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[NEWS BRIEF]

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 1 - JANUARY 2021


Referring Patients to Personal Trainers: Benefits and Pitfalls

As more physicians prescribe exercise as a way to reduce health risks or treat certain conditions, some are referring patients to personal trainers as a way to help them establish sound exercise routines and encourage compliance.

Though no organizations officially track such referrals, representatives from three of the national organizations that certify personal trainers say physician interest is increasing. These groups expect to see a growing need for personal trainers' services as the aging of the population swells the ranks of people who have chronic conditions such as obesity, hypertension, and arthritis.

The American College of Sports Medicine (ACSM) has long certified the personal trainers and exercise specialists who work with cardiac and pulmonary rehabilitation patients. And the American Council on Exercise (ACE) recently introduced a clinical exercise specialist certification—an advanced certification—in addition to its existing personal trainer certification, according to Tony Ordas, ACE director of certification. Ordas says the new certification is a response to the aging population and to health insurance practices. "Patients are getting fewer doctor visits and fewer physical therapy visits, but they still need guidance and/or supervision," he says.

However, there are barriers to increased collaboration between physicians and personal trainers, he says. For one, physicians may have a bad image of personal trainers, based on what they see on TV. "There are people on TV posing as personal trainers, hawking the fast, easy fix," he says.

How Can Personal Trainers Help?

Ordas says most personal trainers assess body fat, strength, flexibility, and balance before establishing an exercise plan, which should include a balance of cardiovascular, strength, and flexibility portions.

Mark Jackman, PhD, is an ACE-certified personal trainer and clinical exercise specialist working in Durham, North Carolina, whose specialty is working with clients in their 40s and 50s who seek lifestyle modification. Several of his clients were referred by physicians and mental health professionals with whom he's developed professional relationships. Jackman says referring physicians give him basic exercise goals for each patient. Jackman then evaluates the patient's fitness status and designs a specific program that the physician reviews and approves.

Regular reports on patient progress are part of the process, he says. "Physicians really seem to appreciate that," he says.

Personal trainers can provide exercise prescription details that are often not taught in medical schools, Jackman says. Also, personal trainers can design a thorough and specific workout program, which most physicians don't have the time to address during the typical office visit. "I don't think there's a CPT code for counseling patients about exercise," he says.

Katherine L. Dec, MD, a physiatrist working in a private sports medicine practice in Richmond, Virginia, says that though she refers some patients to personal trainers, she doesn't routinely do so because of the cost to patients and because she assists them in setting up an exercise program and encourages them to exercise and change their lifestyles. Her referrals have included an elite athlete who needed a frequently monitored strength and conditioning program during the off-season, an industrial worker recovering from a work injury who needed to maintain the fitness level achieved in physical therapy, and a patient new to exercise who needed regular encouragement.

Because personal trainers have flexible hours and settings (eg, studio, home, or health club), Dec says they can be a good choice for patients who have difficulty getting to physical therapy locations. She notes that personal training sessions can be less costly than physical therapy for patients who don't have physical therapy benefits and don't need advanced treatments.

Referral Tips

Both physicians and trainers say that before referring a patient, the physician should check the trainer's certification and experience and whether the trainer carries liability insurance. "I don't refer to trainers when I don't know the details of their certification or their experience with the particular type of patient they'll be seeing," says Dec. Jackman advises physicians to anticipate the fit or "chemistry" a particular trainer would have with the type of patients likely to be referred. "Does the trainer have experience with lifestyle modification issues, or will they know what patients will need during the postrehabilitation period?"

David L. Herbert, an attorney with expertise in the legal aspects of sports medicine and a senior partner at Herbert & Benson in Canton, Ohio, says that checking a trainer's experience and qualifications before referral will help protect the physician if liability issues arise. He says a physician could be accused of a negligent referral if he or she had not verified the trainer's qualifications (see "Finding Personal Trainers and Certification Information," page 18) or failed to monitor the trainer's activities with the patient.

Dec says she gives the patient a written exercise prescription to hand to the personal trainer. "I may also communicate later with the trainer if the patient has biomechanical issues or a chronic illness, and I'm particularly cautious when there are changes to their strength work," she says. "I then see the patient within a week, or longer if I'm comfortable with the personal trainer's certification and experience, to assure that the trainer's program is appropriate for the patient."

One red flag is recurring patient visits to your office for acute musculoskeletal injuries, says Dec. She notes that such patients may not be getting proper instruction in lifting mechanics or the trainer may lack experience with patients who have injuries or chronic illnesses.

Problems can also arise if trainers suggest treatments or diagnoses or change the direction of the physician's suggested program. "One of my patients who sustained a shoulder injury was directed from a well-balanced program of shoulder girdle work to an overemphasis on anterior muscles and overhead lifts," Dec says. She advises physicians not to underestimate the influence a personal trainer can have on a patient. "The personal trainer is almost like a coach. Patients see them regularly, they want to succeed and follow their advice, and they assume the trainer is communicating with you about treatment modifications," Dec says.

What Certification Means

There are no state or federal licensing regulations for personal trainers. Patrick Hagerman, a personal trainer and strength and conditioning specialist certified by the National Strength and Conditioning Association (NCSA), estimates that there are about 10 national and 100 local organizations that certify personal trainers. Hagerman is chair of the NSCA's personal trainer special interest group. "There are differences among certification programs, and not all trainers are equal," he says.

Only three personal trainer certification programs are affiliated with the National Organization for Competency Assurance (NOCA), a national nonprofit group that offers its member professional organizations resources on psychometrically sound certification and licensing procedures. The ACE and the ACSM are members of NOCA (1), and NSCA is accredited by the certifying arm of NOCA (2).

Group representatives say each organization has its own perspective on personal training.

ACSM. Walter Thompson, PhD, a member of the ACSM's certification and education committee, says the ACSM certification program has been around for 25 years and has an international scope. Thompson, director of the Center for Sports Medicine, Science, and Technology at Georgia State University in Atlanta, adds that the ACSM's exercise specialist and personal trainer certification programs are the only ones that have a practical and written component.

ACE. Ordas says ACE-certified personal trainers have a broader chronic-disease focus than those from the ACSM, which he says have a more cardiac and pulmonary disease focus. Personal trainers who have the advanced ACE clinical exercise specialist certification typically have worked as personal trainers for about 5 years and have clients with chronic diseases or recently discharged from physical therapy.

NSCA. Hagerman says that NSCA-certified personal trainers have a strong musculoskeletal focus; for example, patients who have multiple sclerosis or are recovering from a musculoskeletal injury or hip replacement would be well served by an NSCA-certified trainer. He adds that NSCA's accreditation by NOCA means the certification test is rigorous and unbiased.

Beyond certification. Representatives from all three organizations urge physicians to look at more than just the personal trainer's certification. "Physicians should get as much information as possible on references, education, and personal strengths," says Ordas. His advice is to get to know personal trainers before making referrals. "Bring your questions and concerns to the table and interview clients who have worked with them," he says.

Insurance and Cost

Personal trainer services are not usually covered by health insurance. Hagerman says the reason is that there is no national licensing system in place. Nonetheless, Jackman says clients should check their insurance policies to see if an exercise evaluation and prescription services are covered. Also, he says clients should review flexible spending account rules to see if lifestyle modification counseling costs are covered.

"When people have to pay out of pocket, sometimes doctors feel guilty," Jackman says. "But it helps to realize that people spend money on all kinds of things; why not their health?" He says personal training helps patients feel better and stronger, have more energy and less pain, lose weight, and have better control over their blood pressure, diabetes, and cholesterol level.

Personal trainers' services generally cost from $30 to $100 per hour, Jackman says, but those who specialize in musculoskeletal issues or chronic illness may charge at the higher end of the range. Most trainers are willing to design a program that the patient can afford—training sessions can be shortened and spaced at longer intervals. The most economical way to work with a trainer is in a group setting in a health club.

Lisa Schnirring
Minneapolis

References

  1. National Organization for Competency Assurance Web site. NOCA organizational members. Available at: http:www.noca.org/orgs.htm. Accessed November 16, 1999
  2. National Organization for Competency Assurance Web site. National Commission for Certifying Agencies. Available at: https://www.noca.org/ncca_list.htm. Accessed November 16, 1999

Finding Personal Trainers and Certification Information

Three of the national organizations that certify personal trainers are affiliated with the National Organization for Competency Assurance (NOCA), a national nonprofit group that offers its member professional organizations resources on sound certification and licensing procedures. For more information on certification programs or to find certified personal trainers in your area, contact the organizations below:

  • American College of Sports Medicine, Box 1440, Indianapolis, IN 46206-1440, phone: (317) 637-9200; Web address: https://www.acsm.org
  • American Council on Exercise, 5820 Oberlin Dr, Suite 102, San Diego, CA 92121-3787, phone: (800) 825-3636; Web address: https://www.acefitness.org
  • National Strength and Conditioning Association, 1955 N Union Blvd, Colorado Springs, CO 80909, phone: (719) 632-6722; Web address: https://www.nsca-lift.org/menu.htm


Exercise Trends for the New Millennium

Cardio kick-boxing and other martial arts knockoffs will peak in 2021 then cool off, according to predictions from the American Council on Exercise (ACE), a group that certifies fitness instructors and evaluates products. Two of the newer exercise fads expected to become more popular are "boot camp"-style classes and group resistance training with elastic tubing and other devices.

Fitness education groups foresee a larger and more varied role for personal trainers in the years ahead. Hank Drought, MS, CSCS, a board member of the National Strength and Conditioning Association, says personal trainers will become more accessible to people of all incomes. Mark Anders, spokesperson for the ACE, says more personal trainers will establish an online presence, offering individual and group coaching, training, and consulting.

Other predicted trends include:

  • Sport-specific training for tennis, golf, skiing, and other activities. Anders says that more activity enthusiasts will be active throughout the week, so there will be fewer "weekend warriors."
  • Mindful exercise programs such as tai chi and yoga. Besides reducing stress, Anders says these activities help build muscle strength and balance, which appeals to aging baby boomers.
  • Water-based programs. Water activities open up several new and interesting exercise possibilities and are attractive because of their low-impact nature, he says.
  • Small fitness centers located in busy public areas such as laundromats, airports, and supermarkets.
  • Fitness for health, rather than appearance. "We think people will be defining health by markers such as blood pressure and heart rate," Anders says.
  • Increased athleticism in training. Drought says aerobics classes and personal training will include methods such as agility drills and plyometrics.
  • Exercise as a tool in disease management, "particularly in patients who have conditions such as diabetes, coronary disease, and depression," Anders says.
  • "Adventure" workouts. Anders says training programs for activities like triathlons, kayak races, and marathons will become more common. "We're finding that these goal-based events keep people exercising," he says.
  • Home gyms as a standard feature in the design of new homes.
  • Technology as an exercise partner. Drought says exercise machines with interactive features and new computer programs will make exercise more interesting and will allow exercisers to track their progress better.
  • Provisions for exercise in city plans and public facilities and institutions. "We expect to see more bike paths and more incentives for people who voluntarily exercise," says Anders.


Field Notes

Study Unveils Scrotum Injuries in Mountain Bikers
Mountain bike riding can lead to a range of scrotal problems in male riders, according to a report presented November 30 in Chicago at the annual meeting of the Radiological Society of North America (RSNA). Vibration and jarring encountered in the sport apparently cause microtrauma within the scrotum, according to a press release from the RSNA.

Austrian researchers used ultrasound to examine the scrotums of 45 serious mountain bikers (age range, 17 to 44 years) and 31 nonbiking controls. Among the mountain bikers, 43 of 45 had abnormal ultrasound findings, compared with 5 of 31 nonbikers. Findings included benign tumors, spermatoceles, calcifications of the epididymis, hydroceles, and twisted veins. Only half of the mountain bikers who had an abnormal ultrasound reported symptoms, the most common of which was pain.

Several prevention strategies were suggested in the report. Researchers advised mountain bikers to

  • wear a jock strap or other support;
  • select bike seats that are designed to reduce pressure on the scrotum;
  • select quality mountain bikes that have shock-absorption and seat suspension systems;
  • ensure proper seat height, angle, and tilt;
  • use a padded seat or shorts;
  • reduce training intensity; and
  • take rests while riding.


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