I Am Not My MRI
Yeah, that’s a MRI of my lumbar spine. The dark round thing in the middle is a large L5/S1 disc herniation that pinches on the right S1 nerve root. This was taken about 10 months ago, about 14 months after I was on the wrong end of a deadlift. For the first year, it was just mechanical low back pain until I woke up one morning with what felt like a strain to my right calf. Odd, considering I couldn’t recall a reason why. Then I realized it was related to my back when I could modify the symptoms by simply performing anterior and pelvic tilts. Uh oh…
So yes, I am a physical therapist with chronic back pain. It happens. Physical therapists dealing with injuries happens more often than many would think. And it’s probably a good thing, honestly. It keeps us grounded and holds us accountable to how we treat our patients. Many say the hardest person to treat is yourself, and I believe it. This post is about how I am managing my own back pain and how I sought out help when I needed it. I still have intermittent back pain, but the radicular leg symptoms are gone, and I am not limited functionally.
For the first year, I was managing the pain on my own through mobility work, core/trunk stability training, and taking Motrin as needed, which was fairly frequent. Truthfully, I may not have been the most compliant patient as the mobility and stability work were not performed daily. The initial severe pain reduced within the first week, and fortunately I never was out of work due to the pain. Over the course of the year, I had several exacerbations, especially when trying to increase my workout intensity and frequency. In the Army, we have to pass a semi-annual physical fitness test, and the sit-up event usually re-aggravated my symptoms. Over the course of the first year, I was definitely better than when the original injury occurred, but the overall progress and frequent exacerbations were frustrating. Once the right leg radicular symptoms developed, I knew it was time for a change.
When the radicular symptoms started, which included sharp glute and calf pain along with intermittent numbness and tingling in the foot, I decided it was time to step back from treating myself for a moment and simply be the patient. It started with a visit to my primary care physician. Due to the chronicity and severity of my symptoms, a lumbar spine x-ray was ordered and, because I responded well to it previously, a prescription for 800mg ibuprofen. The imaging results showed multi-level degenerative changes with significant decreased disc space height at L5/S1 (between the lowest back bone and the tailbone). I continued to self-manage for another six weeks until an unexplained exacerbation of the radicular symptoms that significantly worsened with the semi-annual fitness test in April 2017. After that event, I returned back to my primary care provider who decided to obtain a MRI. Two weeks later I was notified of my results and was referred to a pain management clinic. I thought the pain management consult may have been excessive, but I was stepping back and playing patient. At least I wasn’t immediately referred to a neurosurgeon!
It was a five-week wait from then until my initial pain management visit. During that time, I reached out to another physical therapist locally who was McKenzie certified (McKenzie is an evaluation and treatment approach not commonly taught in PT programs but can be effective). For me, my symptoms worsened with forward flexion but had no changes with extending backward. With this approach, you try performing repeated movements in a non-painful direction to see if it reduces the symptoms in the painful direction. I responded very well to repeated prone press ups, which has similar mechanics to extending backward. After performing 10-15 reps, I would have immediate reduced symptoms when flexing forward. So that was my homework assignment: 10-15 prone press ups every two to four hours. Additionally, my evaluating PT had a special motorized table (REPEX table, video below) I could be strapped into that would passively extend me. I looked and felt silly, but it worked to relieve the symptoms. I went to his office four times weekly for two weeks to receive this treatment.
By the time I saw the pain management physician for my initial evaluation, I was already doing much better. I brought him my imaging results, discussed my symptoms, and was thoroughly evaluated. Since I was improving, he did not recommend a spine steroid injection (whew!) and wanted to try a low dose trial of Gabapentin nightly to see if it would improve the mild radicular symptoms I was still experiencing. When I returned for my two month follow-up, the radicular symptoms were about gone and back pain was still improving. Based on his guidance, I continued to take the Gabapentin for an additional month as I continued to increase my physical training. By late summer 2017, I was off all medications and experiencing mostly chronic low back pain with only intermittent mild radicular symptoms.
Since my first PT evaluation, I continued performing repeated prone press ups just not as often as previously prescribed. I took the advice from The Doc and Jock Podcast and viewed each day as “back day”, meaning I was performing exercises daily to improve mobility and stability. I completed another semi-annual fitness test in October with only mild increase in symptoms due to the sit-up event. Everything was progressing well and looking/feeling good with only intermittent mild exacerbations along the way. Then came the holiday season….
As with many individuals, my healthy lifestyle choices went off track from Thanksgiving through New Year. Not only was I exercising less frequently, but I was completing my press-ups and daily back exercises less often, too. Additionally, my diet worsened, alcohol consumption increased, stress levels elevated, and sleep quality declined tremendously. By the time 2018 rolled in, I was heavier, deconditioned, and experiencing more pain. With the new year, some changes had to be made, and I needed more discipline and focus.
My first priority was to review my physical goals and create a workout program that allowed me to accomplish those goals without exacerbating my symptoms. At the start of the year, my priorities were to be active without pain and to recondition myself (lose the holiday weight, improve metabolic performance). Strengthening was a second priority I decided to re-visit after accomplishing my first set of goals. I have another semi-annual fitness test in April. I am using that event as the end point of my current training cycle and will likely shift focus towards strengthening at that time. At the time of this post, we are about six weeks into 2018, and I am feeling the best I have in two years. Here are the modifications I made to my lifestyle that got me to where I am now:
Due to my family and work life, I workout at home before my family wakes up. I am typically up by 4:00 and start the day with a class of grape juice followed by black coffee while reading the Bible. By 4:30 I am in the garage getting started. The first 20-30 minutes each day is dedicated to a warm-up, specific mobility drills, and prehab exercises to include one hip, one trunk, and one shoulder stability exercise. The warm-up piece also includes techniques to improve my left anterior knee pain (voodoo band, gapping techniques, quad tendon work) and right ankle dorsiflexion (voodoo band, banded dorsiflexion). I also go through a full body movement flow putting my body through its end ranges. The prehab stability exercises I change daily for variety.
On Mondays, Wednesdays, and Fridays I complete a metabolic conditioning workout where the focus is to simply keep moving. I designed six workouts that all include a monostructural element (rowing), a barbell exercise, a kettlebell exercise, and some body weight gymnastic movements. I keep track of the progress and typically repeat the workout every two weeks. They typically take 25-30 minutes. Tuesdays and Thursdays are dedicated to two movements: Turkish Get-Up (with Windmill) and Overhead Squat. The goal on these days is to work on mobility through stability training. I use only moderate load and perform the exercises at a slower tempo, usually pausing at transition points of each movement. On Saturdays I will either go for a low intensity run or a slow ruck march under heavy load. Sundays are for recovery where I will perform a stretching routine and may take a 15-minute ice bath. Each evening, after putting the kids to bed and watching TV with my wife, I will get on the floor and stretch for 20-30 minutes.
I have significantly improved my diet since the holidays. I do not eat 100% “clean” and do allow two cheat meals weekly, normally Friday and Saturday nights. I am getting a serving of fruit and vegetables at each meal. I have also significantly decreased my alcohol consumption. Previously, I would have some drinks every weekend but have cut back to every other weekend. I believe getting back on a fairly healthy diet has not only helped my back pain but has also improved my physical performance, decreased body weight, and improved my sleep.
As just mentioned, my sleep is improving. I still struggle with allotting adequate time and only average six and half hours nightly. That is the downside of waking up early. Consuming less alchohol has significantly helped with my sleep on the weekends. Also, our two year old who has never been a great sleeper is improving her sleep, allowing my wife and I more frequent nights of uninterrupted sleep. The power of sleep is amazing and oftentimes neglected. I look forward to our daughter sleeping more through the night and adjusting my hours to alott 7+ hours nightly.
I mentioned previously my stress levels during the holidays were elevated. This was not due to just the regular stress the holiday season brings but also due to work-related issues. Our clinics were severely understaffed due to the Army transitioning three senior officers to other locations without immediate replacements. As the most “senior” officer remaining, I was placed into a position reserved for someone of much higher rank and more experience. Also, I was being considered for a promotion and anxiously waiting for the results to be released. Fortunately, as of last week, we now have all personnel positions filled (so I can step out of that role) and received news I will be getting promoted in the near future.
Bottom line, I am a chronic back pain survivor. I am not completely pain free each and everyday, but I am significantly improved and have minimal, if any, limitations. By adjusting my programming and lifestyle choices, I have been able to make great progress in the past six weeks alone. I know what my MRI shows, and I’m sure the anatomical change is not much different now versus ten months ago. It’s honestly hard to not let the MRI define who I am and set my limitations, and I can appreciate what my patients are going through as they relay their results to me. However, just like them, I AM NOT MY MRI!
Thanks for reading.
2 Timothy 4:7
I have fought the good fight, I have finished the course, I have kept the faith
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