Have you ever been asked something so fundamental that you just did not know where to start? Imagine this scene: Little Jimmy walks up to you and asks, “Why is the sky blue?” To which you smartly respond, “Well Jimmy, the sky appears blue because of a light scattering effect in the upper atmosphere. The blue color is actually light bouncing off of billions of molecules of air.” You stand smugly, confident in your answer and mastery of all things hoity-toity when Jimmy asks, “Why does it work like that? Why isn’t the light that’s reflected red or NorCal Green?” Well…. In addition to noting Jimmy’s astute aesthetic observation that the sky would indeed be quite impressive NorCal Green, you are a bit stumped with fundamentally why things are the way they are. You can describe how something works, but the why is a bit stickier. This may be a stretch, but questions of scalability are a bit like this for me.

Most days one can find a question on the CrossFit message board along the lines of, How do I scale CF for my 56 year old mother, or a 9 year old female soccer player with exercise induced asthma, or…

The how of scalability is pretty straightforward: Start slowly and progress conservatively. The why of scalability seems screamingly obvious. “Don’t kill people” should intuit well, but I have seen both the How and Why buggered by physical therapists, moms, dads and cops. I think the etiology of the “aerobicizer in the headlights” phenomenon may be the under-appreciation of key concepts and a lack of real world experience. Regarding these concepts, I’d like to touch on some theoretical information so y’all will have a guide or framework to draw upon when considering programming for ANYONE.

Most of the questions regarding scalability concern what is normally described as a “special population”. Well, that’s crap. Anyone who has not done CrossFit or some other kind of high-intensity training (or who is de-conditioned after a lay off from these activities) is, in essence, a special population. Case in point: There have been a few near-miss fatalities in tough hombres like SWAT officers and SEALs who failed to appreciate the fact that ramp-up and progression are vital not just to success, but to survival.

Also, if you are coaching for a living, it helps to have better than a 5-10% retention rate of people coming through the door… but that is a topic for another day. Once I’ve bored—er—shared with you the theoretical stuff, I’ll use some real world examples of how we have modified training in our clinical practice at NorCal Strength & Conditioning such that we have both a high success and retention rate. As you shall see, rehab, prehab and scalability are intimately related topics and it is our intention to help tie all this together.


A Various Variety Of Variables

When we talk about exercise, whether running, lifting or, God forbid, cycling, we are usually concerned about some aspect of intensity. The classic death-wish aerobicizer tracks what % VO2 max they are training whereas the Everetts of the O-lifting world (both skinny (http://www.cathletics.com/images/gpc.jpg and studly http://www.crossfit.com/mt-archive2/Josh_Everett_050120.jpg) track what % of their one rep max they are training on any given lift. Knowledge of these relative percentages or intensities proves vital to effective planning of the training stimulus.

For those of you new to the game, Training Stimulus is analogous to Level of Ass Kicking. Want a big ass kicking? Dial the intensity up and do a bunch of it. Now the term Do a bunch of it is code for volume, and in this case it means a heap’n help’n of volume. There are a few terms that are related to intensity and volume and the relative level of fanny kicking that activity produces. These terms are loading or mass and range of movement or distance.

Here are a few mathematical considerations of these variables:

Work = Load x Range of Movement
Power = Work / Time

Other than being a geeky survey of mechanics, what’s the point? Well, in the context of scalability, increasing mass (load) or distance or decreasing the amount of time an activity is performed increases the intensity. In simple terms, lift a heavier weight, move it farther, move it faster, or in the case of running, swimming, rowing etc., get where you are going faster, and you have increased intensity.

As you recall, if you raise the intensity, you raise the ass-kicking-potential (AKP). So when someone asks “How do I scale a workout for my 56 year old mother?” they are really asking “what is a reasonable AKP for Mom?”

Let’s look at the squat as a generic example for these concepts and then delve into some of our clinical examples.

If you check out the CrossFit Journal on the squat, you will get a very thorough exploration of the movement and the common form errors. In its purest form, the squat involves moving from a standing position to a position in which the hips are below the knees and then returning to a standing position. That is the ideal. But what if our hypothetical mom is 5’ 2” and 267 lbs? Well… unless she has been competing in Strong Woman competitions, she is likely very deconditioned, weak and severely overloaded by her excess bodyweight. Is she still a candidate for the squat? You bet! But you must limit both range of movement and intensity to levels that allow for perfect form. How do you do this? Put a box behind her that is about 2” shorter than her bum. Get her squatting PERFECTLY to this box. How many reps and sets? If she is frail, perhaps only a set or two of five or ten repetitions in the first session. More than that if she is hardier. As she becomes stronger, you can incrementally decrease the height of the box, thus increasing her range of movement and consequently the amount of work performed.

Here is a good spot for a digression. The serious student of the training game might be asking the question, “What about Rhabdomyolysis?” How do I avoid killing dear old Mom? Well, in a word, that comes down to FAILURE. If you drive someone to failure you are creating an environment quite conducive to rhabdo. Why is that? Exercise causes some muscular damage, which is an element of rhabdo. Driving exercise to failure depletes ATP completely. This triggers enzymatic changes in the cells that allow calcium to enter the sarcoplasm, and this greatly exacerbates the damage caused to the cell. If you have a new trainee and you drive him or her to failure on a movement, you are guaranteeing this person will be sore. Do some serious loading on those same muscles in a few days, and you may be priming the person for a trip to the hospital or worse.

If the person is on statins, eats a very crappy diet, or suffers from certain lipid metabolism diseases, the amount of loading that can do them in can be amazingly small. As I learned from Craig Patterson of CrossFit Vancouver, BC: If the client begins to power down (fail), the client is DONE. This avoids both litigation and an empty gym. Nifty, eh?


Summary

Load Start things light, ya knuckle head! We have had people REALLY sore from less than 10 walking lunges. You really have no idea how little it takes to break someone off. Go easy.

Range of movement If structural limitations exist, limit ROM to that range in which perfect or near perfect form can be maintained. Examples are the squat and Health Lift (see figure 2).

Intensity People get all panty-twisted on this intensity term. Stop it. It’s nothing more than “What % of effort are you expending for a given activity?” If we are talking 1 RM back squats, then apply it that way. If you are talking a 400 meter run, what percentage of your best time are you looking at? For scalability issues, more intensity means more tissue breakdown, soreness and all that goes with it. Want to increase intensity? Increase the load, ROM or the speed in which an activity is completed.


Clinically Speaking

The following are case histories from clients we have trained over the past few years. I will describe how we used the variables of load and range of movement, with an eye towards work capacity, to design effective programming for each person.


Dolores

Dolores is a 45 year-old woman, 5’4” 232 lbs at our first meeting. She is a night shift nurse and has been a pack-a-day smoker for better than twenty years. Her nutrition, work capacity, sleep pattern and mental health are in shambles. In the technical parlance of medicine, she is a mess. Our first session involved rowing 1000 meters on a Concept 2 rower at a 3:40 500 meter pace. Dolores showed reasonable hip recruitment on the rower, although her range of movement on this exercise was quite compromised due to severe flexibility issues. We next looked at her shoulder flexibility using a PVC pipe for standing press. Dolores had some shoulder pathology and pressed somewhat forward instead of actually overhead. To compensate for this, she showed a common tendency to lean back to give the appearance of an over-head position. Many years of this type of movement have likely contributed to degenerative disc disease in her mid thoracic region. Dolores was severely compromised in her squat strength. She could not stand without the aid of her arms if she was in a standard office chair. Dolores showed a pronounced tendency to squat from her toes and placed severe sheer forces on her knees in the process.

Approach

We made suggestions to address several lifestyle factors. We recommended blackout curtains for her bedroom so the sleep she did get would be more restful and restorative. We recommended a Paleo diet with an emphasis on very low glycemic load veggies with only a modicum of fruit in the form of berries and melons. We utilized the Concept 2 rower extensively in the construction of mixed modal workouts. Dolores performed some form of squatting almost daily to a box placed approximately 2” below her bottom at full standing height. Frequently used movements included body rows, farmer's walks and push presses. Body rows were performed on low hanging rings and the loading was adjusted by slowly moving her feet forward. Dolores’s first exposure to the push press was with 2.5 lb plates in each hand. Farmer's walks were used to “liven up” the brisk walking she performed. In this initial stage, a sample workout looked like: 3 rounds of a 100 m walk, 10 partial squats, and 5 body rows.

Over the course of four months, using slow incremental progression, Dolores lost nearly 35 lbs (no direct body composition measurements were made; however, it is safe to assume that she gained a significant amount of muscle during this time, thus overall fat loss was in excess of 35 lbs), reached low-normal blood pressure from a previously hypertensive reading, and even quit smoking. She was eventually able to perform workouts with full depth squats, use dumbbells weighing 20 lbs on push presses and was able to run 400 meter repeats fairly easily.

I think two factors are responsible for this success. The first and most important was Dolores’s willingness to alter her lifestyle. The second is our insistence on perfect form on all movements coupled with reasonable progression, allowing for a constant sense of pride and accomplishment on Dolores’s part. This allowed for some challenge without crushing her and making the process feel insurmountable.


Carl

Carl is a 45 year-old male who has had six hip replacements. He suffered a necrotic hip injury at age 26 with a full hip replacement being the resultant treatment. Prior to and even after the injury, Carl was a high level athlete. In fact Carl achieved a significant skill level in Wing Chun Kung Fu. In the past several years Carl’s activity level has decreased while his wine consumption has increased. As a consequence, he has gained 20-25 lbs of excess bodyweight.

Considerations

In the case of a hip replacement, there are a few important points. The first is that certain movements such as crossing the legs (right leg over left in the case of a right hip replacement) turning the toe in (particularly under load) and squatting below 90 degrees can dislocate the hip. The other consideration is how long an artificial hip lasts. For most replacements, that is about ten years; however, this is based largely upon how much the limb is used. Younger individuals tend to be more active and this is why Carl has weathered six hip replacements in twenty years. Carl was keenly aware of the movement restrictions on his hip (no leg crossing or squatting below 90 degrees) and we discussed the tradeoffs as I saw them with embarking on an exercise program. If he lost weight, he would increase the life of his current hip as the decreased loading would mean less wear and tear. Counter to this, however, is the fact that increased activity would introduce MORE wear and tear. Obviously being fitter would mean other health benefits that weigh heavily in the overall cost/benefit analysis, but these are (at least to me) not clear-cut propositions. Then as now I do not know what the final story is with regards to the inherent tradeoffs. I tend to believe that improved fitness, even if it means a shortened life on his current hip, is preferable, but it is not my hip or my life!

Approach

Carl chose to undertake the program and we endeavored to introduce as much stimulus with as little ballistic loading of the hip as possible. Heavy emphasis was placed on the Concept 2 rower while squats were progressed from very shallow to a full 90 degrees. Perhaps counterintuitively, D-ball slams were a mutual favorite. A favorite for us because of the obvious demands of the movement and for Carl because he could smash the hell out of something. What about the prohibition against squatting below 90 degrees? Using the concept of limited range of movement, I had Carl throw the D-balls to a cinder block, thus shortening his range of movement to slightly above 90 degrees. We also made good use of the muscle snatch as it allowed for large range of movement and full hip extension with no ballistic landing inherent in typical snatching, cleaning and jerking.

Perhaps the most shocking movement to be included in Carl’s training was the deadlift, or as applied in his case, the health lift. Carl exhibited severe core instability with associated low back pain. Bum hip. Bum back. Bummer. We used movements such as sit-ups, planks and back extensions to re-establish core integrity but the abs and low back fire together in day-to-day activity and one should conduct most training in this way. We could draw from many movements to satisfy loading of the anterior and posterior musculature of the trunk, however why not go with a universal movement that elicits the greatest neuroendocrine response of ANY movement? The health lift proved to be hugely beneficial to Carl’s low back and provided no small amount of enjoyment to Carl as he was able to progress to some fairly heavy loads, all with a DECREASE in his day-to-day hip pain. Time will tell as to the wear and tear factor of the increased loading, but it is safe to say that quality of life, self-image and overall fitness have been dramatically improved.


Wrap

I hope this got you thinking about scalability and the fact that there really is no “special” population when you consider the totality of human movement. It’s easy to overdo any new activity and it is only through smart, incremental exposure that one may make progress and eventually find some level of mastery. Check out the Brand X site (http://www.brandxmartialarts.com/) for modified workouts and make sure to subscribe to the CrossFit Kids Magazine (http://catalog.brandxmartialarts.com/) for scalability, kids style (http://catalog.brandxmartialarts.com/images/issue2.jpsg).

Oh yeah. The next time you see that smarty pants Little Jimmy, why don’t you ask him why grains are the base of the food pyramid…