Barbell Medicine - From Bench to Bedside

In part one of this article series we discussed terminology, incidence, and the implications of spondylolysis and spondylolisthesis. In this second and final installment, we’ll discuss returning to training, sport, and competition.

The majority of Barbell Medicine readers dealing with back pain or who have been diagnosed with spondy are likely concerned about returning to strength training. When clinicians think of strength training, they often picture absolute max-effort events with hundreds of pounds on the bar. But returning to barbell lifts such as the squat, bench press, and deadlift can be scaled with an initial goal of exposure to the movement building gaining capacity, before transitioning back to a focus on strength gain. 

Starting Out

As soon as someone can move through a full range of motion and tolerate activities of daily life without symptoms, they are okay to begin working with a barbell or other loaded implement again. The trajectory will depend on an athlete’s goals and training history. In some instances this may involve a bar weighing less than the standard 20 kg — but once again, the initial phase is just to “train” more than “gain”.

The equipment available to a person determines the training options available to them for rehabilitation. We will lay out advice for returning to the barbell lifts in an ideal scenario. There is no need to purchase specialty equipment, and people can change the intensity of exercises with the equipment they have in order to train productively. As mentioned above, we will set an arbitrary cap on the intensity of effort during the rehabilitation phase using an RPE of 7.

A beginner lifter can likely continue on their prior path following a program such as The Beginner Prescription or The Bridge, although they may need modifications in the early phase such as lowering target RPE by 1-2 points, and/or reducing the total number of work sets based on tolerance. A more experienced lifter who is used to running a low-rep scheme for their working sets (e.g., 1-3 reps) may need to transition through a block of training that would be considered more “hypertrophy”-oriented with higher rep targets and lower absolute loads.

The time frame for a return to fully “normal” squat, bench, and deadlift training can vary for each lift and from person to person. While the competition form of the lift may not be feasible, all exercises can be appropriately modified to where an athlete is performing some variation.

Squats

A safety squat bar (SSB) can be a useful tool as a means of axial loading using exercises such as a Hatfield squat. This allows the athlete to stay more upright and not force as much spinal extension in the early phase of training. It bears repeating that lumbar extension is perfectly fine in normal training conditions, but as movements are being reintroduced in a rehab context, constraints may be necessary to build tolerance. If SSB variations are not well-tolerated, an athlete may need to begin with a goblet squat using lighter weights while improving range of motion and control.

Machines such as a hack squat or leg press can also be used in the reintroduction phase. The initial goal is to have more constraints in place before allowing more freedom of movement as an athlete progresses. However, even as an athlete returns to a barbell back squat, these machines and variation of bars remain useful as supplemental exercises.

A typical programming scheme might involve squatting twice per week for 3-4 sets of 8-10 repetitions, working up to an RPE cap of 7. The movements can be done with a SSB or standard barbell, and a pin squat can be substituted if an athlete is having difficulty hitting their desired depth. The primary goal of the first session is to establish a tolerable range of motion, which will increase in subsequent sessions. In this way, the target RPE of 7 is anchored to “one pin lower than last session”. The goal of the next session may be increasing weight at the same pin height, and RPE is anchored to loading through that range. The time frame for increasing intensity will vary by athlete but we expect a typical athlete to tolerate full range of motion within 2-4 weeks. It is perfectly fine to wear a belt, knee sleeves, and shoes during this phase if desired, although these are not absolutely necessary either.

Bench Press

The bench press is typically limited most by the high-arch competition setup. Rehab can begin using a feet-up or flat-backed setup relatively early. Once again, pain symptoms are the primary indicator for progression. An athlete may be able to tolerate a feet-up bench press early on and can use this and a means of continuing to train. A machine chest press can serve as a substitute if bench pressing is not tolerable. Once ready to work into more spinal extension, the feet can return to the ground — or slightly elevated off the ground on plates — and begin working on leg drive and returning to the desired arch position for the competition-style bench press.

Another way of introducing lumbar extension is using a dumbbell incline bench press. With RPE still capped at 7, an athlete can begin to work into pressing with spinal extension with minimal risk of increasing symptoms. The same 3-4 sets of 8-10 reps, up to a cap of RPE 7 is a reasonable reintroduction strategy. As an athlete progresses, we use a hypertrophy-style, higher-rep training block before working up to heavier loads for low-rep sets at higher intensities.

Deadlift

Contrary to popular internet lore, it does not matter if a person deadlifts using conventional or sumo technique. To reintroduce a deadlift pattern, we can begin with any of a variety of exercises such as good mornings, Romanian deadlifts, or deadlifts from elevated blocks. An athlete may benefit from utilizing a sumo stance early on to allow for a more upright torso, although this may not be necessary. If an athlete finds one variation that is more tolerable than others, it can be used more for a training effect, whereas other variants for an exposure effect. This may look like the following:

Session 1

Any well-tolerated deadlift variation:

4 sets of 8 repetitions at RPE 6/7

Session 2

Any less-tolerated deadlift variation

4 sets of 8 repetitions at RPE 5 or 6

Session 3

Machine Hamstring curls

3 sets of 10 repetitions at RPE 9

Single-leg Romanian Deadlifts

3 sets of 8 repetitions at RPE 7

Conditioning & General Physical Preparedness (GPP)

The role of conditioning and general physical preparedness training cannot be overemphasized in this phase. The question is often whether an athlete needs to work “through”, or work “around” a problem. If training intensity is necessarily limited due to rehabilitation constraints, people will benefit from more exercise variation in other areas. This can involve continued use of machines or dumbbell exercises, and continuing to use movements involving spinal extension and rotation.

In this phase it is imperative that an athlete not “lose sight of the gym for the bar”. In other words, they should not become so focused on straight barbell-based movements that they forget to continue with a more broad-based fitness regimen.

We recommend using multiple exercises to emphasize lower back strength, and avoiding a myopic focus on conventional barbell deadlifts alone. These include glute-ham raises, back extensions, good morning variations, back extensions, and reverse hyperextensions. While we don’t have good scientific evidence for specific strengthening of the area, it stands to reason that the stronger an athlete’s back, the more stress it can tolerate in training and competition.

Returning to Sports Participation

As the diagnosis of spondy is seen more frequently in sports involving spinal rotation and extension such as baseball and gymnastics, we will also consider broad recommendations. Each sport will require individual starting points and emphasis, contingent upon the skill level of the athlete as well. A level 7 gymnast will start with a different set of exercises than a level 4. Following the same progression for rehabilitation, the “light and slow” phase may involve more movement-based skills that are not as challenging. For a baseball player, this could involve starting soft toss or swinging a wiffle ball bat.

There are times when an athlete may only need to shut down from competition but can still participate in drills and practice in a limited manner. Absolute rest, or even very limited rest with a “motor control”-oriented rehabilitation program often ends up creating an additional problem. While an underlying injury physiologically heal, the athlete is now out of shape and unprepared for return to sport. Most often, there is some exercise that can be tolerated as a means of staying in shape while progressing through rehab.

While the primary rehab focus is on addressing lower back symptoms, the overall goal is a full, safe return to sport. If an athlete has spent three months performing 2 hours of “rehabilitation” per week with the goal of returning to 10 hours of sports participation, no amount of exercise in that time frame can adequately compensate for the volume of training lost. If an athlete is able to train, even with low intensity cardio work, they are better positioned to return to sport as overall volume and intensity increase.

As an athlete begins to tolerate full range of motion without symptoms through slower movements, speed needs to be gradually reintroduced. A baseball player may progress from soft toss to limited pitching off the ground or mound. A gymnast may progress from single stunts to chaining multiple stunts together. This does not mean that they forgo basic strength training; as part of general physical activity guidelines, adolescents and adults should be all participating in strength training at least twice per week. This does not mean every athlete needs to be using a barbell, but external load is necessary to facilitate adaptation for both health and performance. What constitutes “sufficient” load is also unique to the person, and we favor using autoregulation (RPE) as a means of determining that load on a daily basis. It is also perfectly safe and encouraged for youth to participate in resistance training. For parents interested in reading more on this topic, we have a whole series that can be found here

Returning to Competition/Full Intensity

After an athlete has returned to training/practice, the next question is ultimately when it is appropriate to compete or perform max effort lifts. The last phase of the rehabilitation progression is “heavy and fast. It is common for a lifter to progress to 75-80% of prior lifts and experience a stall. Often this is as much due to confidence with the weight as it is ability, and a small jump in weight can create a dramatic increase in the perception of effort. If this occurs, it can be advantageous to use “drop sets” in programming. For example, if a set of 4 repetitions at 315 pounds is rated RPE 7, but 4 reps at 325 pounds is rated RPE 10, it can help to program small drops in weight and emphasize speed through the repetitions. If an athlete can perform a lift for significantly more reps at the same effort with a 3-5% drop, this can be a means of building confidence back for maximum effort.

For a ball sport athlete, exercises need to be integrated into contact drills (where applicable) prior to return to sport. It is one thing to perform a movement in a sterile setting without an opponent, and another entirely to have an opponent in the way, giving their best effort to keep an athlete from moving how they want. It also may involve playing different positions to limit maximum effort in the initial phase. For example, a baseball player may need to start out on first base prior to transitioning back to the outfield to limit long throws. The process will be different for each sport and it is necessary for coaches and rehabilitation professionals to understand the demands and be able to apply the time and space necessary to prepare an athlete for return to sport.

To summarize the overarching concept: no parent would think it a good idea to have their child take three months off from a subject in school then return to a test. We should not take that approach with sport either, as competition is ultimately a test of their athletic development.

Wrap-Up

While it can sound scary to receive a diagnosis like spondylolisthesis or spondylolysis, outcomes are good with conservative care, including modifying activity and limiting competition. Athletes do not need a specific set of exercises; they may benefit more from broadening the scope of their training during rehabilitation to remain as conditioned as possible for their sport as symptoms settle down. Without a specific mechanism of injury, it is difficult to correlate symptoms with findings on imaging tests like X-rays and MRIs. In the adult population, “acute” spondys are rare, and when they do appear on imaging, could also be from a prior activity.

If you are struggling with your rehabilitation process, you can reach out to the Pain and Rehab team for a consultation and assistance with returning to the activities you love.

Special thanks to Dr. Austin Baraki and Dr. Salinda Chan for their help with this article.

About Derek Miles

Derek Miles is a residency trained physical therapist currently working at Stanford Children’s Hospital as the Advanced Clinical Specialist in the rehabilitation department. He worked at the University of Florida prior for 10 years in sports medicine treating a variety of athletic injuries from overuse to post-operative. He is involved in the peer review process for academic journals and has spoken at national level conferences within the physical therapy profession. If not treating patients or in the gym Derek is likely either cooking some form of meat or reading books related to various random topics. He occasionally brews a pretty good American Pale Ale as well.

Read More by Derek Miles

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