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Motion Forword - September 2023 - No3

Welcome to Motion Forword - Words of a Therapist! Number 3!

Motion Forword is about discussing the combined benefits of movement with a positive mental attitude. Using my personal/professional experiences, evidence-based research and some of your own experiences.

Bringing some hope, positivity, happiness and maybe usefulness to those, perhaps like yourself, that needs a pick me up.

Something about me - Reframing Self-care

‘You don’t have to go to the gym when moving people around like this all day!’’

I often get this sort of comment when people realise how physical my job is! Human bodies are quite heavy after all!

But actually, I go to the gym for many reasons. One of which is to make my job easier and reduce the likelihood of my own back flaring up!* *If you don’t already know, no, I am not Superman and, yes, I do get a bad back too! For as long as I can remember in fact!

If we look after ourselves (physically, mentally, emotionally) it not only reduces our chances of hurting ourselves at work. It improves our ability to do the job we do!

So rather than looking at my job and thinking: ‘well I have a really active job, I don’t need to go to the gym’, I think of it like this: ‘My job is physically demanding, I need to make sure I’m strong/fit enough to do this for [insert unknown career length!] without injuring myself’

It’s not full proof. There have been times when my back has flared up and I’ve had to adapt. But we cannot expect to live our lives completely void of pain. If human-beings never developed pain, we wouldn’t have made it this far as a species!

Imagine never being able to recognise when you’ve hurt yourself! We wouldn’t last very long.

Self-care is a means of improving ourselves enough that if something were to happen, we could deal with it better than if we hadn’t done a thing. The patient’s I have had that have managed and recovered best are those that have taken an active role in their care and taken responsibility for their recovery. (See A True Sciatica Story below!)

This interesting infographic about spinal discs (IVDs) by Physio meets Science* demonstrates how keeping active has more benefits than risks to our body’s than being inactive or sedentary.

*For the full list of references click the hyperlink

Something for you - Bear Poking

My Canadian family on the other side of the pond send (alarmingly frequent) videos to the joint family group of brown bears! Raiding bins and mouse traps in their neighbourhood (I know crazy!)

By complete coincidence I have been using the phrase ‘Stop poking the bear’ when speaking with patients about their injury or pain.

What on Earth are you talking about now Nathan?!

Well… Consider this… If you’ve ever sprained your ankle you will limp and use a crutch to take the weight off of the ankle in the first instance. Depending on the severity of the sprain, you’ll most likely do so for a few weeks before you can start weight bearing normally again.

Totally reasonable right?

But for some reason, people look at, respond and treat back pain differently…

With a bad back, most people will lean forward, hesitantly get out of chairs or cars and probably walk a little different. But the advice by every Tom, Dick and Harry (and sometimes from ourselves) is to ‘straighten up’, ‘walk normally’ and ‘just get on with it’.

Now… if you were told to do the same for your sprained ankle, you would tell them to s*d off!

So why don’t we for back pain? It is pretty much the same thing! (Physiologically speaking)

Hence… Stop poking the Bear!

By ignoring your body’s instincts to ‘take the pressure off’ or ‘ease the pain’ you’ll only be making the problem worse. Simply because we are told being bent or wonky is bad (or something ridiculous).

Trust your body to do what it needs to do. You won’t be stuck bent over forever, it is simply a temporary position our body’s adopt for healing and recovery.

A True Sciatica story

September 2022 - The burning leg pain got worse. The plethora of pain modifying drugs weren't helping and caused constipation that may have put more pressure on the nerve. On bad days when the pain was at its worst, Conor resorted to laying flat on the floor whilst at work and even taking a couple of trips to A&E…

Back in July 2022, Conor limped into my clinic. Adopting a forward bend, leaning right posture to make things more comfortable (see above!) He’d been suffering for 2 months with left lower back pain and leg/heel/foot pain.

Before work and family became his main focus, Conor used to be a keen runner and BJJ enthusiast.

What seemed to set off his pain was the new hard flooring in his kitchen and a long walk. Which doesn’t seem like much, but a study of 385 people by Maurer and mates in 2020 showed how inactivity/sedentariness had a higher likelihood of disc degeneration. Suggesting that Conor’s reduced activity levels may have been related to the onset of his problem.

He was 32 years old* and is a father to 3 young children, two of which have autism and ADHD. His pain was affecting his ability to work, drive, look after the children and support his wife.

*Remember, you don’t have to be ‘old’ to suffer!

After an assessment, I was quite convinced that he had a lumbar disc herniation (LDH). This was causing compression on his left L5/S1 nerve root which was creating the leg/foot related symptoms. I knew this could take a long time to heal/recover, many months most likely.

My process with these types of cases isn’t to immediately send them down the MRI/surgery route. The evidence suggests that conservative management (that is no surgery) can have as good long-term outcomes as surgery. I wanted to see if improvement was possible without it, avoiding the potential negative side-effects of surgery.

Often this isn’t the route patients want to take when they are in severe pain and want answers.

But in this case, Conor trusted me and we would review it each step of the way.

In the first few weeks, Conor’s symptoms waxed and waned but often worse than they were better. Medications like dihydrocodiene, gabapentin and naproxen helped him get through the day.

He was diligent with the exercises we went through and we adapted them as appropriate so they worked for him. The goal was trying to take pressure off the affected nerve. As ‘walking straight’ flared up the leg pain when receiving advice from… you guessed it, every Tom, Dick and Harry (again,... see above about poking the bear!)

2 months on, in early September with little progress and two trips to A&E, Conor was struggling and resorted to crutches. He had been given a MSk (Musculoskeletal) specialist referral which could get him an MRI referral. Which I was in favour of by this point and would refer privately if this didn’t come off. As it so happens, the NHS MRI referral took several weeks but by early October he had the MRI.

My treatments and advice seemed to help with Conor’s symptoms. Settle the immediate discomfort, allowing him to ditch the crutches, do light duties at work and it was worse in the morning rather than all day. Conor was grateful for my efforts. But it wasn’t lasting, as I knew would be the case. As much as I wish it was this simple, we can't ‘put the disc back in’.

By the time we got the results of the MRI, Conor’s symptoms were easing and becoming more bearable. At least to the point he could continue working albeit in some discomfort and taking less pain meds. The MRI showed a left L5/S1 disc sequestration with a corticosteroid injection treatment in the following month.

The injection in December gave Conor some more freedom and was able to come off the meds. Things weren’t perfect. But Conor maintained a stoic attitude and remained positive in the knowledge that things would get better. We capitalised on these improvements looking to do more where we could.

I remained optimistic but realistic as there were a few more ups and downs. Especially after a 6hr round drive and a day of sitting in a classroom in January which really seemed to kick off his leg symptoms again. Describing it as ‘piece of string on fire going up the leg.’

The idea of surgery had been discussed. Conor was a good candidate for surgery and I was supportive of this option. He was young and fit, had a positive attitude towards his recovery and had done so much rehabilitation. I provided the pros and cons but he was hesitant and later decided against it after speaking with a spinal consultant.

Conor continued his rehabilitative exercises and lived his life as normally as possible. By March/April Conor was playing football with his son, washing his wife’s car, not having to take medications every day and back to work.

‘It feels like freedom’ he said.

Now, over a year since the problem started. Conor still feels that he doesn’t need surgery and has even signed up to a local football team. Plays with his children and can even run! A follow-up MRI also showed the disc sequestration had improved. Suggesting it was healing of its own accord alongside his symptoms.

Conor’s story highlights the trepidations and drawn-out unpredictability of back pain and sciatica.

But with a multidisciplinary approach, persistence, patience and a positive mental attitude you can get to where you want to be without the need for short-cuts or magic bullets.

Thanks for reading, until next month… Motion Forword ⏩⏩ Nathan

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