Life Through a TV Screen – PT. 4
Disclaimer: This next chapter will be part personal experience, part physical therapy education based on existing research literature. It is not necessarily medical advice, and you should contact your doctor for specific medical advice matching your individual needs.
May 2022
The weather continues to warm up in the Bay Area. It is interesting to reflect on how much can change in the span of a few years. It was exactly 4 years ago this month when I clocked my 1500 m. personal best of 4:02 at a meet in Sacramento, equivalent to a 4:21 mile. That was my pinnacle of miler fitness, and now I am in the process of working through the low point of my cumulative running career.
A throwback to the 2018 Sacramento State Open, when I ran my personal best in the 1500
When I first started my job the last week of April, I had an onboarding process that allowed me time in the clinic to alternate between lying down and sitting/standing to do my work. I would also go to bed at a timely hour with the goal of maximizing sleep and recovery. As the weeks went by, my patient caseload would gradually build. It was nice to have a gradual ramp up process as I could use my open time in the clinic to do PT exercises and rest. The first week of work, I would return home every night extremely sore in my back, hip and hamstring, and would lie down for a couple hours before eating dinner and doing my PT exercises. As the weeks went by, I gradually tried to build my overall work capacity.
The drive home from work is one of the toughest parts of the day. Some days, when my pain is bad enough, I am unable to find a comfortable position to sit and drive. Other days, I am able to find a semi-manageable position for my body to allow me to drive home. In either scenario, once I get home, my back and leg are usually in quite a bit of pain and I am hunched over unable to stand up straight. It is not until I have a chance to lie down for a couple hours that my pain eases a little bit. Some nights, I could sit okay at the dinner table with a manageable level of pain. Other nights, my pain is so bad that I would grimace the entire time while eating dinner, an exquisite stabbing ache traveling from the back of my hip and following the sciatic nerve pathway down my right hamstring. “Survive and advance,” I would tell myself with each day. I would take work one day at a time, trying not to think too much about the next day, the next week.
I had a conversation with my PT at the end of my second work week. We talked about prognosis, progressions with exercises, and factors to consider with my condition (If you are interested in the program that I have currently, you can scroll to the bottom of the page where there is an addendum). Based on my current trajectory, it will likely take another 4-6 months to be back to 100% running if I am able to continue to improve. If my body and function is not quite where it should be after another 2 months of good consistent rehab, I would probably reach out to my primary care provider to get referred for a surgical consult. While I hoped that I won’t need surgery, if my non-operative options are exhausted then I was okay with going forward with it.
Mid-way through the month, I started to include a little bit of biking for 20-30 minutes, every other day, as progressive, low-intensity, submaximal fitness and endurance activities are strongly recommended for pain management and health promotion for patients with chronic low back pain (1). For my first bike ride, it was about 30 minutes on mostly flat terrain. It was rather windy, my quads burned, and I was pedaling slower than my 5k race pace. I didn’t care about any of that though. It was so nice to feel the sun, the fresh air, the feeling of being outside after spending months on end lying in bed in pain. With each week, I tried to slowly build my biking by increasing the minutes and changing up the intensities. Morning rides seem to be okay, although my body is still absolutely exhausted by the end of the work day. On the weekends, I tried to gradually progress both biking duration and intensity.
The first bits of biking in many months. Each ride is a chance to breathe fresh air, but also a gamble for how my body will respond to the extra stress.
“It was so nice to feel the sun, the fresh air, the feeling of being outside after spending months on end lying in bed in pain.”
Even though I am working full time and have a consistent routine, I don’t feel like I’m thriving. I still feel that I am just existing, trying to do the minimum to scrape by as I attend to my rehab and hope that I can continue to improve with time. Life still feels like I’m watching it pass by on TV.
Towards the end of May, as my patient caseload continued to climb, I found myself more frequently struggling to make it home after a work day. My biggest patient caseloads in a day were only 7-8 patients, short of the 10-11 per day that I needed. Despite my caseload still technically being in the building phase, I felt like I was already close to my physical limits. On the days when my symptoms were the worst, I would drive home in tears. Massive surges of pain would hit me as I would take a few steps from my car towards my house, and those days I would sit at my doorstep crying tears of pain mixed with frustration. I would limp through the house, hunched over in pain as my parents would look on with worry.
Something needed to change. If I didn’t do anything now, my caseload would only continue to build and the trajectory for my body did not look promising.
I reached out to one of my managers to discuss my case with them. Working in a clinic where your co-workers and managers are experienced clinicians, it is next to impossible to hide an injury that is having a profound effect on your physical ability to function. My managers thus far have demonstrated understanding for my current status and have made some arrangements to make my caseload and work more manageable.
At the end of the month, my PT and I talked again about my condition and made some modifications to my exercise program. Although I was able to get my schedule adjusted, the adjustments don’t start until mid-June and my schedule is completely full with patients. The first couple weeks of June will be another big test of my rehabilitation status as my progress seems to be pretty stagnant overall. Although some aspects have improved, the improvements may or may not be enough to overcome the increased physical demand on my body. For now, I will be reaching out to my primary care provider to try to get the ball rolling with setting up a consult with a surgeon to discuss options and have a surgical option available if it comes to it.
Thanks for following along for this chapter, stay tuned for the next chapter!
References
1. George SZ, Fritz JM, Silfies SP, et al. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304
Addendum
This section is just to explore a little more of my rehabilitation process. Since the last chapter, the lateral shift has improved but will still return at the end of the day or earlier depending on the degree of nerve irritation. It will reset after a full night of sleep, which means that it is at least stable. I have split my exercises into 3 categories: primary, secondary, and as needed. Primary exercises are done every day, no matter what. Symptom management is always considered as I usually need to work the next day. Secondary exercises are included as frequently as I am able to based on my symptoms. As needed exercises are done only when I feel my body needs it. These are either for pain management and/or lateral shift correction
Primary:
- Sciatic nerve glide in supine, holding ankle dorsiflexion for 5-8 seconds to stress the sciatic nerve
- Prone press-ups
- Lateral sidebending while holding a weight
Secondary:
- Traditional Deadlift with 45 lb. weight
As needed:
- R. sciatic nerve glide w/ my body positioned in a lumbar rotated position, R. side up
- Side plank dips (serving as a side glide progression), performed on both sides
- Side glides using an elbow to stabilize the thoracic spine (to put more emphasis on the lumbar spine)
From an exercise progression standpoint, I have now increased the aggressiveness of my prone press-ups and sciatic nerve mobilization in supine. The press-ups have also been modified to focus on extension through the thoracolumbar junction (the point of the spine where the curve changes from the rounded thoracic spine to the arched lumbar spine), and the ankle movement with sciatic nerve mobilization now has a sustained hold in dorsiflexion to try to further decrease sensitivity of the sciatic nerve.
For the biking, 30 minutes initially was enough to increase my numbness and tingling in my right foot, but 20 minutes seemed to allow my body to hold steady. I have also found that I can’t really bike after work, as I attempted a 10 minute ride and had to make multiple stops due to my nerve pain. The biking will be interesting to integrate into my daily routine, and also may be my entry back into my pre-work exercise routine. With time, the hope is that I can gradually build my capacity to bike.
Outside of the home exercise program and the biking there is the tracking of time in an upright or semi-upright position at work. In the beginning my patient caseload was fairly low and I could progress my work capacity in a relatively linear fashion. As my patient caseload grows, I shift towards alternating between treating patients and finding a space in the clinic to lie down for rest while documenting or waiting for my next patient. In the month of May, I have found that my body is holding steady at about 70% of my time being in a non-lying down position (either sitting, walking around or standing hunched over). This has translated to being able to see about 7-8 patients in a day and then taking strategic breaks throughout the day to manage my pain.
A screenshot of the data that I have collected so far. The graph is a little messy, but I am tracking a few different metrics to determine how much (or how little) progress I am making: number of patients I treat in a day, time spent in an upright position in hours, total time in the clinic in hours, and percentages of time in comparison to how much time I’m in the clinic on a certain day vs. total max time that I would need to be able to handle being in an upright position (9.25 hours a couple days a week including my lunch break). Green denotes days and weeks where I am increasing time upright, while yellow is a “de-load” week possible through how my schedule panned out that week.
