November 05, 2012

Hysterectomies, Core Exercise, and Firing Clients: Ask the Personal Trainer

Hey kids, it's time for the next installment of "Ask the Personal Trainer!"

And notice how I'm using photo selection as a subliminal way to butch it up around here, so the whole hysterectomy thing doesn't scare off the boys?

Oh wait. A cute vintage image of a body builder, however muscular, is perhaps not all that manly and macho a design choice.  Dudes: just pretend there is a photo montage featuring football heroes, pitchers of beer, big juicy steaks, large-breasted women, and any other gender stereotyped eye-candy that will help you sneak past references to womens' malfunctioning uteri and the surgical removal thereof.

If it's any consolation, we feel the same way about sitting through those endless erectile dysfunction commercials. Do we really need to have to visualize a bunch of elderly guys walking around with 4-hour erections?

And actually, you don't have to have a uterus to require abdominal surgery, so there's good info for anyone who recently had a surgeon hacking around in their insides.

Plus, deep core work is good for everyone's physiology, and might be the actual answer to all those searching for the "one rule for a flat stomach".   (Though I think the REAL rule is stay the hell out of the cookie jar).

And we're also going to talk about unmotivated clients and whether to kick 'em to the curb or not.  

Note: there was also going to be a rotator cuff question this week, but I realized it was crazy to run so many questions at once, so that will appear next time.  Stay tuned!

First question:

1. If you are working with a client who has had a recent hysterectomy, assuming she has clearance from her doctor, how do you help her rebuild her core muscles and exercise generally without risking post-surgical injury or damage?

Taylor Ryan: 

 [Taylor Ryan is a certified personal trainer and nutrition consultant; check out her personal blog Lifting Revolution for tips, recipes, workouts and more!]

Dealing with a women that has just gotten clearance from her doctor to get back to exercise is something I am accustomed to! Working with only women I deal a lot with issues like this quite often.

First, I would explain the importance of focusing on strengthening the core (the connective tissue is cut and the core loses strength). Then take baby steps to get back into doing core exercises. Doing too much too soon can slow internal healing and do more harm than good.

Good exercises include:

Pelvic tilts, where you lay as if you’re going to do a sit up. Instead, push your back flat to the ground by tucking the tailbone under and tightening the core muscles. Relax and repeat.

Knee planks. Doing a full plank may be too much, so it’s best to start with a knee plank. Same idea, make sure the but is tucked under, and the shoulders are directly over elbows, engage the core muscles and hold for as long as possible.

And finally, a great core strengthening move would be using a stability ball. Crunches on the ball, or even a knee roll outs. Sit on knees, facing a stability ball. Place elbows on it, and slowly roll the ball away from the body, keeping the back straight and abs tight. Go out to a comfortable distance, but one where you can still feel the abs working, and roll back to start position.

The thing to keep in mind is not to do too much too soon. Sure, you might have been doing leg raises the day before surgery, but trying to do them as soon as you’re allowed won’t be a great idea.

Chris Kelly:

[Chris Kelly is a fitness writer, personal training studio owner and frequent dispenser of burpees. He specializes in quick and effective workout routines to fit fitness/nutrition in to a busy schedule. Check out his blog at Peak Wellness online.]

Many years ago while conducting a bootcamp, we were performing jumping jacks as part of the warm up. On this particular day, we had several new participants in class and around rep 28 of a set of 50 (give or take) two ladies made the comment that they had to use the bathroom.

Clearly an excuse I thought to myself as I instructed them to keep going to around rep 45-- when it actually happened! Both new moms seeking to get back in shape, these very nice ladies illustrated to me that many of us share issues faced by those who have experienced a Hysterectomy.

To put this to the test, one simple test we perform with all new clients is a simple plank hold:

- Bad plank:

- Good plank:

As we compare each image, we see one resembling a terrible dance move while the other demonstrates the ability to maintain a relatively flat back. What we also find is that individuals who assume this inchworm like posture feel their arms and legs without a hint of their core.

This is an almost certain indication of a loss of function of the muscles of what we call the inner core. The inner core is made of a group of muscles deep inside our body (transverse abdominus, multifidus, diaphragm and pelvic floor) whose job is to stabilize the movement of larger muscles such as our arms and legs during movement.

This means that every time we take a step or raise our arms overhead, the inner core muscles tighten around our joints to ensure proper movement occurs. Though they are too weak to produce the movement themselves, they simply contract statically (think holding in place versus moving) to ensure larger muscles are kept in check.

The interesting thing about these muscles is that they are often inhibited in individuals with chronic neck, low back and pelvic pain. While sit ups and crunches might make a nice six pack (or case of back pain), they do not address these muscles and usually make the problem worse.

The reality is that rehabbing this issue and developing a flat stomach involves the same basic progression which can benefit everyone (click each step for an instructional video).

Activate the proper muscles- An issue that accompanies the majority of the issues described above is stress breathing. The is a key player in inner core function and training deep belly breathing is a crucial to improved function of this area. I recommend performing the drills included in our video for 1-2 minutes in the morning and before bed to each the muscles of the inner core to activate normally.

Use your abs- The next step is to learn to contract the abs and butt during core exercise to ensure core exercises are hitting the right muscles.

Train Muscular endurance- Once we have established basic belly breathing and abdominal bracing, the next step is to improve static endurance in exercises such as the plank, side plank and bridge. The key with each exercise is to keep the abs and butt contracted while maintaining belly breathing.

Floor no more- Once we have gained endurance in static position, the final step is to add movement and train in standing positions which more resemble daily life.

Get Ripped- Here is a progressive routine for all readers interested in developing real results with exercises which can be done quickly in your own home.

Dave Smith:

Dave Smith is a personal trainer who specializes in quick and effective body weight exercise routines that can be done anywhere, anytime - Check him out at

It is so important to strengthen the "core" muscles after having any abdominal surgery since it's the core that provides stability and a base of strength for all other exercises. Too often people are injured while doing "easy" exercises like squats or lunges, not because their legs are weak but because their core is not providing proper stability for the exercise to be performed safely.

In this video I demonstrate a series of core strengthening exercises that I use with clients who are post-surgery, post-pregnancy, or who have very weak core muscles to begin with. Notice how the exercises build off one another to allow anyone to safely work towards a more advanced core training program.

Video: How to Strengthen Your Abs After Abdominal Surgery


Here are some things I learned from my own hysterectomy recovery:

When the experts say "start slow" they ain't kidding.  You can be in amazing shape before your surgery, but if you take the time off your body needs to heal, and are at least minimally concerned about not ripping your guts open by doing too much, it's amazing how rudimentary you have to get in terms of ab work. And it takes a really long freakin' time before you can challenge your abs the way you used to.

On the plus side, many of us who thought we knew what we were doing about core/abs work discover that we really had no clue all along!  Getting introduced to those muscles deep inside, and actually trying to activate them properly was a huge frustration and occasioned much cursing and whining. But it's also pays off in terms avoiding back problems and other injuries down the line, so it's time well spent.

If you are an active person and recovering from a hysterectomy or other surgery, and have insurance or a large bank account, I'd strongly recommend you push your doc for a referral for physical therapy.  If it's a hysterectomy, there are folks who specialize in that.  (If you happen to live in San Diego, I'd recommend Comprehensive Physical Therapy, they're awesome).

Most doctors seem unused to working with active folks who are eager (and perhaps too eager) to get back to the gym, and are a bit at a loss as to specific exercises that are bad or good.  And even the most helpful personal trainer is not going to know the details of  your surgery.  A physical therapist can be a great bridge between your physician and your personal trainer if you have one, or your plucky self-help exercise plan if you don't.

In general, my understanding is that the most dangerous moves after a hysterectomy tend to involve lifting your legs while on your back, or doing anything that exerts too much abdominal pressure on the pelvic floor.


 Another great resource for post-hysterectomy support and ideas is HysterSisters.

Next question:

2. What do you do about unmotivated clients, and do you ever "fire" them?

Dave Smith:

To me, "firing" an unmotivated client is admitting that I couldn't do my job. Do I do it? Nope.
A good trainer will always find a way to help even the most unmotivated clients take steps in the right direction. While it's unrealistic to expect every client to eat perfectly, exercise intensely, and sleep 8 hours every night, it is completely realistic that they can begin working towards those goals.

I have a list of "healthy lifestyle actions" that my clients rate on a scale of 1-10 (1 = impossible to do, 10 = 100% doable). This list includes a range of actions with a few that are so simple (yet still important and effective) that anyone can rate as a 9 or 10.

For example, one of the actions asks clients to "drink a glass of water each morning when they wake up" while another suggests "taking an omega-3 supplement each day" and the list goes on.

The point is that everyone can do something to work towards better health. An unmotivated client might simply choose that morning glass of water (and even that might be a struggle at first!). But, they are taking action and are beginning to assume responsibility for their health and for reaching their goals.

Chris Kelly:

I wouldn't use the word "fire" as much as guide in the right direction. I feel very strongly that finding the right trainer for your personality and comfort level is key to achieving success and this comes down to understanding what you really want.

With both personal training and small group training we conduct at our gym, we feel very strongly that developing a long term approach-- which includes setting specific goals, discovering interests which help you to maintain motivation such running a 5k or joining a softball league and overcoming scheduling issues-- is essential to getting results.

Basically, we teach clients to eat, schedule and enjoy fitness in addition to just working out at our gym. This is a fairly long term process and weeds out a lot of individuals who would rather attend a larger bootcamp fairly infrequently or casually go to the gym. In the beginning, we go thru a very thorough interview and workout session to understand the needs of each client and whether they are a good fit for our system.

Here is a letter I publish frequently for our clients to illustrate what we look for in an ideal client:

You say you want to lose weight, build muscle or lose body fat more than anything. You tell me it is a 10 out of 10 on your bucket list. If so, here are my questions for you:

  • Do you show up 10-15 minutes early to warm up properly for each workout?
  • Are you in the right frame of mind (aka no cell phone, talking to friends, etc) to train when you arrive?
  • Do you devote time on the weekends or week day to plan and/or cook your meals?
  • Do you devote 30-45 minutes to exercise in your off-days?
  • Do you have a training partner that supports your goals?
Look, I am all for everyone having fun and enjoying themselves when we work together but once the session begins it is down to business. My job is to offer effective coaching and information to get the result that you need. Your job is to take the steps necessary to get that result.

The reason I feel training is awesome is that it is all about you. What other opportunity in life do we have today to devote 60 minutes to building your goals and your body? I want you to focus on making this the best part of your day.

I am proud of all you are achieving and I hope you have a great week.

Taylor Ryan:

To date I have yet to “fire” a client. Because I do small group classes, one bad seed can bring the whole group down. I’ve seen it happen, it’s no fun... for anyone. When a client is unmotivated it’s normally because something else is going on. They’re paying for my services so clearly they want results... they’re motivated.

When they seem to be in a funk, the best solution is simply to sit down one on one and find out what’s going on. This helps for several reasons.

For one, you get to the bottom of it, and make them aware of their attitude (surprisingly enough, some people don’t realize when they’re being pains in the butt), and second, it shows you care. They appreciate the time given to them, and often times just realizing that one thing can make all the difference.

Because this has always helped, I haven’t had to say adios to clients, but I would in a heart beat if the negativity continued on. Everyone deserves stress relief from a workout, and if it’s causing stress, then get rid of it!


I don't do personal training, but I do life coaching and wellness coaching, and often deal with people who are looking to get into better shape. Maybe I'm just lucky, but I've never had to "fire" a client either for lack of motivation.

(Is that because most of my clients come from Cranky Fitness? Hmm, it does seem like the impressive thoughtfulness, perseverance, and resourcefulness of my clients are consistent with the awesomeness of blog commenters here generally!)

That's not to say that folks haven't had ups and downs, but often this has more to do with outside circumstances or changing priorities. If it's purely motivation that's an issue, I've found that clients have an amazing ability to inspire themselves and work their way through roadblocks.  Often just a few questions, some brainstorming and troubleshooting, and a bit of planning can restore what feels like "lost" motivation.

Thanks so much, Personal Trainers!

Also, I wanted to let readers know that in anticipation of the challenges over the holidays, Chris Kelly has teamed up with expert nutritionist Graeme Thomas to host a free 28 day fitness BOOST challenge, which comibines community accountability with a custom fitness and nutrition program geared to your goals.

The deal is:  you sign up with a friend who shares your goal. The program is set to kick off in early November and they are accepting the first twenty applicants on a first come, first serve basis.  For more information, check out our BOOST webpage and you can contact Chris at

What do you think about core work, recovery from surgery, trainers or coaches firing their clients, or anything else?  And if you've got questions you'd like to see dealt with in an upcoming column, leave 'em here or email me!

Evil Ab Thing: Jesup Gym
Bodybuilder image: Velvet Tangerine


  1. Excellent info on post-abdominal surgery workouts especailly about avoiding leg lifts. Good to know. I don't need, but someday I might and I do not want to find out the hard way.

  2. As a spine specialist, I can say for certain that crunches are one of the absolute worst exercises for the spine. There are so many other safer, more effective things you can do to strengthen the core that I have no idea why crunches became the movement of choice. I have a six pack and haven't done a crunch in 15 years.

    Early on in my career, I used to fire patients that weren't following my instructions. It was just so frustrating when I cared about their health more than they did. But over the years I have changed this viewpoint. I think it's important to meet a client where they are and try to be an inpirational guide more than a dictator. I have much more fun in my office this way, and clients come to realize that I love them either way. You never know when it's going to "click" for them and they're going to finally go for it.

    1. Great input, Dr. Mark-- I knew crunches had fallen into disfavor lately but didn't know why. Sounds like it's not doing the back any favors!

      And it's great that you see yourself as a guide rather than a dictator; wish more folks in the medical profession framed it that way as well!

    2. I came to this page as a recent level three spine fusion patient. I am in outpatient physical therapy and taking water and core classes at our gym. That's for your site:)

  3. Thanks sooooo much for the post op advice and exercises!! While I could find some of the exercises mentioned above during my post-op recovery research, I could not find a progression of exercises and how to measure when it is time to add more to the workout. As I was released a couple of weeks ago to start working out this is perfect timing.

    Also, my Dr wouldn't give me a prescription for physical therapy. :-( Since there is no standard protocol for post-hysterectomy rehab, she didn't think it would be worth it. Although, she did mention "no crunches" and no trail running on steep downhills (my favorite), as the core muscles would not be strong enough to keep my body stable & upright if I started to slide/slip.

    Yes, I'm 50 year old woman (or a woman that just celebrated the 25th anniversary of my 25th birthday) and I love to run on the edge of out of control on steep, rocky, dirty, muddy, trails with snakes, rabbits, tarantulas, bobcats, deer, and various other varmits joining me.

    1. Darn it that your doctor isn't a physical therapy fan! But sounds like your the determined sort who will figure it out and do as much as you can without injuring yourself.

      And wow, I'd be chickensh*t to run down hills like that! Well, I'm a klutz too, so no doubt would go tumbling.

      Glad the trainers were able to help and also glad you stopped back. Hope you become a Cranky Fitness regular!

  4. First, thank you. The trainers posts are a lot more helpful than I had hoped for.

    I had been somewhat unmotivated and excuse maky post hysto - I am seriously gifted excuse maker and my face is sufficiently pliable to make for strong emotional looks. BUT I think I can do these suggestions and I have a new interest in planks which I had sort of poo poo'ed before. Hubs read your post and we watched the videos together and he is going to help and take pictures of me so I can see what my form looks like and what I can do/feel to get the form right. He is going to do the exercises with me!

    I needed to be told what to do and why. Yep. Hugs all around to my virtual trainers. Invaluable help since it is not really discussed in depth at the docs or even online.

    Meanwhile I will mindscrub that geezer with the marathon erection out of my mind. Ditto for Theisman and his prostate issues. Gag. Can't exercise those problems away. Yep, even the petrified wood.

    1. Goodness you crack me up. And don't know if you've gotten to the end of the "no hanky-panky" post surgery restriction, but be careful with all that romping around with the hubs and the video taping and all. You may have to take a cold shower and not just from the exercise.

      And "petrified wood"--love that!

  5. I've talked to my current and previous personal trainers about the topic of "firing" clients who half-ass their way through life but expect miraculous results from a few sessions, and they have both "fired" or "declined to continue working" with at least a few people during the courses of their careers. I asked them about it because I observe (in real life and in the blogosphere) a great many people who do just that -- eat "whatever," "can't give up" pizza and beer after work on Fridays, "don't have time" to exercise outside of their sessions w/trainer, "had to" eat birthday cake last weekend, "can't do" intense exercise (the definition of "intense" is variable) and then complain that they "shelled out $$$ for a trainer and didn't lose any weight." A lot of people labor under the delusion that personal trainers are magicians and just by merely signing up with one, they're going to have the body of a fitness model in six weeks. A trainer is there to teach you how to exercise properly for your fitness level and how to improve your fitness level through proper nutrition and exercise; to motivate you, push you, turn your weaknesses into strengths and give you the confidence and desire to be strong, lean, flexible and have endurance -- to give you the tools to keep yourself healthy. Not to somehow make you lose 15 pounds in six weeks just because you show up for your six sessions and do nothing else the rest of the time.

    1. Wait, personal trainers AREN'T magicians? Damn, I was misinformed!

      Great comment -- I've been lucky enough not to run in to that many whiny overindulgent slugs but it makes me feel sorry for personal trainers who have to deal with them!

      Although the "had to" eat birthday cake? Guilty as charged!

  6. For some reason the reply did not work. Anyhoo, I came back to tell you that I did all the exercises suggested and planks - jayzus! Good idea to do the knee. The videos really helped. Also using the ball to roll out really worked (great description). Thank you trainers.


    You must have a vulcan mind meld with me on the hanky panky. Seriously, nobody talks about that. I was/am? iffy on testing the surgeon's sewing skills. Things are still jockying for position in the abdomen and there have been a few elbows thrown. I wonder at the wisdom of using my "stump" - lol - as a punching bag. I think less violence is in order these days.

    OK TMI. But seriously. Nobody sez.

    1. Check out the Hystersisters site, the post-op section. There's a lot of hanky panky discussions. I haven't seen any mention there was TMI from anyone.

      And a double thumbs up to trainers advice & videos. Great exercises and good progressions.

    2. Well shoot, munchberry, sorry about the reply thing. I hate when blogger screws up because I have NO CLUE how to fix it.

      But yeah, BC is right, hystersisters is great for TMI hysterectomy discussions, including the hanky-panky prohibition!

  7. Yes, i remember having to take core work slowly after each kid. It took me a while to get basic strength back in that area.

    As for firing people, it seems a shame, but i can see how there are some people who are just not a good fit with certain trainers.

    1. Having no kids myself, I have such admiration for how you moms somehow manage to bounce back after having them--seems like such a radical thing to do to a body!

  8. I suppose I could search the archives of your blog but I am lazy tonight. Have you (Crabby) talked about how to find a trainer? I am ultra lucky in that the trainer I am currently with is free to me and others for a few months, curtesy of a city program to promote fitness! He's also over 50 and relates to some of the challenges these older bodies have.

    In the past I have looked for a trainer that I would have had to plunk down some bucks for, but all I could find were yuppy-yappy college age kids that don't relate well to the older client. Perhaps I have been just unlucky.

    And the many are so into the "Let-us-sign-you-up-and-take-your-deposit-because-that-is-how-we-make-money and we-know-you-will-quit-in-a-few-weeks-anyway" mindset, a gal doesn't feel they really care if they help you or not. Nor do they believe you will be dedicated in any way for any length of time.

    Have you done a posting on such things m'dear?

    1. Sorry Sherri, no I haven't written a post like that, but it seems like a really good topic! I'm too cheap/cranky/inflexible to have done more than a 3 session package once when my gym was running a special. The guy was pretty good but that was just random luck.

      Wonder if your current trainer (assuming he's not available once your program is up) would have some recommendations? I'm thinking either word of mouth or local trainer websites that articulate a philosophy you agree with might be a place to start. Maybe that would make a good trainer question for a future post--they may know how to spot the knowledgeable ones from the pretenders. In fact I just saw a groupon today that offered personal training certification for $149 and all you had to do was take a quick online course and an open book test!

      And yeah, there are indeed some scammy gyms out there. I've had pretty good luck with Y's, and the bigger chains like 24hr fitness or Golds. But then my expectations about getting "help" beyond access to equipment and some sort of locker room are pretty minimal.

      Good luck!

    2. Thank you for saving me the time to hunt and search to see if you had covered this topic. :)

      We are hoping we can get the current trainer to work with a small core group of us old fogeys at least once a week for a reasonable fee. He has shown interest in doing this, so we are hopeful!

      I am too, I mean FRUGAL to pay for many many sessions of training. I just want someone to tell me to do this, this way and that, that way and do this many reps. It is least at this point, for me to have someone there to help me get my form right and to suggest doing this or that machine, in the right ways.

      btw, I have put a link on my walkerlady blog to your blog here. I hope you are ok about that?

    3. I think it's really smart to get some trainer help; it probably would have spared me some clueless injuries if I'd been better about getting help myselft to learn proper form! And a group training session sounds like a great idea for keeping costs reasonable.

      And thank you so much for the link, I really appreciate it!

  9. I couldn't even begin to comment on all the things in this article that I enjoyed. This is a great series and I look forward to the rotator cuff.

    I did agree with the trainer on one bad seed in a group training environment. It can be tough stuff. I so like my current group and how much we support new people that I am always a little stunned if I try a new group and it tends not to be that way.

    Wonderful post!

    1. That's great that you found stuff to enjoy, and we've already got some good stuff lined up on the rotator cuff and more in the works. Sorry for the delay!

      So cool that you have a great current group for training, it is amazing how one person can drag everyone down.

  10. I am late but you are not forgotten! I get these in my email late yesterday so if I am not on the computer at night, I response next day. :)

    Great sum up of ways to help people not only with recovery but just starting too! Always good to double check ourselves no matter how long we have been doing this! :)


    1. Thanks Jody, and I'm late too on replying to comments; exciting election yesterday got me distracted!

    and never fired a client :-) although AS a client I would probably have been unceremoniously let go...

    1. If anyone fired you as a client it would be because your obvious awesomeness would be freaking them out--hard to figure out how to improve upon it. :)

  12. (Dammit Exploder...stop eating my comments!)

    I am totally digging these trainer posts! Thanks Crabby! I'm definitely adding a few of these moves to my workout regime. Becuase while yes, I've had a few kids, let's not forget public enemy #1 for core strength: The desk job. And I has it. : )

  13. This is excellent material, Crabby!!

    Not that I wanted to learn any of it, but..too late, I did, so thank you!

    Most middle-age men now-a-days on erectile dysfunction meds with four hour erections still can't see them without a mirror!

  14. Hi Crabby,
    Like to add personal trainers improves your overall fitness and helps you in reaching and maintain a healthy body weight. Personal trainers take charge of your program, find the right way to workout and focus on your health concerns and find the best way of workout for you.
    san antonio personal trainer

  15. As I was surfing the net I was lucky that I found your blog. Seems an interesting outcome on your topic. It made me amazed. Thanks, keep on posting.

  16. great stuff. those exercises seem to be hard but worth trying

  17. I am 3 wks post op from da Vinci hysterectomy. I was very active before, running, boot camp, weight training and cross fit. My md released me to return to my bootcamp classes as long as I didn't do abs and core right away. I have attended 2 classes so far and have been able to do them not in my normal 100% beast mode, but certainly can feel it. This is the 1st place I have found with info related to hard core exercise post hysterectomy!! I have looked at hyster sisters blog but again sounded like people who have never exercised before. The boot camp that I attend is led by a personal trainer, and there are about 6-10 people per class. Everyone is so worried about me and think I'm doing to much. I'm following md instructions as far as doing abs, but I feel very sore. I am just nervous about ripping my insides out. My husband tells me your bladder and intestines are going to fall out in the floor and you will tell the trainer "be back in 1 wk". I'm just sore and feel pain and soreness in my abs and groin area, no unusual bleeding or anything like that. I just hope I would know if something wasnt right??

  18. My favorite trainer -- the one I've raved to you about, the one who swore we'd be working together till I was fully rehabbed (I have to stop believing men who speak with authority without substantial amounts of supporting evidence) -- is leaving the studio where he's been for 8 years, with comparatively very little notice, and so everyone from the owner and her husband down to his new clients from last week is ... in "some kind of place", as one of my friends puts it about something else, and so I am preoccupied and not productive at the least convenient time of the year for me to be that.



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