Life Through a TV Screen – PT. 5
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.
June 2022
Memorial Day Weekend was supposed to be an opportunity to rest, and yet my body somehow still entered the month of June with elevated levels of pain. Some patients were canceling their visits last minute on the same day though, so I took the week one day at a time. By the end of the week, I was able to find some pockets each day to rest and keep my body’s pain levels at a steady state. Having the day be a 4-day week I think was helpful. I still had the next week though, a full daunting 5-day week and my biggest patient caseload yet. Throughout the second week of June, I kept the conversation going with my PT, giving updates on how my body was feeling and what I needed to do to set myself up to maintain my ability to work. (For updates on the plan of care for the month of June, you can scroll down to the addendum). I was overall able to maintain my pain levels and symptoms at a steady place, manageable enough to stop the spiral that I felt like I was descending upon at the end of May. To me, this seemed like a win at a critical juncture determining whether I can continue to work while going to seek the care that I need. Unfortunately, it wasn’t going to be enough.
I received mail from Jarrett Eller of Elmwood Athletics. I had originally ordered some stickers (stay tuned for some near future merchandise hopefully!), and only expected to receive stickers. I was mildly surprised to also see a card in the envelope with the stickers, and even more surprised to read the contents of the card. Inside the card was messages from college teammates, Elmwooders and my college coach wishing me the best with the recovery of my current injury. It was a small yet thoughtful gesture, the effort put forth not lost on me. It was a reminder that even as I continue to navigate the injury with varying degrees of struggle each day, people important to me in my life are supporting me through this endeavor and for that I am grateful.
A couple bigger checkpoints unfolded halfway through the month: a visit with my PCP, and a conversation with one of my managers at work. I had a chance to see my usual primary care provider after finally having my insurance take effect. After my visit and discussing the options that I have pursued, he recommended to me that I go forward with either seeing a neurologist or seeing a neurosurgeon. A neurologist may potentially perform a nerve conduction velocity study to assess the health of my nerves and they may be able to provide a second steroid injection. A neurosurgeon may choose to go forward with surgical intervention to treat my injury, provide a steroid injection, or refer me back to another provider depending on the severity of my symptoms. Each pathway has its pros and cons, and the providers that my PCP recommended are all ones that he has high trust in. After taking time to consider multiple factors, I decided to proceed with scheduling to see a neurosurgeon.
On the work side of life, there is an ongoing conversation between myself, HR and 3 of my managers. One of the higher up managers informed me that I need to contact HR to apply for disability benefits. I have started to get the ball rolling with reaching out to HR to determine what steps I should take to apply for disability. It’s interesting to even be thinking about this option, let alone going forward with it. In high school when I first set my goal of becoming a physical therapist, I would have never dreamed that when I finally achieved my career goal, I would be spending the first 2+ years struggling with a chronic back injury.
During the last week of June, I was able to get in for a new patient consult with a neurosurgeon, one who is highly experienced and trusted by my primary care provider. As I laid out my story to the surgeon, I made sure to be as specific as possible with all of the details that I provided about what I’ve tried, what’s worked, what hasn’t worked, and what my overall history looks like.
He had a few questions for clarification, and then performed a physical exam on me to assess my current function and symptoms. We then discussed my options.
(To the side: the clinic complex where I went for my patient consult with the neurosurgeon)
“You have two options. The first is that you learn to just deal with your symptoms and hope that it heals on its own. The cutoff for a disc herniation size being likely to heal on its own within a year is 8 mm, and yours is bigger than that so most likely it will not heal on its own. You may gradually get less symptoms over time, but the disc may scar down and calcify, which can lead to other problems. The second option is a surgery called a microdiscectomy. You have a structural issue and the surgery would help to remove the part of the disc that is impinging on the nerve, and get rid of your leg symptoms.”
Those were my two options: leave it alone and gamble with possible long-term complications, or commit to surgery and get pretty good outcomes. Given my chronicity, decreased overall quality of life and high trust in the surgeon, I decided on surgery. We talked about the risks, expectations for healing timeline and when I can return to certain activities. Ultimately, I want to return to competitive running. However, my surgeon stated that I need to really think about how hard I train because training really hard is why I’m in this predicament to begin with. As much as it disappoints me to hear this, I do think that it is worth considering and something I’ve thought about time and again.
Now at the end of June, I wrapped up my last week of work before going on disability. It feels sad to say goodbye to patients and goodbye temporarily to my coworkers, but I have to do what I need to do in order to take care of myself. My new plan for treatment after consulting with the neurosurgeon is to go forward with the microdiscectomy surgery, which will happen sometime in July. I will also be on disability leave starting in July. Some expected checkpoints that my surgeon laid out are as follows:
- 2 weeks out: return to work for non-physical jobs
- 4 weeks out: return to work for slightly more physical jobs (probably the timeline that I’ll aim for).
- 12 weeks out: return to sporting activities
I have mixed feelings going forward in this point of the process. I know that there will be a finite endpoint to this journey, something that is really tough to find as a patient and a provider for chronic injuries and that’s a big win. On the other end, I’m a little nervous about surgery, and once I get back to running, I have no idea how much training I’ll be able to handle or if I’ll ever run any PRs again. Ultimately the feelings are positive though I think, as the alternate thought of living with debilitating pain long term with no definite end in sight weighs heavily. I have faith that I’ll be able to eventually return to running and competing at some level. For now, I will be observing life pass through the metaphorical TV screen for a little while longer.
Addendum
This section is just to explore a little more of my rehabilitation process. Since the last chapter, my symptoms and overall condition have been mostly stable. While they’re not getting significantly worse, they’re also not getting better. The biggest change to the program that I made is actually dialing back the intensity and aggressiveness of the exercises to give my body a chance to create a “micro-deload” that will allow my body to accommodate for the increase in patients that I’m treating. Once stable with the intensity of my symptoms day to day, the themes going forward were finding ways to stay at baseline and finding ways to very gradually build capacity for stimulus on the nervous system. I still 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. Most of the program is unchanged in terms of the exercises I’m doing, except one change from the primary category is the removal of sciatic nerve glides. This decision is based on a randomized clinical trial study published in April 2022 and I have decided to see how my body responds to the absence of a dedicated neural mobilization exercise (1).
Primary:
- Prone press-ups
- Lateral sidebending with/without holding a weight
Secondary:
- Traditional Deadlift with 55 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)
Biking this month is gradually building or maintaining with intensity and volume. I have noted subtle changes in my cardiovascular capacity, as my rides are a little bit faster with lower peak heart rate than they were in the beginning of May. I did take a couple days off of biking for going to appointments, but otherwise biking has been fairly consistent.
Outside of my rehab exercises, I continued to track my time in an upright or semi-upright position at work. At work, I also implemented multiple strategies for preservation of my body and pain management. These have included having the PT aides go to bring my patients to the clinic space to minimize walking around, using extra time from PT follow up visits to lie down for documentation, using half of my lunch break to lie down, and extensive chart review for pre-planning follow-up visits. The pre-planning of my follow-up visits included selecting the most important things that I’m going to check & re-check (i.e. my clinical asterisks) and developing plans with backups for a patient depending on whether they are getting worse, getting better or staying the same. My treatment style included less manual hands-on techniques than I would normally do, opting instead to try as best as I can to come up with an exercise that will replicate the intended treatment goal of a hands-on technique. Finally, I tried to emphasize the precision of my verbal cues to describe exactly what I want a patient to do and how I want them positioned so that I can try to limit physically demonstrating certain things and save that for the times when I really need it.
This section wouldn’t be complete of course if I didn’t talk a little bit about surgical interventions for lumbar disc herniations since I have chosen to go forward with surgery. Surgery is not necessarily indicated for all disc herniations. A retrospective cohort study (level 2b evidence for those familiar with research) published in 2021 had 97% of patients within their group of almost 278,000 patients successfully treated non-operatively (2). Of course, that leaves 3% that did end up needing surgery. The current gold standard for surgical intervention in disc herniations is a microdiscectomy. The general indication for microdiscectomy is a patient with single-level disc herniation and evidence of nerve root compression that has residual or unremitting radicular symptoms after failed conservative treatment modalities (3). A few different types of microdiscectomies exist, but all of them involve removal of the fragmented or herniated disc tissue (3).
Clinical outcomes for microdiscectomies are good. A large, multicenter, prospective, randomized controlled trial called the Spine Patient Outcomes Research Trial compared open discectomy with nonoperative management. It demonstrated that while both treatment groups did achieve good clinical outcomes, patients who underwent discectomy had greater improvement than those who had nonoperative management (3). As for the type of technique used, Level 1 evidence comparing the common techniques for microdiscectomy, both open and tubular, support that both techniques have similar clinical outcomes and complications (3). While I won’t have a say in what type of technique is performed, I have trust in my surgeon as he is very experienced. It will be interesting to say the least once I have made it to the other side of the surgery process to begin the post-operative rehabilitation.
References
1. Sousa Filho, Luis Fernando, et al. “Neurodynamic Exercises Provide No Additional Benefit to Extension-Oriented Exercises in People with Chronic Low Back-Related Leg Pain and a Directional Preference: A Randomized Clinical Trial.” Journal of Bodywork and Movement Therapies, vol. 30, 2022, pp. 140–147., https://doi.org/10.1016/j.jbmt.2022.01.007.
2. Lilly DT, Davison MA, Eldridge CM, et al. An Assessment of Nonoperative Management Strategies in a Herniated Lumbar Disc Population: Successes Versus Failures. Global Spine Journal. 2021;11(7):1054-1063. doi:10.1177/2192568220936217
3. Dowling TJ, Dowling TJ. Microdiscectomy. [Updated 2022 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555984/
