Should fitness instructors or personal trainers become embroiled in litigation, it is more likely than not that it would be within the field of civil law that deals with torts and contracts. The instructor or trainer probably would find him/herself defending a tortuous claim of negligence for having failed to act or for having acted in a manner that reflected substandard performance. However, there exists the possibility that the instructor or trainer could find himself/herself in violation of criminal law. If this were the case, it would most likely be a result of violating the scope of practice.
Scope of practice refers to the limitations imposed by law on different vocational pursuits, pursuits that require specific education and experience as well as demonstrated competency. Jurisdictions have their own laws, licensing bodies, and regulations that describe requirements for education, training, competency and those activities that fall within the purview of the practitioner. In effect, what the practitioner can and cannot do defines one’s scope of practice. However, when an individual who is not licensed engages in the practices of a licensed profession, then he or she is violating scope of practice.
The term “scope of practice” is used not only by national and state licensing boards for various professions to define the procedures, actions, and processes that are permitted for a licensee but also by professional associations like the American College of Sports Medicine (ACSM) to outline responsibilities and limitations for a certificant. For example, ACSM’s Certified Health/Fitness SpecialistSM (HFS) is “a degreed health and fitness professional qualified to pursue a career in university, corporate, commercial, hospital, and community settings.” The HFS is skilled in the following:
- Conducting risk stratification.
- Conducting physical fitness assessments and interpreting results.
- Constructing appropriate exercise prescriptions for healthy adults and individuals with controlled conditions released for independent physical activity.
- Motivating apparently healthy individuals with medically controlled diseases to adopt and maintain healthy lifestyle behaviors.
- Motivating individuals to begin and continue with their healthy behaviors (1).
However, any HFS who strays from this job description and overreaches his or her documented competencies, by intruding into the field of a licensed health care professional, is in violation of criminal law as a result of exceeding or going beyond one’s scope of practice. When this is the case, the HFS and other instructors/trainers may become guilty of a misdemeanor of the first degree and, in some cases, a third-degree or even second-degree felony.
When instructors or trainers take on clients, they basically are stating that they have sufficient knowledge of exercise science and an understanding of their clients’ capabilities to provide safe and progressive exercise programming. In effect, they take on the responsibility of exposing their clients to the stress of exercise without imposing undue risk for injury and, perhaps, even death.
Clients rightfully can expect that their programs will bring about positive change without harmful effects. Generally, clients anticipate that their instructors/trainers have a significant grasp of anatomy, physiology, and exercise science to ensure safe and effective workouts. Often, clients assume that because instructors/trainers have been educated in anatomy and physiology, they have knowledge, even medical knowledge, beyond that which is required for exercise programming. Consequently, it is frequently the case that clients will pose medical questions to their instructors/trainers.
Unfortunately, instructors and trainers, in a desire to live up to their clients’ expectations, may feel pressured to provide answers to their clients’ medical questions. Rather than explaining to clients that to answer such questions would be going beyond their training and expertise, instructors/trainers may give opinions about medical concerns. This opining could verge on providing a clinical diagnosis or practicing medicine or allied health care without a license.
In light of this concern of practicing medicine without a license, it is important that instructors and trainers share with their clients that health appraisals, to include medical histories, are screening devices and not to be construed as a medical evaluation. To ascertain that there is no confusion on the part of the client, the instructor/trainer should have the client sign a witnessed statement, at the end of the medical history form, similar to the following: “The undersigned swears that the information provided is true and correct to the best of his/her knowledge and recognizes that this health appraisal is not the equivalent of a medical evaluation or diagnosis.”
In a like manner, when the instructor or trainer is taking a client’s blood pressure, it is essential that the client understand that this action is for screening purposes only. Should the client’s blood pressure be abnormally high, the instructor/trainer ought not tell the client that he or she has high blood pressure but rather that he or she ought to be evaluated further by a physician. Instructors/trainers must understand, and their clients must recognize, that they are “suspecticians” not “diagnosticians.”
Similarly, if the instructor or trainer does lung function or spirometry testing for forced vital capacity (FVC) and forced expiratory volume for 1 second (FEV1), he or she may suspect that a client has emphysema. Analyzing the FEV1/FVC ratio enables one to determine whether a client has difficulty with expiratory efficiency. Again, this warrants referring the client to a physician who in turn may order additional testing to determine whether, in fact, the individual does have chronic obstructive pulmonary disease. The instructor/trainer should be careful not to identify specific disorders (e.g., emphysema) because he or she could be viewed as providing a medical diagnosis.
Many instructors and trainers are using rapid blood chemistry analyzers to develop a blood profile on their clients, a profile reflecting total, high-density, and low-density cholesterol; triglycerides; glucose; and other parameters. These portable analyzers could be used as a screening device or a mechanism to monitor, hopefully, positive changes over time. However, it is imperative that comments like “it may be time for statin drugs” are not offered because this type of counsel could be interpreted as medical advice.
For those people providing allied health care without a license, there are concerns about intruding on the domain of physical therapists, dieticians, and psychotherapists, as well as other health care professions. The following examples are just some of the areas in which instructors and trainers should be cautious to avoid any hint of going beyond their scope of practice and violating criminal law.
Many instructors and trainers as part of their initial assessments/evaluations will do a postural analysis of their clients. If abnormalities are observed, instructors/trainers are frequently noted to promote specific exercises in an attempt to correct postural deviations such as excessive lordosis, kyphosis, scoliosis, and abducted scapulae. They assume that stretching and strengthening exercises will encourage adaptive lengthening and shortening of muscle-tendon complexes and, thereby, improve postural alignment. Unfortunately, a review of the literature reveals a lack of reliable data to substantiate the claims that exercise, in itself, will correct postural deviations (4). Not withstanding this fact, the concept that instructors/trainers are testing for postural problems and then prescribing corrective exercises is tantamount to providing a diagnosis with subsequent prescriptive remedies. This falls within the domain of a physician or physical therapist and may be viewed as an instructor/trainer exceeding his/her scope of practice and violating criminal law.
Instead, the instructor or trainer who tests for postural abnormalities should describe such an assessment as a screening mechanism, with the idea of referring his or her client to a physician or physical therapist if there are suspicions of abnormalities that could affect the client’s health. Along this line, there are other abnormalities that the instructor/trainer may observe that would generate “red flags,” thereby warranting further medical analysis. Such concerns might include unnatural gait, excessive foot pronation or supination, squinting patella, varus or valgus postures, excessive Q angle, and upper or lower cross syndromes.
Instructors and trainers frequently are asked questions regarding injury prevention and treatment. Although the instructor/trainer, through application of safe exercise programming, may help clients understand the cause for and avoidance of unnecessary injuries, the concept of treating existing injuries falls outside of his/her domain. True minor strains and sprains may lead to an instructor/trainer’s recommendation that the client use the “RICE” principle (i.e., rest, ice, compression, and elevation); however, when it comes to other potential neuromuscular and/or musculoskeletal disorders (e.g., plantar fasciitis), referral should be the action taken. Although instructors/trainers may knowingly or unknowingly use modalities used by physical therapists, they are not licensed to practice physical therapy. Competent instructors/trainers know when it is appropriate to refer to a physical therapist and, by doing so, bridge the gap between fitness training and injury rehabilitation.
There have even been cases of instructors and trainers practicing chiropractic care without a license, for example, an instructor/trainer “cracking” a client’s back or neck in an effort to resolve “stiffness.” Chiropractic is licensed and regulated in all 50 states and provides an alternative form of medicine emphasizing diagnosis, treatment, and prevention of musculoskeletal disorders, with an emphasis on correction or treatment through manual manipulation or adjustment of the spine. The instructor/trainer who provides such spinal manipulation could cause permanent damage, in which case he or she could be found guilty of a felony subject to imprisonment and/or a substantial fine.
The practice of nutrition and dietetics without a license is all too often observed, especially among fitness instructors and personal trainers. Most states require licensure before one is able to write specific diet plans for clients. Frequently, instructors/trainers tell clients exactly what and how much to eat for every meal and, sometimes, what supplements to take. If instructors/trainers are well versed in nutrition, then it is acceptable and advisable to educate clients how to develop lifelong healthy eating habits. Yet, providing specific meal plans and marketing oneself as a nutritional or dietary counselor are illegal in most states, unless one is a licensed dietitian/nutritionist, licensed nutrition counselor, or registered dietitian.
In addition, in most states, there exists a state statute requiring that a person may not knowingly engage in the practice of dietetics and nutrition or nutrition counseling for remuneration unless that person is licensed by the state. A person may not use the name or title dietitian, licensed dietitian, nutritionist, licensed nutritionist, nutrition counselor, or licensed nutrition counselor, or any other words, letters, abbreviations, or insignia indicating or implying that he or she is a dietitian, nutritionist, or nutrition counselor, or otherwise hold himself or herself out as such, unless the person is the holder of a valid license issued by the state (3).
Most states also prohibit one from presenting as his or her own the nutrition license of another individual or providing false or forged evidence to a Nutrition Board or Dietetic Practice Council. Individuals are prohibited from using or attempting to use a license that has been suspended, revoked, or placed on inactive or delinquent status. Understandably, businesses or facilities are prohibited from using unlicensed persons to engage in dietetics and nutrition practice or nutrition counseling. A person who violates any of the above prohibitions is committing a misdemeanor of the first degree punishable by a fine and/or even imprisonment not to exceed 1 year (3).
To better accommodate the important relationships between diet, nutrition, exercise, and health, instructors and trainers might best serve their clients by aligning themselves with licensed nutrition counselors and/or registered dietitians. Having the availability of this type of referral network only adds to the professionalism of the instructor/trainer’s service and enhances the probability of client success. Some instructors/trainers will purchase computer programs developed by licensed nutritional professionals to legally provide detailed meal plans.
With respect to unhealthy nutritional habits and/or exercise addiction, instructors and trainers may find themselves working with clients who have an eating disorder (e.g., bulimia, anorexia nervosa) that requires professional attention. For example, orthorexia nervosa is a fixation on “healthy” eating that can lead to an “unhealthy” set of problems, especially when persons eliminate many products and foods from a normal diet. Orthorexia nervosa defines this subset of people who are obsessed with eating healthy.
Another potential concern is for the instructor or trainer who has an athletic client who exhibits behavior typical of the female athlete triad (2). Disordered eating, amenorrhea, and osteoporosis are the serious issues with which the trainer must deal. However, as with the client with bulimia, anorexia nervosa, or orthorexia nervosa, instructors/trainers should involve health care professionals trained to deal with the female triad. Clearly, personality disorders fall within the purview of social workers, psychologists, and behavioral therapists who understand the social ramifications of these problems. To ignore these grave conditions or to try to solve them without professional assistance is to go beyond one’s scope of practice and, ultimately, endanger one’s client. Cognitive behavior therapy and other modalities of treating personality disorders must remain with those individuals appropriately trained for such challenging work.
Although there exists a lack of statutory laws and/or detailed association standards (i.e., ACSM, National Strength and Conditioning Association, International Health, Racquet and Sportsclub Association) explicitly defining what is the scope of practice for fitness instructors and personal trainers, there are numerous guidelines found within published texts and authoritative literature outlining professional responsibility in this realm. It should be noted that there exists case law where instructor/trainers have been sued for practicing medicine or allied health care without a license. Standard of care (degree of care that a reasonably prudent fitness instructor or personal trainer would use under similar circumstances) must be the overriding philosophy in working with clients to ensure that one remains within his/her scope of practice and does not violate that of another profession.
Disclosure: The author declares no conflict of interest and does not have any financial disclosures.