Training Clients with Arthritis, Chronic Illness or Chronic Pain: How to Coach and Adapt

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I had just successfully summited Mt Kilimanjaro, flown home, and sold my house. I packed whatever stuff fit into my car and started the cross-country drive to relocate in Vancouver. After 3 long days of driving, I arrived on the West Coast. As I clambered out of the car in the parking lot of my new apartment, my legs slowly regained sensation leaving me with an aching pain in my knees.

Having been an athlete, coach and trainer for the 14 years before that, it made sense that 3 days of inactivity might make me a little stiff. But a week later, despite stretching, foam rolling, getting in a couple of light workouts and even trying some cold-water dips, my knees felt worse. This marked the first time in my adult life that rheumatoid arthritis would plague me for more than a few days. That six months changed me forever.

 

My friend (and a fellow PPSC-certified trainer) shared a concept with me a little while ago that I think is important:

EVERYONE HAS A CERTAIN NUMBER OF USABLE HOURS IN THEIR DAY

 

Usable hours mean you can work, train, serve others, be out running errands, handle the general stress of life, etc.

 

Most healthy people have 8-12 usable hours.

 

You probably lose a few as you age. You can cut some of those by living in a chronically stressed state or by having an unhealthy lifestyle. But a SEEMINGLY healthy adult who battles a chronic illness might be working with only 3-4 usable hours a day. Living with unseen challenges like chronic illness or an autoimmune disease AND trying to function in a world that continues to demand productivity, results, work ethic, hustle, drive and no excuses can be incredibly difficult.

 

For me it meant depression, isolation and the profoundly devastating realization that I couldn’t continue working in fitness. How could I demo a squat, lead a yoga class or inspire a client if I couldn’t even walk up the stairs to the second-floor gym without pain?

 

It felt like I had lost myself to this unpredictable, unmanageable demon that would plague my knees for weeks on end but then also show up in my neck on Monday, my wrists on Wednesdays, my spine on Thursday and my jaw on the weekend. It didn’t matter if I was well-hydrated, tried to stretch before bed, went to a massage, ate nothing but athletic greens for a week or took high doses of pain medication.

I paid the bills by picking car parts at an auto warehouse for six months and it was all I could do to finish an 8-hour shift without limping or hiding in the stacks sobbing because the passion and fulfillment I had known in serving people through fitness felt lost to me. My career taken from me without a say in the situation. Or, at least I thought.

 

Deconstructing Chronic Pain

Chronic pain is widely varied and generally misunderstood. It is defined as pain that lasts for 3 months or longer. It can occur anywhere in the body and it can range from being mild & annoying to so severe that it disrupts even simple daily activities.

Anyone can get chronic pain.

It’s more common in older adults but it is NOT a normal part of aging. Older adults are more likely to have long-term medical issues like diabetes or arthritis, which can lead/link to chronic pain.

What causes chronic pain is not always clear. It can come from physical injury, inflammatory triggers or because brain chemicals that usually stop pain after you get better from an illness or injury are not working properly. Damaged nerves can cause the pain (called neuropathic pain). And often, chronic pain occurs without a known cause.

As I’ve worked with individuals who have autoimmune conditions and chronic illnesses, I’ve noticed that stress can trigger or exacerbate their pain. I’ve noticed things like work-life balance, nutrition, sleep, mindset, and exercise can be critically important. How resilient your support system is and how your practice self-care are just as important as the weather forecast and the latest headlines in the morning news. All of which leads us to evaluate in real time with a simple,

 

“How are you feeling today?”

 

And, in general, dealing with all these things seems to make them more susceptible to the bacteria/viruses that have “normal” adults missing 1-5 days of work/training. In the case of compromised individuals, it can take MONTHS to “recover.”

Part of what can be so hard in dealing with chronic pain is how the medical system works. Seen & unseen biases affect communication, access and treatment plans, and the realization that research and success in these areas is still in its infancy.

When I was a very young child I was diagnosed with “Juvenile Rheumatoid Arthritis” after about 2 years of visiting different specialists, running countless tests and being passed around like a hot potato. In their eyes, how could a 2-year child even express what their symptoms might be?

 

When I was a very young child I was diagnosed with “Juvenile Rheumatoid Arthritis” after about 2 years of visiting different specialists, running countless tests and being passed around like a hot potato. In their eyes, how could a 2-year child even express what their symptoms might be?

Today, a simple internet search shows 9 different diagnoses within that juvenile category and another 13 organizations that all serve adults with varying diagnoses in other categories. And that was just large national resources for one single country.

For every client/person I’ve met who has been given a “firm” diagnosis, I meet at least 2 more people who have similar pain & symptoms but are in the frustrating gray area of inconclusive results. The frustrating wait for the long lists of specialists for another crack at figuring out what is going on without being dismissed as simply “in my head”. I admire people who do their best and try to maintain a sense of hope. I completely understand people who throw their hands up in the air and try to move on with generic medications, huge sacrifices in their quality of life and constant pain.

 

Exercise & Chronic Pain

I want to be really clear before this article continues:

*I’m a certified personal trainer with a BA in Psychology.

*I have attended lots of certifications and availed myself of lots of webinars, home-study courses and informal mentorship opportunities with both fitness and clinical educators.

*I have served clients with a very wide range of goals & abilities for more than 15 years.

But I’m not a doctor.

What I’m offering is anecdotal & relational. I’m sharing a perspective.

 

 

I’m encouraging you to get empathetic, curious and seek to understand. I’m offering things that work for me and my clients but a big part of earning the right to help them in finding a way to succeed in the gym has come from letting them be the experts in their pain. Let them decide where to draw the line. Understanding the unnamable and indescribable nature of their experience means that my knowledge is only a road map.

Driving the actual road is a very different experience and the person behind the wheel, the client, gets to make the actual call on speed, direction and when we pull over for a pit stop.

That being said, I feel honored to have participated in a lot of “road trips” with incredibly brave and inspiring clients. Here’s a few things that have yielded consistent success.

 

Energy vs Intensity

Just like all clients, some days feel good and some days, not so much.

Attentive pre-session check-ins have been really important. All clients do a Train Smarter Strategy Session and we discuss what we want to achieve, what I recommend working to improve and what makes training fun and enjoyable so that each client has a personalized program. Knowing that they have apprehension around pain, I typically am much more transparent about their program than with clients who just want weight loss or muscle gain.

Give the client copies of the program ahead of time and communicate that workouts are meant to be a guide and can be modified at any time. This trust helps create space to communicate and ensure they look forward to sessions vs. fearing exercises that are challenging or the perception of exhausting splits.

Ask about their energy level. How much good quality sleep they got the night before, where they stand on fuel & hydration for the day and any life stresses that show up in the session.

 

*Coaching Tip*

I use numerical scales, ex. “How much energy do you have today, 1 being very low and 5 being very high?”

It takes time to build the trust, but I try to be someone who can listen to embarrassing or uncomfortable symptoms or experiences without judgement or shame. Changes in digestion or elimination, skin conditions that flare up, embarrassment around needing to ask for help with simple tasks or challenges they face in their relationships or work environments.

These are all symptoms a client would normally hide unless they were a space they deemed comfortable.

Just like stress can exacerbate pain, shame is corrosive to mindset and self-worth. I try to get clear of what I can help with vs what extends beyond my professional scope. But even if I don’t have an answer for them about something, I can hold space and listen, sharing the load without taking it on.

 

The Session

What that means to how the workout actually gets executed for the days is that we sometimes decide to reduce volume, intensity or duration to make a better match to their current state. I really want to find a way to help them feel successful because just showing up can be a huge win so if we can execute against any part of the workout guidelines, that boost in confidence can be really helpful.

Increase the time spent in P1, P2 & P3 (Soft tissue and corrective phases) of the 6-phase dynamic warm-up.

Pain is a sympathetic driver. So maximize the parasympathetic focus of the first block of the warm-up and the exploratory component of the corrective phase.

Decrease the volume or intensity of working sets (less set/reps/load) and/or change the variation of the foundational movement pattern by choosing an exercise that is lower down on the pyramid.

Clients with chronic pain are still humans and need to move in the ways that all humans move. Helping them learn these movement patterns so they can move correctly and efficiently can make it easier to navigate the daily tasks of their life even with chronic pain. Remember, all deadlifts are hinges, but not all hinges are deadlifts!

Increase parasympathetic breathing time at the end of the workout.

I will sometimes incorporate fascial stretching or percussive therapy at the same time, but the client gets specific direction on crocodile breathing or supine 90/90 breathing before they leave the gym. Making this a non-negotiable with painful clients has been a game-changer.

Decrease workout duration or frequency during long-term flares.

If we were working out for 60 minutes 3 times per week and higher levels of pain are just not decreasing, drop to 2 times per week and/or 45 (or even 30) minute sessions. Think back to those usable hours – clients with chronic pain might go from 6-8 usable hours during “remission” down to only 2-4 hours during flares. If we use too much of that time in training, then the daily demands of their life mean they start reaching into “overtime.”

 

Knee Pain

Knees are always the first place I feel a flare and the last place to settle down. As much as squat/hinge/lunge/push/pull/carry is my training philosophy I definitely have to make some adjustments for myself and for clients who are dealing with inflammation/pressure, pain, limited range of motion and increased sensitivity.

 

Replace Goblet Squats with Suspension-Assisted Squats

Suspension allows us to decrease the knee flexion requirement by leaning back and unloading bodyweight into the arms/pull movement. It’s also easier to play with depth without the fear that getting back up will be too hard. The benefit of maintaining a squat pattern in the workout is that any activation/strength we can maintain in quads, hamstrings, glutes and core translates to improved performance in things like getting up out of a chair, using the toilet and being able to lift kids/groceries, etc.





 

Replace Lunges with Split Squats

It’s been my experience that inflammation and pain makes the little proprioceptive reactions of balance harder. Maintaining 2 points of contact throughout single leg training (and even adding a stick or wall to hold onto) can be really helpful and increase confidence.





 

Hinge MORE

Since hinges are hip dominant and strengthen the posterior chain, if we are challenged to find any comfortable ways of performing knee-dominant squats/lunges/split squats we can still leverage the hinge. I still hinge relatively heavy weights even on days that my knees are bugging me.

Movement encourages the movement of blood and fluid throughout the body leaving a rejuvenating effect. Emphasizing this protocol allows me to mentally check the box I crushed the workout without feeling the crippling effects of crushing my body through insensitive training methods.





Hand & Wrist Pain

Especially with arthritis, hand & wrist pain can be frustrating because the actual big working muscles & joints feel ok but the hands/wrists can’t bear getting loaded up or managing positions required to train.

 

Replace push ups with cable presses

The wrist extension required to get into a push up can be prohibitive. Changing the exercise to a cable press allows for the wrist to stay in a neutral position and different handles (especially fat gripz) can be more comfortable. Added bonus – we don’t have to get up and down off the ground (super slow-motion burpees).





 

Modify pull exercises with hands-free options

We love irradiation for overall recruitment – but in this circumstance – grip requirements can be a really limiting factor when arthritis attacks the joints in the hands. Using the ankle cuff attachment and wrapping it around the wrists or using a tool like the CFX trainer make pulls accessible. We all know how important pulls are anyway – this is even more important when pain makes clients more sedentary than usual.





 

Use Manual Resistance

One of my clients suffered a stroke and, upon returning to the gym, was dealing with hemiparesis (stroke on the right side of the brain affected muscle tone and coordination on the left side of the body.) The left limbs were limp and had a lot of atrophy. Their left side would also move on its own/not follow the intentioned path of motion. Using a free-hand and user-directed path of motion equipment (like DBs and cables) was frustrating.

So we started using manual resistance for certain exercises. I was able to adjust the amount of pressure to match the strength of the limb and the contact provided proprioceptive feedback that helped direct the path of movement.





 

Conclusion

Painful humans are still humans. The benefits of pillar stability, dynamic scapular stability, functional lumbar & hip synergy, etc are just as (if not more) important to help clients move, train and manage their lives.
The confidence and resilience that we get from pursuing fitness can be literally life changing.

After 6 month picking auto parts, I finally realized that the only thing that would save me was finding my way BACK to fitness. I let go of the expectation of pro-athlete level performance and started to win back basic function, scaled strength and all the mental and emotional benefits of moving my body. I began to celebrate small successes and serve others with my passion.

Implement the PPSC system. Continue educating yourself and learning deeper to serve your clients. But most importantly, lead with your humanity and your empathy.

I see, everyday, that the actual cure for pain is love.

 

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ABOUT THE AUTHOR

  • Becky Peterson
    December 28, 2020 at 9:14 am

    Excellent article! Training is for everyone and those clients in constant pain need it even more I think. Some really great things here. Thanks Logan!

    • David Otey
      December 28, 2020 at 10:44 am

      Logan brought the heat with this one!

  • Jen Kates
    December 28, 2020 at 12:58 pm

    Great article, Logan! I work with a few clients who experience chronic pain and disease, and this is spot on. Pick the lowest hanging fruits to make movement a reality for them.

    • David Otey
      December 31, 2020 at 7:53 am

      Love to hear you are already practicing what the article is preaching!

  • Cara Bryant
    December 29, 2020 at 5:05 am

    From one arthritic joint to another – Brilliant article.

    • David Otey
      December 31, 2020 at 7:54 am

      Thank you, Logan is awesome!

  • Amiee
    December 29, 2020 at 11:04 am

    This is absolutely so inspiring! Thank you for sharing this here! I love that fitness and training isn’t “one size fit all” with you. Great piece!

    • David Otey
      December 31, 2020 at 7:54 am

      Absolutely! We are in the business of changing lives via troubleshooting situations.

  • Tyler Buckingham
    December 30, 2020 at 9:53 am

    Brilliant. I absolutely love learning from Logan! Knowledge, empathy, & expertise in every post, article, & message. Thank you!

    • David Otey
      December 31, 2020 at 7:55 am

      Logan is a true professional!

  • Christian Guerrero
    December 31, 2020 at 8:17 am

    It was great to read your story and get to know a little bit more about you Logan! I too have struggled with injuries and found that the best way to get past them is through sound training philosophy, specifically the principles of the PPSC!

    Also, I couldn’t agree more, the cure for pain is most definitely love.

    Thank you for the insight 🙏

    • David Otey
      January 3, 2021 at 10:58 pm

      Logan is a true pro so it was such a pleasure to get their insight on this!

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