T Nation

Question for Cressey

Hey Eric, or anybody for that matter who can answer these questions:

  1. I have a new client who informs me that he has a spinal fusion (complete) from L3 to S1. he neglegted to tell me this originally and it wasn’t until i started him on box squats that i noticed he had a real tough time getting any type of lordosis in his lumbar spine. he then informed me of this nugget of information. my question is, what should i do/know about training this guy? are there any specific exercises i must include and/or avoid. i have already found extreme weakness/poor coordination in his lower abdominals from where he had surgey.
  2. I have another client who tore his supraspinatus in a skiing accident over 17 years ago. at the time he did little rehab for it and the surgical intervention was to staple the muscle back onto the bone. now i have to train him and he absolutely cannot do any overhead work (no duh!) and it has resulted in him looking all slumped over. he even has a drinking problem because of it ala ted stryker in airplane the movie. i can’t do bar squats with him either because of the shoulder restriction (i was thinking of getting a hip belt squat from ironmind) and everytime he uses the arm above shoulder height he looks like he has cerebral palsy (no offense but that is the only way i can describe how weird it looks). have you got any suggestions for this guy?
    thanks in advance,
    sincerely
    mike cruickshank

[quote]MikeShank wrote:
Hey Eric, or anybody for that matter who can answer these questions:

  1. I have a new client who informs me that he has a spinal fusion (complete) from L3 to S1. he neglegted to tell me this originally and it wasn’t until i started him on box squats that i noticed he had a real tough time getting any type of lordosis in his lumbar spine. he then informed me of this nugget of information. my question is, what should i do/know about training this guy? are there any specific exercises i must include and/or avoid. i have already found extreme weakness/poor coordination in his lower abdominals from where he had surgey.[/quote]

I didn’t realize I had signed up for a Q&A column:)

Anyway, fusion surgeries can be performed for a variety of reasons, many of which are closely related to weakness in the core. You really can’t go wrong with plenty of core stability work. Start with the simplest exercises, concentrate on form, and progress as he gets more and more proficient. Keep in mind that by “core,” I don’t just mean abs; you need to work everything in manner functional to his activities and goals. Good starter exercises include prone and supine bridges, for example.

Also, I think you need to reconsider your approach to working untrained individuals. I’d estimate that 85% of the people that walk into a gym for the first time couldn’t squat safely, yet your first thought was to stick him on the box. Only after did you assess his core stability. You have to walk before you can run, and a toothpick certainly can’t be expected to support a boulder. Give him some opportunities to get proficient with single-leg work with less loading initially; there will be a good carryover to both his daily life and overall strength as you progress with him.

And, as with any client (especially those with injuries), everything must be symptom-limited. Constantly seek his feedback on what he can handle and what he can’t.

More to come…

[quote]MikeShank wrote:
2. I have another client who tore his supraspinatus in a skiing accident over 17 years ago. at the time he did little rehab for it and the surgical intervention was to staple the muscle back onto the bone. now i have to train him and he absolutely cannot do any overhead work (no duh!) and it has resulted in him looking all slumped over. he even has a drinking problem because of it ala ted stryker in airplane the movie. i can’t do bar squats with him either because of the shoulder restriction (i was thinking of getting a hip belt squat from ironmind) and everytime he uses the arm above shoulder height he looks like he has cerebral palsy (no offense but that is the only way i can describe how weird it looks). have you got any suggestions for this guy?
[/quote]

Yes; don’t do overhead work if it bothers him! I’m of the school of thought that feels overhead pressing is pretty overrated, anyway (depending on the goals, of course).

Seriously, Mike; you seem like a pretty bright guy. You ought to be able to put a program together without overhead work. Front squats are great for people with shoulder problems who can’t back squat, in many cases. It doesn’t sound like this guy is planning on competing as a shot putter in the Olympics anytime soon, so you’re looking at a general fitness program that’s much more easily designed than a sport-specific program.

Great post by EC, and even though I’m not him, I’ll try to help out here :wink:

  1. Do what EC said with the core/glute activation work. Also, it should be noted that with spinal fusion there tends to be hypermobility above and below the fusion. Think about it like this: If things are really tight in one area, other areas are forced to compensate. Therefore, the area you mentioned will be very stiff, but the areas on either side above or below it will be hypermobile to compensate. Something to think about.

  2. I have had great success using the safety squat bar when people can’t barbell squat. A few years ago I sprained a ligament in my wrist and couldn’t squat with a barbell for almost a month. I did tons of work with the safety squat bar and actually got STRONGER because of the poor leverages it creates. Something to think about if you have one available.

Stay strong
Mike

thanks for the response guys. eric, i didn’t mean to put you on the spot here, i just figured that of the hundreds of people who reguarly post here, you would be the most qualified to answer this question. i based it on the articles you have written and some of your other posts.
the box squats that i have the first guy doing are not axially loaded, i only have him doing them on the box so that he has something to catch him cause his hammies are too weak right now to effectively stick his butt back enough to control the motion. i am actually using a 2 foot box so the distance is not that great. i have been doing lower abdominal leg raises and will include some prone “bridges” with him using a dowel rod to closely monitor his lower back arch and overall alignment. can you or anybody else suggest some other core movements for the glutes etc. right now his routine is

  1. box squat with bodyweight (butt back almost like a powerlifter in order to emphasize the hamstring, glutes and low back. 3-4 sets of 10
  2. stability ball leg curls w/assistance 3 sets of 8 to 10 reps
    (i picked these cause hip lifts off a stability ball were basically putting this guy to sleep they were so easy)
  3. single leg step up holding dumbbells off a 1 foot box. 3 sets of 10 to 15 reps each leg
  4. lower abdominal coordination drill due to surgery he has a hard time using his abs on leg raises, he uses mainly upper abs and rectus femoris on the drill, so i have him put his hands on his ASIS and go a couple of inches in then a couple of inches down so that he can palpitate the insertion point of the abdominals. this seems to help him do a better job of recruiting the right muscles.
  5. normally i have him do grip work on this day, he is 65 years old and has noticed a tremendous loss in grip strength over the last few years, so much so that he has a hard time opening jars, in just a couple of weeks he has noticed a tremendous difference in his hand strength. i guess the only thing i could add on are some prone bridges for 3 sets of max holds into this routine.

Regarding the client with the low back fusion, get him doing sign. amounts of stability ball training. You can have him do wall squats with a stab. ball behind his back to help support his lumbar lordosis and prevent excessive trunk flexion which will significantly increase the compressive loading and shear on the lumbar spine. Lunges and step-ups are also good options. Also, he needs to do Prone on the ball alternate arm leg ext. , Supermans, I also have patients do reverse hypers on the ball, start with one leg at a time and then progress to two.
By leg raises, I hope you do not mean the old military style lie on your back and lift your legs 6-10 inches off the ground and hold. If this is the case, it is a bad idea for anyone with low back patholgy. In fact, it is an orthopedic test for low back pain. I would suggest focusing on his normal activities of daily living and to try to design a program that will increase his functional ability to perform those activities. If you would like further info, please feel free to ask, although more details of the guys ADL’s would be appreciated.

Regarding the shoulder client, I would send him to a chiro or phys. therapist, or PMR doc that specializes in sports injuries and that is trained in myofascial release. From the sounds of it, this guy has sign. ROM loss and his glenohumeral/scapulothoracic rhythm is messed up. It sounds like he has developed a type of frozen shoulder due to not performing rehab post surgery. While rehab exercise is going to be a sign. part of treatment, I think your effectivness will be limited unless someone addresses the underlying problem. If I am wrong in my assessment of his status, please let me know and I will be glad to suggest some exercises.

Take care