For most business owners and operators risk management is considered time-consuming, laborious and expensive; but the truth is, it could be even more so if a system and plan is not implemented. The fitness industry is a high risk one; our daily work involves risking the wellbeing and lives of individuals with the advice that we give or don’t give.
Risk management is the combination of an event or a hazard and the probability of its consequences.
Risk management involves a systematic analysis of one’s business, finances, facilities and their related programs and services. A key reason for taking risk management seriously is that we are dealing with participants; therefore, risks arise. The implementation of a good risk management program can also serve as a customer service and marketing tool to attract clients to your facility. The easiest way to identify risk is to walk around your facility, inside and out, when it is empty, reasonably busy, and very busy.
These start as soon as you start your own business or become responsible for maintaining a facility.
These are the most commonly known and controlled risks and include access, ventilation, flooring, surveillance, and signage.
A number of changes have occurred in the training and education of fitness instructors over the years. Management has a responsibility to make sure that in addition to holding the required code of practice qualifications, individuals meet your organisation’s standards. These have increased with more outdoor training and Boot Camps which have become very popular over the past couple of years.
The fitness industry collects sensitive information from clients which must, by law, be treated according to the Privacy Amendment (Private Sector) Act 2000 and the Health Records and Information Privacy Act 2002 (HRIP Act). The key thrust of the Privacy Amendment (Private Sector) Act 2000 is that we can only collect information with the consent of the client. You must respect the privacy of your clients; therefore all of your records, paper, electronic or other media based (including backups), need to remain private and secure.
After you identify risk, you need to prioritise it with regards to its’ likelihood and consequence. By identifying the risks and then prioritising them according to Table A, you will be able to begin establishing control systems in a systematic and ordered manner. When you have identified and assessed a risk, you must implement a plan to address it, and then act on it. Too frequently centre management invests the time and money to put a risk management system into place but then does not follow up and review the system. Conducting routine audits is an excellent way of assessing progress and helps to identify unsafe features and conditions. Developing a risk management system is not only a safety measure but also a customer service and marketing issue. Dion has been involved in the sport, recreation, fitness and health industry for over 25 years as an athlete, coach, trainer, massage therapist, administrator, educator and researcher.
Department of Research and Development, North Norway Rehabilitation Center, Tromso, Norway. Department of Neurohabilitation, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway. Objective: To assess the effects of an intensive, multidisciplinary rehabilitation program for patients with early to mid-stage Huntington’s disease.
Interventions: A one year rehabilitation program, consisting of three admissions of three weeks each, and a five-day evaluation stay approximately 3 months after the last rehabilitation admission.
Main outcome measures: standard measures for motor function, including gait and balance, cognitive function, including MMSE and UHDRS cognitive assessment, anxiety and depression, activities of daily living (ADL), health related quality of life and Body Mass Index (BMI).
Results: Significant improvements were observed in gait function, balance, in physical quality of life, anxiety and depression, as well as in BMI.
Conclusion: A multidisciplinary intensive rehabilitation program in patients with early and mid stage HD is associated with improved balance, gait function, physical quality of life and with reduced depressive and anxiety symptoms. Huntington’s disease (HD) is a hereditary autosomal neurodegenerative disorder caused by an expanded Cytosine-Adenine-Guanine (CAG) repeat in the HD gene 1 . In recent years, the interest in investigating the effects of non-therapeutic agents for managing and improving the symptoms of HD has been growing.
In 2009, The Norwegian Directorate of Health initiated the establishment of a pilot project to investigate effects of HD patients’ participation in an intensive multidisciplinary rehabilitation program.
A total of 37 patients were enrolled in the rehabilitation program in the two rehabilitation centers in Vikersund and Tromso.
Information about the project was spread by posting information on the web sites of both inpatient rehabilitation centers, the web site of a specialized national competence center for rare diseases, and announcements through the Norwegian patient association for HD. The structure of the rehabilitation program was identical for both rehabilitation centers, with three in-patient stays of three weeks each during one year.
Family members were included in the program during the first few days of the first admission as well as during the evaluation stay. Barthel index, a 10-item rating scale, was used to evaluate the level of assistance needed by a participant to perform basic activities of daily living 27. Mini Mental State Examination (MMSE) was used to evaluate the participants’ general cognitive status.
The Hospital Anxiety and Depression Scale (HADS) is a 14 item self-report questionnaire, and was used to assess symptoms of anxiety and depression. The Short Form-12 (SF-12) a self-report questionnaire consisting of two component scores for Physical and Mental quality of life, respectively, was used to assess the participants? quality of life and participation and was assessed at the beginning of each admission 31.
For gait and balance variables, the linear mixed effect model of Analysis of Variance (ANOVA) was used to show mean changes from baseline (stay 1) for stay two, stay three and the evaluation stay (stay 4). For the remaining variables, comparison between baseline and the final evaluation was done using Paired t-test or non-parametric Wilcoxon Signed Rank test depending on the distribution of the data. The patient recruitment was based on physicians’ referrals, and only one patient who was referred did not meet the inclusion criteria.
There was significant improvement in gait (measured by TUG, 10MWT and 6MWT) from baseline through stay two and three to evaluation stay as shown in table 1. The results of the present study show that participation in a structured intensive multidisciplinary rehabilitation program is associated with improved balance, gait function, physical quality of life and with reduced depressive and anxiety symptoms in patients with early to middle stage HD.
From the start of the project, it was clear that this was part of patient health care quality assessment and improvement. It is important to be aware of some methodological considerations of the project.This study is not a randomized clinical trial, but a descriptive study over a period of one year, as part of the evaluation of the implementation of an intensive multidisciplinary rehabilitation program.
Strengths of this program include standardized protocols and systematically executed multidisciplinary approach, which had been carefully planned in terms of use of assessments, measurement points, aiming to have the same rater at both the baseline and final evaluation admission. Taken together the present study supports previous results from Zinzi et al (2007) that an intensive multidisciplinary rehabilitation approach can be useful in the management and treatment of symptoms of early and middle stage HD.
Participation in multidisciplinary rehabilitation program seems to be beneficial for persons in early and middle stage Huntington’s disease. A structured multidisciplinary rehabilitation program improves motor function and quality of life.
Interclass correlation coefficients were calculated to assess the relative test –retest reliability. In addition, every fitness facility has accidents waiting to happen, be they due to facility design, equipment malfunction or insufficient supervision, so considering this, caution should not be thrown to the wind when it comes to managing risk. A ‘hazard’ is something that has the potential to cause physical or mental harm, while a ‘risk’ is the likelihood that a hazard will actually cause harm. Many risk management initiatives are driven by occupational health and safety legislation and local industry codes of practice, which adopt a more reactive response. It is wise to ask a professional colleague or external consultant to look at your centre as they may notice risks that have always been there, but which you have never identified as a problem area.
The insurance coverage that businesses must have are Professional Indemnity ($2-$5m), Public Liability ($10-$20m), and Worker’s Compensation. Poor hygiene practices, failure to notice defective products and improper equipment design can also lead to problems.
In a case in the United States a health club was sued for US$320 million in punitive and compensatory damages for the death of a member who allegedly died because of nutritional substances that were recommended to her by a personal trainer. Ensure your staff have the appropriate qualifications when working with special populations. You cannot control recession, depression, inflation nor limited supply and increased demand. Sensitive information within the Privacy Amendment Act’s principles is defined as health related information, and it can be argued that this includes fitness assessments and prior medical disposition.
On a practical basis this can be covered in an overall privacy policy within your centre, or as part of the terms and conditions of membership.
You must retain the medical related and historical information about your members during the period they engage your services. If you implement proper elimination and reduction strategies, hopefully, you will not have to rely on your back-up plans. Likelihood is categorised into ‘almost certain’, ‘likely’, ‘possible’, ‘unlikely’ and ‘rare’.
Table A below has some examples filled in, but your club’s risks will depend on the nature of the facility and the clientele.


If you identify injuries or incidents that happen in a particular area, people slipping on the stairs for example, look at why it is happening and then do something to reduce its’ occurrence. The plan to eliminate the risk could involve researching the practicality and pricing of installing stair grips to the steps and setting a date by which the risk should be eliminated or reduced. Risk management is an ongoing process and should be evaluated monthly, quarterly and annually. A method of reviewing systems, equipment, practices, and procedures develops and this safety-conscious culture helps improve communication amongst staff. When your members and clients see that you are taking pro-active measures to make a safe and healthy exercise environment, it sends the message that you care about their wellbeing. His risk management expertise began in the United States where he consulted with city recreation departments, health clubs and universities. Effects of a One Year Intensive Multidisciplinary Rehabilitation Program for Patients with Huntington’s Disease: a Prospective Intervention Study. The disease is characterized by motor disturbances, psychiatric symptoms and cognitive decline 2,3. The present paper reports the quantitative results after one-year participation in the program. Participants were referred by their general practitioners or by specialists in neurology or psychiatry. The program consisted of up to 8 hours of various activities five days a week, from Monday to Friday, and one of the sites (Tromso) also offered four hours of supervised activities during the weekend. Most adjustments were made by a neurologist in order to reduce choreatic movements or other motor and clinical symptoms such as depressive symptoms and sleep disturbances. If necessary, additional follow-up for participants and family members was provided between the various rehabilitation admissions.
The program was established with-in the current reimbursement scheme for rehabilitation in Norway, with a daily reimbursement of approximately 3 000 NOK (equals 500 USD) per patient.
21,22 b) 10-Meter Walk Test (10MWT): the participant is asked to walk 10 meters as fast as possible.
Four items were rated 0-3 or 0-1, and rest of the six items were rated 0-3 for a total maximum score of 20 with higher scores indicating better performance. The maximum score is 30 points, with higher score indicating better general cognitive status.
Participants with a BMI lower than 21 were monitored by a dietitian during the full three-week stay. Participants reported significant improvement in the physical component score on the quality of life measurement when comparing baseline to evaluation (table 2). Additionally, only one cognitive measure (SDMT) showed significant decline, and no decline was observed for the remaining cognitive measures.
This implied that after each stay, a comprehensive medical report was sent to the referring physician and other relevant allied health care personnel. However, this is still only the second study looking into the effects of a multidisciplinary approach as treatment for HD. We hope that results from our study can contribute and inform care development for patients with HD.
We would like to thank all health care personnel in the Rehabilitation centers in Tromso and Vikersund. A novel gene containing a trinucleotide repeat that is expanded and unstable on Huntington’s disease chromosome. Taking a proactive approach by considering and implementing the following principles and practices could potentially save you millions of dollars.
Business risk insurance and income protection (especially for personal trainers) are also advisable.
The lawsuit stated that the client should not have been taking the supplements because she was also on medication for hypertension. Several NSW councils have developed policies with regulations in relation to the use of public space by commercial personal training operators. Instructors working on the gym floor need to be vigilant at all times and be on the look out for any ‘at risk’ situations. All the information we collect as part of our standard operating procedures within our centre can be deemed to be sensitive.
The integrity of the information must be maintained; if an unauthorised person accesses your gym management system or your client database or paper files, that integrity is jeopardised. It is also good practice to maintain it for at least seven years as per financial archiving standards. Do not spend time, money and effort to draw up a plan only to put in on the shelf to gather dust.
It is useful to allocate a member of staff the responsibility for monitoring and reviewing the system; this might be your OHS officer or an interested and proactive staff member. Having a good risk management strategy in place may prove to be more powerful and effective in the long-term than a creative promotional campaign. Dion has been involved in coordinating national sport championships in the USA and successful event management initiatives in Canberra including the Corporate Health and Fitness Challenge, Fitness and Health Expo, and the Australian Get Healthy Challenge, all of which he founded. There was also emphasis to implement of coordinated health care and social services for the patients.
Only one cognitive measure (SDMT) showed significant decline, while no decline was observed for the remaining cognitive measures. A clinical diagnosis of HD is typically made when an individual has overt motor symptoms and a family history of Huntington’s disease.
These studies showed beneficial effects and have also investigated sensitive standard physiotherapy outcome measures 10–15.
Results of the qualitative evaluation of the experiences of the participants, their family members and healthcare providers will be reported elsewhere. Based on referrals and the patients’ own preference, they were enrolled in the rehabilitation programs in the two sites. Furthermore, the program aimed at establishing good co-operation between the rehabilitation centers and the health care professionals in the participant’s local community, with the aim of securing adequate follow-up after participants completed the in-patient rehabilitation study.
The cost of a three-week program for each patient will hence be approximately 63 000 NOK (equals 10 500 USD). A 10-meters walking area has two meters extensions before and after starting and finishing line so that allows participant to start and finish walking smoothly. This test was assessed at the beginning of each admission, a total number of four assessments points. Even items from the Depression sub-scale and uneven items from the Anxiety subscale is also possible to rate 29,30.
All assessments were conducted by experienced staff, as far as possible, by the same staff member.
We found that the changes in two gait measures (TUG and 10MWT) exceeded the minimal detectable change values and therefore the changes are clinically meaningful. These results suggest beneficial effects of an intensive rehabilitation approach on symptom development of early to middle stage HD, and are in keeping with the findings reported by Zinzi et al (2007). The report clearly described the patients’ multidisciplinary needs, with a final medical report sent after completing the entire 1-year program. All patients had received a clinical diagnosis of HD, based on symptoms and known CAG repeat expansion, but we were unable to record the number of CAG repeats for the patients. Furthermore, in addition to functional outcomes, the present study seems to have contributed to increased establishment of long term and coordinated health care delivery for the participant.
In the future, it would be interesting to investigate whether this type of intervention will result less need for supportive care in long-term since this was not in a scope our study.
Furthermore, we thank the Norwegian Huntington?s Disease association and the Norwegian National Center for Rare Diseases for their support and input in the planning of this study. One of the issues for councils regarding the use of public spaces for fitness activities is risk management. Examples are; a member lifting a weight incorrectly or lifting too heavy a weight without a spotter. Someone diving into your shallow water pool would be a high priority risk since it is a potentially catastrophic consequence and likely to occur (from my experience in aquatics). Dion is a regular speaker on risk management at FILEX and on various topics including corporate health and networking at the American Alliance of Health, Physical Education, Recreation, and Dance (AAHPERD).
Average age of diagnosis is 40-45 years, but often symptoms have already been present for several years at the time of diagnosis 2. Additionally, two important multidisciplinary rehabilitation studies have been conducted 16–18. Additionally, the present project aimed at performing a more in depth quantitative evaluation by using a greater variety of assessments, including measures of quality of life, ADL function, motor and cognitive function throughout three times 3-week intensive multidisciplinary rehabilitation program. The project was submitted to the ethics committee who considered that a formal approval was not necessary (ref. Additionally, there were patient education sessions and group discussions for participants. The UHDRS motor and cognitive assessments were performed by the same trained professionals (JCF and MvW).
Furthermore, adding additional outcome measures (quality of life, UHDRS-cognitive battery and gait assessments), has strengthened previous results in showing that physical quality of life is improved and that specific cognitive domains (psychomotor speed, executive function) overall show no significant decline.


This may have contributed to a better understanding of the needs of the patients by their local health care personnel. Furthermore, it is important to note that patients in our study received slight adjustments to medication when necessary during the course of the program. In Norway the positive effects of the study have resulted in the establishment of permanent rehabilitation services for HD patients. It would be interested to know if it is possible to gain similar positive results with a shorter intervention program for instance 2 x 3 weeks intervention versus 3 x 3 weeks intervention during 12 months included cost-benefit analysis.
Finally, we would like to express our gratitude to all HD patients and their family and caregivers, for participating in this intensive program. When producing your risk management documentation summarise every activity that is done in your facility including the training processes and the safety precautions. Someone dropping a light weight on his toe would be a minor consequence and likely to occur. He previously served on the board of Fitness Australia, was President of Fitness ACT for four years, was on the ACT Minister’s Advisory Council for Sport and Recreation, and is currently Vice-President of the ACT branch of the Australian Health Promotion Association.
Disease duration is commonly between 15-20 years, but symptom development and severity vary greatly between individuals. Zinzi et al (2007) reported that early to mid-stage HD patients who participated in a two-year intensive multidisciplinary rehabilitation program, containing six in-patient stays of three weeks in a rehabilitation center, were able to maintain or improve their cognitive and motor function 16. Another goal was to obtain better retention numbers by closely following up the participants during the course of the program. Physical therapy focused on improvement of balance and gait, occupational therapy sessions included training of Activities of Daily Living (ADL) and cognitive function, fine motor exercises and assessment of the need for assistive devices.
A multidisciplinary team set rehabilitation short and long-term goals together with the participant.
22,23 c) Six Minute Walk Test (6MWT): the distance the participant walks within 6 minutes is measured in meters, 23,24 d) Berg Balance Scale (BBS), which consists of 14 subtests covering various activities such as static posture, transition, challenging positions, associated with balance control. All outcome measures used in the present study are widely used in the field of neurological and geriatric rehabilitation.
Our study accomplished considerably better retention with 31 out of 37 patients (83,8%) completing the full one year program, compared to Zinzi et al (2007) where only 25 of 40 patients (62,5%) completing the third rehabilitation period (first year of the study). Whether and how long the observed beneficial effects can be sustained needs to be assessed with longer follow-up. Economical evaluation of the intensive rehabilitation program is very interesting question but this was out of scope in our study.
By prioritising the risks, you can easily identify how much money to invest to change or modify that risk. Having owned his own fitness facility and massage therapy clinic in Canberra, Dion’s company now has five divisions comprising corporate health, education and training, online bibliographic services, business and life strategy, and event management. Dietitians followed-up each participant and a social worker and psychologist also offered individual follow-up. Each participant was discussed in a multidisciplinary team during each stay in order to secure optimal rehabilitation for each individual.
The quality of performance on each of the 14 tests was recorded using a 4-point scale gaining a maximum score of 56 points. The UHDRS Cognitive Assessmentwas used to evaluate change in cognitive function from baseline to evaluation stay 20, and includes the following tasks: a) Verbal Fluency Test, requiring the participant to generate as many words as possible beginning with a specific letter (F, A and S) in 60 seconds.
The Stoop interference test, an executive function task, measuring cognitive inhibition showed a slight decline of -0.04 points.
Our study demonstrates that HD-patients are able to complete a structured rehabilitation program, and possible explanation for the high retention rate in our study could be planned effort to assist and maintain regular contact with the patients in between stays, and that financial expenses with participating in the program were covered by the health care system. Moreover, there is a need for randomized clinical trials to study the effect of multidisciplinary intensive rehabilitation intervention on progression of HD, and it is important to investigate which participants profit most from such intensive rehabilitation. Future research is needed to evaluate of cost-benefit of intensive rehabilitation program among HD population with an appropriate study design. However, cognitive and behavioral changes are known to frequently occur many years before clinical diagnosis 4,5 resulting in functional decline already early in the disease 6.
All participants and their family members received written and oral information, and gave their written informed consent to participate in the project. Further information about description of rehabilitation program is in the Appendix, table A.
Overall there was no significant change in mean UHDRS cognitive scores among participants during the study period. The use of complex and long self-reported rating scales and long assessment batteries should be considered when planning future multidisciplinary rehabilitation studies and programs for patients with HD. Some risks may never go away; the only way to take away the risk of having a pool in your facility is to fill it up with concrete. Additionally, metabolic changes (increased appetite, weight loss etc.) and sleep disturbances are known to develop 4,7,8. Participants and caregiver?s who completed at least one course of the full rehabilitation protocol program (3-week intensive multidisciplinary treatment) reported improvement in physical function, swallowing, balance, increased independence, improvement in mood, less apathy and improvement in social relations 17.
The final and important goal of this project was to implement the establishment or initiation of coordinated health care and social services for participants, using a so called “Individual plan”. The participants in the present study all completed an evaluation stay three months after discharge of the third stay. Nurses observed and helped participants with reduced cognitive function or who showed problems in ADL function due to chorea. We found that an increased number of patients reported having, an Individual Plan, indicating that a larger number of patients have received established long term coordinated health care services.
If your facility has a successful swim school which is a big money spinner then it obviously shouldn’t be removed in order to eliminate the risk, but measures should be taken to reduce the associated risks.
Current treatment of persons with HD consists mainly of symptom management and improving quality of life 7.
Another study is a pilot study comparing participation in a multidisciplinary rehabilitation program (once a week over 9 months combined with home-based exercises three times a week for 6 months) with a control group of early to middle-stage HD patients. An Individual Plan is a statutory tool for co-operation between patient and local health care providers or the labour and welfare organization to secure long-term follow-up for persons with chronic diseases and disabilities in Norway. For all participants the following demographic information was collected from the medical records at the time of the first admission: age, gender, marital status, estimated disease duration. The results of the study suggest therapeutic benefit and good tolerance of multidisciplinary rehabilitation 18.
It contains an outline of patient’s goals, recourses and the services he or she may require due to disability. Additionally, baseline clinical characteristics were collected using standardized assessments, including the motor, functional and behavioral assessment of Unified Huntington?s Disease Rating Scale (UHDRS) 20. Assessments a) – d) were completed at the beginning and end of each admission, resulting in a total of seven assessment points.
Information about patients’ medication use according to disease stage at baseline is in the Appendix, table B. Currently, there still is a lack of randomized clinical trials investigating the effects of multidisciplinary rehabilitation programs or other forms of non-medical treatments.
Assessment e) was completed at the beginning of each admission, generating a total of four assessment points.
It’s not required that patient need to receive specialist healthcare to receive this plan and it can be used at any level of health care services.
It also specifies when the different actions are to be carried out and who is responsible to execute these actions 19. Dietary intake in adults at risk for Huntington’s disease: analysis of PHAROS research participants. Sleep and circadian rhythm alterations correlate with depression and cognitive impairment in Huntington's disease. Effectiveness of Physiotherapy, Occupational therapy, and Speech Pathology for people with Huntington’s disease: A Systematic Review. Client and therapist views on exercise programmes for early-mid stage Parkinson’s disease and Huntington’s disease. What effect does a structured home-based exercise program have on people with Huntington’s disease? Effects of an intensive rehabilitation programme on patients with Huntington’s disease: a pilot study. Patients’ and caregivers’ perspectives: assessing an intensive rehabilitation programme and outcomes in Huntington’s disease.
The effects of multidisciplinary rehabilitation in patients with early-to- middle-stage Huntington’s disease: a pilot study.
A 12-Item Short-Form Health Survey: construction of scales and preliminary test of reliability and validity.



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