually indicates a problem with a joint or a muscle that is not normal.
Special Concerns for Clients with Arthritis
The goal with arthritic clients is to limit progression of the existing damage in the affected joints. Consequently, the focus should be on posture, strength and flexibility. The following guidelines should be taken into consideration:
- Do not over fatigue muscles, as this can increase joint pain.
- Mild isometric exercises are helpful, especially during flare ups, but remember isometric contractions are contraindicated for people with high blood pressure.
- Remind your clients to take pain medication about one hour before exercising.
- Some clients like a hot shower or some other form of heat to loosen up joints before exercise. Others prefer ice for aching joints. Applying an ice pack or other cold compress is probably best after a workout because the cold tends to decrease blood flow to the area, which can actually increase the risk for injury during use of the joint. A bag of frozen vegetables makes a good “ice pack” at the end of a workout. It is flexible, cheap and reusable.
- Any exercise that causes pain two hours or more after exercise should be changed or replaced.
- Discomfort or soreness is okay. PAIN from the exercise itself is NOT okay.
- watch carefully for an exercise that is causing increased pain. Clients often won’t complain about pain for fear of disappointing you. They just get used to it and drive on.
- “No pain, no gain” is a WRONG attitude! It should be “WHERE THERE IS PAIN, THERE IS NO GAIN!”
- While stretching is extremely important, avoid overstretching. Some clients can hold a stretch for only a few seconds.
- Always warm up slowly and completely to ensure joints are as warm and supple as possible.
- Do not expect clients to keep joints in the same position for too long. Prolonged stretching of a single joint, or even just holding a joint in one position for too long, can make it difficult to straighten the joint without pain.
- Use only pain-free range of motion. Stop exercising if PAIN occurs.
- Daily range of motion exercises, especially first thing in the morning, can really decrease morning stiffness. Help clients design a program to be done at home.
- Short and frequent exercise sessions are best. Vary endurance and strength training on different days. During acute episodes or flare ups, avoid exercising the affected joint.
- For strength exercises, use tubing or hand weights with a lower level of resistance.
- Compensate by doing a higher number of repetitions to fatigue the muscle.
- It is especially important to choose tubing with a lower resistance because the intensity level increases as the band is stretched. Therefore, the greatest resistance is encountered when the muscle is past its range of mechanical advantage.
- Try to do range of motion exercises, even during a flare up.
- Some people might never be able to tolerate resistance exercise, but they might be able to tolerate weight bearing exercise.
- Make sure your client is aware of the mood benefits of exercise. Many people with chronic conditions (especially arthritis) are prone to depression. Make certain they know exercise has been proven to be as effective as medication in fighting depression for most people.
- For the client with severe arthritis, water exercise in a pool kept at 90 degrees will be the best choice, if available. If it is not available, try to find an activity that can be tolerated.
- For clients who are unable to do continuous activity, try doing a minute or two on one type of machine, rest for 30 seconds and then switch to another type of machine that uses different joints.
- Take things slowly and don’t forget to provide frequent rest periods. To accommodate these extra rest periods, you might just have to schedule as much as 60 minutes to allow for 30 minutes of work. Remember that the duration and frequency of exercise is more important than the intensity. This is true for everyone but especially for seniors with arthritis.
- Many people with arthritis suffer from low back pain. Proceed cautiously, but encourage lower back strengthening exercises.
Special Concerns for Clients with Back Pain
While back pain is common among all ages, it is often a chronic problem for older persons, especially those with arthritis. It is usually classified as either chronic or acute pain. Chronic pain lasts for longer than three months, and the recommended treatment includes exercise. If you have clients who have been seeing a physician or therapist, make sure they have been released or cleared for physical activity.
- Consider secondary conditions like arthritis, heart disease or osteoporosis when designing a program.
- Your major goal for a person with back pain should be to prevent overall deconditioning.
- Be aware that people who have experienced acute episodes might be TERRIFIED of re-injuring their backs. You need to be supportive and understanding.
- Input from the physician or physical therapist is a good idea when designing low back exercises for anyone suffering from low back pain. Again, make sure the client has been cleared to resume activity and ask if there is already an exercise regimen in place.
- Remember good pain versus bad pain. Stay within the client’s pain threshold and watch out for sharp pain. Clients who have been in therapy know the warning signs. Have them tell you their guidelines. You can learn a lot of practical information from them that might even apply to other clients with back pain.
- Aerobic exercise that puts minimal stress on the back is necessary to encourage endurance training. The exact mode of exercise will vary from patient to patient but a recumbent bike is often a good choice.
- Strength and flexibility are also important. In the initial stages of exercise, use the abdominal crunch or pelvic tilt to strengthen abs and back extension exercises (but not the Roman Chair) to strengthen the back. If the client has chronic pain but has not been under a doctor’s care, these exercises are a good place to begin.
- If in doubt, refer to the appropriate professional.