New trainee with back problems - need help to teach her to set her back, please

[Pieter Nagel]

I am humbled that a close friend, 40 year old female, has entrusted me to coach her. I have no coaching experience other than teaching myself from the grey and blue books, and watching coaching videos out of curiosity.

She has likely Ehlers-Danlos - hypermobile in wrists, elbows and ankles, possibly more joints, bruises easily, and has (invisible to me) scoliosis and a mild (?) but noticeable kyphosis.

I suspect cervical instability as well, because she gets frequent neck pain, up to the base of the skull, often needs to brace her head/neck with her hand because it feels too heavy, sometmes has vertigo when she turns her head too fast in the wrong direction, and has some signs of dysautonomia (episodes of sudden blood pressure spikes above an already elevated baseline, heat/cold intolerance and excessive sweating). I suspect mechanical irritation of her spinal cord by instable vertebrae.

The deal is that I will gently introduce her to weight training until she trusts that this will help her, then hand her over to a coach with gen-pop experience (no SS here, unfortunately, I am in South Africa). She is also planning to get evaluated and referred by a physio with experience with Ehlers-Danlos.

Enough background. My concern is coaching her to set her spine. Not surprisingly, her spine and scapulae seem very weak, and she can scarcely activate those muscles when cued. The "chest up" cue elicits no noticeable change in spinal curvature. I have taken her through the "lie on the floor and lift your shoulders/knees off the floor" exercise. She says she feels the muscles contracting, but her upper back barely moves a millimetre and the lower back I can't see moving. So I plan to keep reinforcing these reminder exercises.

I am currently taking her through progressively deeper sit-to-stand "box squats" until she can get into the bottom squat position. We are currently using a homemade wooden "technique bar". After two sessions her bench is at 4kg, her DL at 17kg (with a round back), and she's still learning a 2kg press with the empty bar.

Strangely, she is able to get a reasonably flat back when sitting in the bottom of the sit-to-stands, so I'm leaning towards loading the sit-to-stands with a little bit of weight when she reaches full depth, to reinforce where she has success. But I am torn between taking the press and DL veeery slow until she can set the back, versus putting them aside for a while, versus being worried that might cheat her of the strength gains and practice she needs to "rediscover" those muscles.

Also not surprisingly, her scapulae are very weak. When cued to retract her shoulder blades just a little bit at the top of the DL to make sure she is standing up straight, she shrugs them to her ears.

I suspect dead hangs from a chinup bar, combined with cues to retract her shoulder blades, might also help. She has said in the past that dead hangs (for the few seconds she can do them) seem to give her back pain a little relief.

Any advice?

[AndrewLewis]

She has likely Ehlers-Danlos

Your use of the word "likely" here concerns me. Is this your diagnosis, hers, or someone else's?

I suspect cervical instability as well, because she gets frequent neck pain, up to the base of the skull, often needs to brace her head/neck with her hand because it feels too heavy, sometmes has vertigo when she turns her head too fast in the wrong direction, and has some signs of dysautonomia (episodes of sudden blood pressure spikes above an already elevated baseline, heat/cold intolerance and excessive sweating). I suspect mechanical irritation of her spinal cord by instable vertebrae.

I'm not going to recommend anything regarding these details, because I don't know what's actually going on based on this post, so keep that in mind when reading my later advice.

The "chest up" cue elicits no noticeable change in spinal curvature. I have taken her through the "lie on the floor and lift your shoulders/knees off the floor" exercise. She says she feels the muscles contracting, but her upper back barely moves a millimetre and the lower back I can't see moving. So I plan to keep reinforcing these reminder exercises.

This sounds like a combination of weakness and control problems. I have never met anyone so weak that they could not learn how to move their body for these movements (if with assistance), so you may have to spend a good bit of time teaching her how to control her lower back. It may get frustrating and time-consuming, but that's part of the deal. Many people are bad at controlling their bodies, and you have to do a lot of work to get them to move correctly.

If you want to show us a video of what you're talking about, I'd be happy to take a look and give more advice.

Strangely, she is able to get a reasonably flat back when sitting in the bottom of the sit-to-stands

This is a good indicator that this is a control problem.

so I'm leaning towards loading the sit-to-stands with a little bit of weight when she reaches full depth, to reinforce where she has success. But I am torn between taking the press and DL veeery slow until she can set the back, versus putting them aside for a while, versus being worried that might cheat her of the strength gains and practice she needs to "rediscover" those muscles.

Focusing on success for someone this weak is a good idea. She needs to be pulling with a flat back though to incorporate those muscles and get them stronger. Can she get a flat back in a rack pull? Hard cases respond well to rack pulls starting high with a flat back, then lower it and do a set, and keep lowering it and do sets until it's on the ground. This should all take place in a single session, but it works very well.

Also not surprisingly, her scapulae are very weak. When cued to retract her shoulder blades just a little bit at the top of the DL to make sure she is standing up straight, she shrugs them to her ears.

Cuing retraction of the scapula at any point in the deadlift is misguided.

[Pieter Nagel]

I feel bad for disappearing on this topic, live intervened.

However, I have nothing but good news to report. In the end the "push your stomach between your legs" cue did the trick, and she is now setting her back well enough. There is still room for improvement, but she can train.

A lifelong ache she had in the middle of her kyphotic hump disappeared at around the 30kg deadlift mark, then reappeared when she had a 2 week layoff, then disappeared again when training resumed. So she is now even more motivated to train and set herself the goal of reaching a 70kg deadlift by the beginning of next year.

Ironically, her complaints to me were about neck pain, not back pain. She says that was because she was so used to the pain that the concept that it could go away didn't enter her head until it actually did go away.

Regarding the concerns about the amateur Ehlers-Danlos "diagnosis" - it is just a strong suspicion. She has had a lot of lifelong issues which fit that pattern very well, or at least some sort of connective tissue disorder. I recommended that she get herself evaluated by a physiotherapist that specialises in that kind of thing if she feels the need to get closure on that. But I get the impression that she no longer feels great urgency in this area since she has experienced for herself how much improvement she can make by herself by just getting stronger.

What angers me is this: she has complained of back pain and neck pain to GPs, neurologists, psychiatrists, and physiotherapists all her life. And not once has any one of them suggested to see if it squats and deadlifts help.

[Mark Rippetoe]

What angers me is this: she has complained of back pain and neck pain to GPs, neurologists, psychiatrists, and physiotherapists all her life. And not once has any one of them suggested to see if it squats and deadlifts help.

The poor things just don't know.