Life Through a TV Screen – PT. 7
Disclaimer: This next chapter will be part personal experience, part physical therapy education based on existing research literature and medical guidance from Derek’s providers. It is not necessarily universally applicable medical advice, and you should contact your doctor for specific medical advice matching your individual needs.
Part of the Kennedy Trail in Los Gatos, CA
August 2022
“How is everything? How do you feel?”
Colleagues and friends alike have asked me these two questions about my back and recovery thus far. I tell them that it’s all still sinking in, that it still feels surreal to me just how drastically my life has improved. I still find myself trying to find the best way to properly articulate the profound level of gratitude and joy that I feel with being able to reconnect with nature, with friends, and with the feeling of consistent exercise over the month. The month of August has historically been a month of transition. Every new school year prior to graduate school would begin in August for me. August was the opening of each new chapter of college cross country and more recently the closing of residency. Now, another August comes and goes, bringing with it a new chapter of the rehabilitation journey.
The first week of August, I had my two-week post-operative check in with my surgeon. The surgeon proceeded to re-check my surgical incision as well as reassess regular walking, heel walking, toe walking, and squatting to the ground and back up without hand assist. We then discussed what my current restrictions and freedoms were (expanded on in the addendum below), and then once all my questions were answered, I was free to go with the plan to return at the six week mark to reassess my progress. I hopped on a call to update my colleague who had worked with me pre-operatively and we talked about rehab considerations for this stage of post-operative care. With ideas in mind from my discussion, I began to build a structured rehabilitation program to get me through to the next post-op visit (The full thought process behind the program is in the addendum below).
As my body continued to improve with overall muscular strength and endurance, I started to build in more errands and activities outside the house. Everyday things such as going to get a haircut, going to various doctors’ appointments, and going to get boba slowly started to increase in frequency. Now that I was no longer having significant amounts of nerve related pain, I felt like the world accessible to me was opening up exponentially with each passing week, the speed only limited by the self-prescribed caution with trying not to overstress myself and by the rate at which my muscles could recover from the newfound demand. Every now and then, I would experience muscle aches in my hips and legs that previously only occurred if I was pushing consecutive 65+ mile weeks with heavy training, reminders from my body to not rush the process, that good things come with time and patience.
Most of the daily rehab routine was consistent: A walk or hike in the AM, rehab program in the PM. I would grab my headphones and phone for music on walks before heading out the door. A variety of music would give the walks a soundtrack of their own. Some days it was introspective piano music. Some days it was indie folk. Some days it was epic orchestral music (e.g. Two Steps from Hell). Some days it was a melting pot of Kygo, Metallica and rap music. Whatever the day’s soundtrack ended up being was whatever I was in the mood for. Over the weeks in August, I settled into a clockwork-like rhythm and looked forward to each exercise session as a chance to get a little stronger, a chance to move forward towards return to running. It feels so nice again to have a relatively established exercise routine and to be doing more exercise than I’ve done consistently in a long time.
Lexington Reservoir in Los Gatos, CA
The last day of August, I went in to have my six-week post-operative follow-up. I ended up seeing my surgeon’s physician’s assistant as the surgeon had to do an emergency surgery. The PA re-checked my strength, answered any questions I had about activity restrictions, and then once all my questions were answered I was free to go. I hopped on a call to consult with my colleague about my updated status, and modified my rehabilitation program. The biggest things that will test my body next month will be some domestic airline travel plans and a return-to-work mid-way through next month. I can say with certainty that it feels wonderful to have now arrived at just past six weeks after my surgery and have begun my seventh week. Now that a foundation has been established, I look forward to building upon that foundation as I work towards this upcoming November.
Thanks for following along, stay tuned for the next chapter!
Addendum
This section is just to explore more of my rehabilitation process and thoughts/research behind it. Currently, my most notable symptoms remaining are residual tingling in my right foot within the S1 dermatome and some residual soreness in my right hamstring. This is to be expected, as a retrospective case series published in 2014 found that in the early postoperative period after a lumbar microdiscectomy (1.5 ± 1.0 months postoperatively on average, range: 0.2–6.3), 62.2% of patients presented with residual radicular pain, 25.7% with a sensory deficit, and 8.1% with a residual motor deficit (1).
From the timeframe of two weeks to six weeks post-operative, my surgeon provided the following guidelines for activity restrictions to continue to protect the surgical repair from re-herniation of the disc:
- No lifting of > 30 lb, no excessive twisting or bending over, no full submersion of the surgical incision site
- No restrictions on driving, but take a break every 1 hour
- No restrictions on walking, hiking, daily activities around the house
- No restrictions with flying on an airplane
At the six-week mark, my surgeon’s physician’s assistant changed my activity restrictions to the following:
- No restrictions on lifting weights, progress gradually based on symptoms
- No restrictions with daily activities, progress gradually based on symptoms
- No restrictions on walking, hiking, general exercise, progress gradually based on symptoms
- No restrictions on starting jumping and hopping within a rehabilitation program, progress gradually based on symptoms
- Ok to start a gradual walk-run program, progress gradually based on symptoms
At the two-week mark, because of how good my function looked, my surgeon stated that I may not need a formal course of PT if things were going well at six weeks. With that said, I can tell that there are notable strength deficits for my right lower extremity compared to my left lower extremity, and that if I were to theoretically jump straight into running full volume and intensity after six weeks, I would probably not be physically prepared to handle the demand.
The theme for the first part of the plan to return to running will be general reconditioning. Initially, I split the reconditioning into two categories: neural mobilization of the sciatic nerve and peripheral lower extremity strengthening. With building the exercise program, respecting my post operative precautions takes precedent. Below is the first version of the exercise program that I built for myself split based on them categories mentioned above:
Peripheral strengthening
- Double leg calf raises, 3 sets x 10 – 15 repetitions, 30 sec. rest, 5x/week
- Ankle inversion w/ resistance band, 3 sets x 10 – 15 repetitions, 30 sec. rest, 5x/week
- Ankle eversion w/ resistance band, 3 sets x 10 – 15 repetitions, 30 sec. rest, 5x/week
- Sit to stand, 2-3 sets x 10 – 15 repetitions, 60 sec. rest 5x/week
Neural mobilization
- Supine sciatic nerve glide with knee extension to create the nerve movement, 2 sets x 20 repetitions
Parameters for the strengthening exercises were chosen with the goal of building muscle endurance, as the commonly used “repetition continuum” for loading recommendations recommends a high repetition scheme with light loads (15+ repetitions per set with loads below 60% of 1RM) (2). For the intensity of the exercises, since I had no idea what my one rep maximum (1RM) is for any of the exercises and have no intent on trying to find out in this stage of rehabilitation, I decided to gauge it based on a reps in reserve scale (RIR scale), as well trained athletes can accurately gauge reps in reserve and can make self-regulatory training modifications as needed (3). Of course, I worked a little more on the side of caution just to give myself some ease of mind.
Before getting into the programming for neural mobilization, a brief commentary on current research regarding neural mobilization’s place in rehabilitation for lumbar radiculopathy and the post-operative realm is beneficial. We have Level 1a evidence in a meta-analysis study published in 2017 that neural mobilization is effective for decreasing pain and disability in patients with nerve related chronic low back pain as a whole (4). Interestingly, there are randomized controlled trials to support the notion that a standard rehabilitation protocol alone or in combination with neural mobilization are equally effective for addressing long term pain, disability and quality of life in patients 1 year out from lumbar microdiscectomy specifically (5) and in a patient group with mixed types of lumbar surgeries (6). With evidence suggesting that neural mobilization may not necessarily provide superior rehabilitation outcomes for the post-operative population compared to standard of care alone, an argument could be made to withhold dedicated neural mobilization in order to have a more time-efficient program with good outcomes.
Exercise programming for the neural mobilization is unfortunately a little bit of a guessing game. Although we have literature to support that there is therapeutic value, good research does not exist yet as of the publication month of this blog post for the “optimal” parameters or “optimal” techniques. From my clinical experience, part of the challenge with choosing parameters may stem from each person’s nervous system having variable levels of sensitivity to stimuli. One person may be able to successfully perform 2 sets of 20 repetitions of a neural mobilization exercise without any significant increase in symptoms, while another person may only be able to start off with 1 set of 10 repetitions.
After weighing my low symptom irritability against the current evidence for intentional neural mobilization not necessarily providing superior outcomes, I decided to cut formal neural mobilization. The program maintained the same theme of reconditioning but the sub-categories were reformed into return to running and preparation for travel. I also made a couple adjustments to the exercise selection to make the program a little more well-rounded, and this is the version I began to implement consistently at 3 weeks post-operative with notes on changes throughout this rehabilitation block:
Return to running
- Double leg calf raises, 3 sets x 15 repetitions, 30 sec. rest, 5x/week
o s/p 5 weeks progression: Calf raise 2 up, 1 down, 3 sets x 15 repetitions, 30 sec. rest, 5x/week
- Ankle inversion w/ resistance band, 3 sets x 15 repetitions, 30 sec. rest, 5x/week
o Removed at s/p 5 weeks, heel inversion at top of range of motion during calf raises emphasized for further incorporating posterior tibialis muscle.
- Ankle eversion w/ resistance band, 3 sets x 15 repetitions, 30 sec. rest, 5x/week
- Standing hip flexion, 3 sets x 15 repetitions, 30 sec. rest, 5x/week
o Changed to 3-4x/week at s/p 5 weeks due to mild irritation of R. hip flexors
- Single Leg Balance with Diagonal Reach, 3 sets x 60 sec. each leg, 5x/week
- Sit to stand, 2-3 sets x 10 – 15 repetitions, 60 sec. rest, 5x/week
Travel conditioning (starting at 5 - 10 lb. weight, progressed by 5 lb. each week)
- Standing Overhead press, 3 sets x 15 repetitions, 60 sec. rest, 5x/week
- Walking with weighted backpack, 600 m. – 1200 m., 2-3x/week
Outside of the home exercise program, cardiovascular reconditioning took form with walking and hiking. A relatively linear progression was planned, with de-load days built in as needed based on how tired my leg muscles were getting. At the two week post operative mark, my weekly steps averaged out to over 5,000 steps per day as reported by my GPS watch. Each week, I originally planned to add an average of about 1500 steps daily, and at 3 weeks post operative began to incorporate walking on paved hilly terrain. At 4 weeks post operative, I began incorporating hiking on hilly terrain as another progression.
As one can probably see, although I ended up close to my predicted average by the end of the block, I definitely did not follow my nice planned linear progression to do so. The bigger factors that ended up guiding my rate of progression was the level of symptoms and overall perceived muscle fatigue. Having been a competitive runner for a long time and being in tune with how my body feels under duress, I can tell when there are certain warning signs indicating that I’m not injured yet but that I need to temporarily de-load to minimize risk of injury development. As my body got stronger and able to handle more demand on the body, I began to move away from walking the same amount daily and towards structuring my walking and hiking in a somewhat similar fashion to a training week, with each cycle starting on Tuesday since my surgery was on a Tuesday. An example of a week’s structure can be found below:
No good rehab plan is complete without goals (both short-term and long-term goals), and a plan to reach those goals. Outside of progressing the number of daily steps, other goals I built in include goals for gradual increase in elevation gain on hikes and strength-related goals for making sure that I am strong enough to travel and strong enough to continue progressing the duration and difficulty of my hikes. As for the overall plan to reach the eventual goal of competition, I think an infographic will help illustrate the process (7).
As one can see on the infographic, there are multiple steps that a runner needs to go through in order to set themselves up for success with return to running regardless of the type of injury or surgery that they are recovering from. My case is no exception, and there will be quite a bit of time spent on the first step to ensure that my body is ready to eventually start a walk-run program. Future chapters of this series will refer back to this infographic to illustrate my progress and the stage that I am at.
References
1. Aichmair A, Du JY, Shue J, et al. Microdiscectomy for the treatment of lumbar disc herniation: an evaluation of reoperations and long-term outcomes. Evid Based Spine Care J. 2014;5(2):77-86. doi:10.1055/s-0034-1386750
2. Schoenfeld BJ, Grgic J, Van Every DW, Plotkin DL. Loading Recommendations for Muscle Strength, Hypertrophy, and Local Endurance: A Re-Examination of the Repetition Continuum. Sports (Basel). 2021;9(2):32. Published 2021 Feb 22. doi:10.3390/sports9020032
3. Helms ER, Kwan K, Sousa CA, Cronin JB, Storey AG, Zourdos MC. Methods for Regulating and Monitoring Resistance Training. J Hum Kinet. 2020;74:23-42. Published 2020 Aug 31. doi:10.2478/hukin-2020-0011
4. Basson A, Olivier B, Ellis R, Coppieters M, Stewart A, Mudzi W. The effectiveness of neural mobilization for neuromusculoskeletal conditions: A systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2017;47(9):593-615. doi:10.2519/jospt.2017.7117
5. Reyes A, Aguilera MP, Torres P, Reyes-Ferrada W, Peñailillo L. Effects of neural mobilization in patients after lumbar microdiscectomy due to intervertebral disc lesion. Journal of Bodywork and Movement Therapies. 2021;25:100-107. doi:10.1016/j.jbmt.2020.10.023
6. Scrimshaw, Sally V. B App Sc; Maher, Christopher G. PhD. Randomized Controlled Trial of Neural Mobilization After Spinal Surgery. Spine: December 15, 2001 - Volume 26 - Issue 24 - p 2647-2652
7. Ardern, CL., et al. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. BJSM, 50(14), 853-864
