Mind-Body Connection
Yoga is thousands of years old and is considered, by the most devoted of followers, a religion. Rooted at its core is the undeniable benefit of discovering the connection between the mind and body. Elements of balance exist in its philosophies and, literally, in the physical postures. Breathe is an important tool used to connect the mind with the body and facilitates control over our sympathetic and parasympathetic nervous systems.
René Descartes (1596-1650) was a French philosopher and mathematician, who also devoted a lot of time to medical studies. Some of his work has contributed to and influenced modern day medicine. Namely, his brilliant thinking about how the brain works and its importance. His contributions came from his thinking; which influenced those who came after and led to discoveries such as: visual accommodation, the reflex concept and the reciprocal innervation of antagonistic muscles. Further, his soul-body dualism, psychosomatic view of the importance of interplay between the senses, and free will in the preservation of health, have contributed to modern day neuroscience (Dan, 2004).
“I think, therefore I am” – René Descartes
Reader: “Seriously man, what does THIS have to do with your back?”
Good point reader. Allow me to continue.
Science and religion have been at odds throughout history. However, both contribute to the ultimate goal of humans finding the best versions of themselves. Connection to, and balance within, our physical and mental being is extremely important. My love of science generates a strong desire to explain “the how” based on research. Understanding the capabilities of our brain is a massive frontier for medicine and an exciting branch of the research is neuroplasticity. I first learned about this concept in my undergraduate degree, and then again during my masters. Neuroplasticity explores our brain’s ability to rewire itself in the face of injury/disease/disorders and this process can be facilitated through focused practice. Norman Doidge’s “The Brain That Changes Itself” is a great book that explains the history and proposed mechanisms of neuroplasticity. Dr. Doidge writes about his encounters with some of the leading researchers of brain plasticity. René Descartes is even referenced early on in the book for his contributions to the thinking that led to modern day scientific support for neuroplasticity. There’s that Descartes again, still helping out science long after his death (metaphysical high five). I am a strong supporter of neuroplasticity because I have seen its effects in survivors of strokes, spinal cord injuries and children born with neurological damage (like Keren’s CP). Also, it has implications for pain management and exercise prescription.
Since March 2018, when I first experienced the recurrent symptoms of my back and leg pain, I have been thinking and acting to change my pain. I saw most of my colleagues for their diagnostic opinions, treatments and exercises. Holding my belief in neuroplasticity dear, I hoped that exercises alone would allow me to fix myself. As I worked on core and glut activation exercises I continued on with my normal daily routines. Walking was limited but running seemed okay. This was most likely due to the decreased ground contact time of running vs walking and endorphin release from exercising. Endorphins are opiate like chemicals in our body that act to reduce the perception of pain. Once warmed up, I did not feel my pain as much, so I continued to run, cycle and play soccer over the summer. Any increase in pain would only last a night or two at most (Did I mention I am a descendant of head strong, stubborn Italians?). I was also able to swim, but I could not do a flip turn and sometimes kicking hurt. I continued with my at home physio routine, as well as going toVinyasa Flow yoga classes. My competitive physio mind saw every day as a chance to fix my back, without having to rely on medication, and avoid another surgery. Winning meant solving my body problem without changing much of my routine. In my opinion, an integral part of practising physiotherapy is learning and teaching how to use movement to heal.
Spoiler! I was not very successful at learning to heal my back. As the summer progressed my pain increased and became constant. By far the worst thing was, and still is, sitting to drive. Sitting creates a 40% increase in force exerted on lumbar discs. There is also an increase in dural tension (tension on the nerve) when disc material is pushing out onto the nerve root. This makes straightening the affected leg out while walking and sitting very uncomfortable; especially while driving a standard vehicle. Extra lumbar support and seat adjustments provide me only temporary relief. If I push things a little too much during a typical day, then it takes a long time for my body to relax at night. Sleep, which is very important, has been difficult at times.
Science Side Note: Sleep is important because it is needed time for our brains to flush out neurotoxins, consolidate memories, and allow new synaptic connections to be strengthened. Quality sleep can result in improved learning and higher reported levels of quality of life. There is still a lot to be answered in the science of sleep and memories in humans. At this point, it is undeniable that sleep is important for our brains. Factors such as: stress and chronic pain, influence our sleep quality.
August 15th was the day when my walking tolerance was greatly reduced and my pain became unmanageable. The next step was to have a MRI. Financially frustrating, but medically relevant for an orthopedic consult, I decided to pay for a private MRI. Fun Fact: A lumbar spine MRI, with contrast dye to better image the nerves and disc material, costs just under $1000 and saves about 6 months of waiting. The result was a confirmation of the recurrence of a L5 disc protrusion with impingement of the S1 nerve root. Great! (loud sigh). I expected this, but now my brain could not deny that the disc is protruding and contributing to my pain. My family doctor sent the referral to my orthopaedic spinal surgeon, and with persistence I was able to book a consult within 6 weeks of my referral. Six weeks was a lot of time for my brain to think and think and think. The pervasive thoughts were: “Is there anything I can I do to avoid another surgery?” “What can I do to manage my pain?” “How long will I be off work?”. The result of the consult was that surgery would definitely alleviate my symptoms but I might have to wait 2-3 months.
**Cue the glazed over look of a patient struggling with chronic pain management, distracted by the disastrous thought of spending 3 more months off work in pain and not able to exercise**
Snap back to reality, oh there goes gravity! (Eminem reference). While that news sank in and my wife continued to listen, I had a mini mental meltdown and then rejoined the conversation. My surgeon wanted to try a corticosteroid (anti-inflammatory) injection under fluoroscopy (continuous x-ray imaging). This was a scientifically sound attempt to introduce a powerful anti-inflammatory directly at site of nerve trauma and potentially decrease my pain, restore my mobility and stave off surgery. Unfortunately, after the expected 2 day increase of symptoms my pain returned back to my baseline but no better.
So…
Armed with determination and time I used the past 8 weeks to experiment with: 1. IMS treatments, 2. massage therapy, 3. the McKenzie Method of dealing with a protruding disc, 4. an inversion table and 5. continued physiotherapy exercises. Unable to work, I have had the flexibility to see different medical professionals and try these interventions (treatments) one at a time. Testing too many variables at once leads to confounding results. How do you know what is working if you are doing too much at once? Less confounding variables = better chance of understanding what is ACTUALLY helping. The flip side of extra time is that it can be the enemy of an idle mind and body. For me, a mind-body imbalance was exaggerated by pain and the inability to exercise anywhere near my normal amount. Quieting my mind through meditation, accepting my exercise limitations and finding other outlets for my energy have been key to maintaining my mental and physical health.
Let’s look at treatment interventions #1-4 separately.
#1 IMS– Intramuscular stimulation is used by physiotherapists to change the resting muscle tension in the muscles being needled. For lumbar disc injuries, it allows the muscles crossing the lower segments of the spine to relax out of their protective spasm. This decreases the compression of the protruding disc and the nerve root. It is also a way to decrease tension in the muscles that are affected by the pinched nerve. When a nerve is compressed there is both a local reaction (around the nerve injury) and a distal reaction (changes in tension in all the muscles that nerve root innervates). IMS can be painful and it does trigger a low level inflammatory response in the treated area(s); which can take up to 2 days to settle down. Conclusion: MY pain was minimally improved after a one day post-treatment increase in symptoms. This improvement was not enough for me to justify the pain of treatment and sitting in the car to drive to have the IMS done. Also, the relief I was experiencing from the IMS did not show a sustained improvement in my sitting and walking ability.
IMPORTANT: IMS is a total system of diagnosis and treatment of myofascial pain syndromes. My lack of improvement does not mean IMS can not be an effective treatment for people with lower back pain, sciatica and nerve root signs and symptoms. Follow this URL for more info on IMS: http://ubcgunnims.com/what-is-ims/gunn-ims/
#2. Massage Therapy. I am a strong believer in the power of therapeutic touch. Detailed knowledge of anatomy provides registered massage therapists (RMTs) and physiotherapists the ability to distinguish between different tissue types and tissue layers in our body. This is extremely powerful in the treatment of musculoskeletal conditions. I have seen a few different RMTs this summer for my back. I tried different RMTs because, like with physiotherapists, there are a lot of different approaches to treating the body. All the RMTs had unique, but fundamentally similar, styles of treatment and I found benefit from them all. HOWEVER, I still did not find long lasting relief from the pain in my back/leg. Conclusion: massage was helping with temporary symptom relief but there is still something biomechanically stopping me from my normal movement patterns.
#3 The McKenzie Method. Robin McKenzie is an extremely well known physiotherapist. He is the author of “Treat Your Own Back” and founder of the McKenzie Method of Mechanical Diagnostics and Therapy (MDT). He developed the lumbar extension protocol as part of the treatment for a protruding or bulging disc in the lumbar spine. It uses repeated lumbar extension exercises to facilitate the reabsorption of disc material and promote centralization of pain. Centralization of pain means less leg symptoms (peripheralization of pain) and more focused back pain that is eventually eliminated with continued treatment. Extension is the most common movement because a very high percentage of protrusions occur in the posterior and lateral portion of the disc. My MRIs (2012 and 2018) show that my disc is protruding more lateral than posterior. The directional preferencefor a posterolateral disc protrusion is extension. Directional preference is the theory that every disc injury has a spinal movement (flexion/extension/side flexion) that works to reduce pressure on the protruding disc and thus alleviate pain. This past April, I attended a McKenzie Method Part A course for the lumbar spine. Yes, I was ALREADY experiencing a recurrence of my symptoms; so my motivation to pay attention and experiment on myself was extremely high. I have been trying to find MY directional preferenceand position(s) for centralization of my pain, with minimal success. Conclusion: For MY back injury, extension is better than flexion. Adding in elements of side flexion has not helped. Despite my efforts, I have not seen a lasting centralization of my pain that is not undone by short durations (< 10 minutes) of walking or sitting. Follow this URL for more info on MDT: https://www.mckenzieinstitutecanada.org/
#4 Inversion Table. As users tilt further back their head lowers toward the ground, and the amount of traction forceon the spine from gravity increases. Tolerance varies based on how your muscles react to the traction and how you tolerate the sensation of having your head below your heart because fluid pressure builds up. Eventually, this causes discomfort and sometimes physiological problems. Pain with traction should be avoided and that is why it is important to start with gentle tolerable amounts (10% body weight, roughly 25 degrees below horizontal). Swimming or being in water are a great way to see if the effects of reduced gravity on the spine will be beneficial (activity in chest to neck level water reduces effects of gravity by 75-90%). Mechanical traction involves a machine and allows users to lay flat in a supported position. Traction machines also have the capability to produce traction forces greater than gravity alone. The current research on the benefit of traction is not clearly shown in any major analyses of systematic reviews; nor is there a well tested traction protocol for disc injuries. The biggest proposed benefit is that traction can relieve pressure on the spine and facilitate the relaxation of deep spinal muscles, relieving pressure off the intervertebral discs and pinched nerves. Koren, a fellow physio at Marda Loop Sport Physiotherapy, was kind enough to let me use an inversion table at her house. I tried two sessions with a day break in between sessions 1 and 2. Conclusion: The traction felt good once I was able to ease into it. The effects were short lived and my symptoms returned quickly after walking to, and sitting in my car. I did not see a significant improvement after the second time using it and I decided that I would either need my own table at home to use regularly or continue the search for something else.
I continued the search.
In addition to the above interventions, and since August 15th, I have tried reducing the amount of refined sugar and gluten in my diet to help with whole body inflammation, continued to practice meditation, continued to do my own modified yoga and swimming, and tried different pharmaceutical drugs for pain management. Also, I have continued to treat myself with acupuncture and physio exercises such as: glut bridging, clamshells and core activation. Drugs, yoga, swimming, cycling and meditation will be discussed in more detail in future posts. Overall, MY pain with movement has not changed significantly.
The wheels of our healthcare system kept turning, until…
About 3 weeks ago, I answered a call from my surgeon’s office and was elated to hear that I had been booked for surgery on October 29th. My elation was mixed with a blow to my pride and ego because I had to accept that this was something I can not fix through movement alone, or on my own. Through mindfulness practice I reminded myself that I am the hero of my story. Needing surgery (again) is not a failure but another step in my journey. I am still on the Merry-Go-Round of pain management, and I will continue to be after my surgery. HOWEVER, the surgery will take away the biomechanical flaw that is currently stopping my normal movement; thus allowing my body to heal and giving me an opportunity to find balance again. All of the experiences I have had to this point have put me in the best possible mental and physical states before surgery.
OKAY! It is time for a very special David’s Brain Moment
I started this blog series to keep my physiotherapy brain occupied. It has been a positive focus for my energy while not being able to exercise like I am used to. There have been some big ideas introduced so that I could provide some knowledge about them and how they apply to ALL of our lives. Here’s a recap:
- Pain/Trauma is INEVITABLE, unique to everyone, and difficult to treat.
- Everyone’s story is unique. Survival is the common goal we ALL share. We are the accumulation of our past experiences.
- Mental health is EXTREMELY important. We need to contribute more energy to mental wellbeing because the brain is plastic (changeable) and is the most powerful organ in our bodies.
- Physical medicine (Physiotherapy) deals with the promotion of physical AND mental wellbeing because the mind and the body are undoubtably connected.
- In science, nature and religion BALANCE is continuously pursued.
Future posts will be released one every week for four weeks, and will continue with my rehabilitation from a second L5 discectomy and S1 nerve root decompression. I will share my experience while continuing to share more information about relevant health and physiotherapy topics.
Thank you for reading up to this point and I hope you’ve enjoyed the ramblings of posts 1 through 8.
Cheers,
David Ridgewell MPT, BSc Kin, CAFCI, IMS
René Descartes Information:
Jeune B. Dan Medicinist Arbog. 2004. 75-117. Accessed from PubMed, October 2018
Wikipedia search
Lumbar Disc Herniation Non-Operative and Operative Management Article:
Amin, R.M., Andrade, N.S. & Neuman, B.J. Curr Rev Musculoskelet Med (2017) 10: 507. https://doi.org/10.1007/s12178-017-9441-4
Sleep References:
M.P Walker & R.S Stickgold (2004). Sleep-Dependant Learning and Memory Consolidation. Neuron.Vol. 44, Issue 1, pages 21-133. https://doi.org/10.1016/j.neuron.2004.08.031
T.W Strine & D.P Chapman (2005). Associations of frequent sleep-insufficiency with health-related quality of life and health behaviours. Sleep Medicine. Vol. 6, Issue 1, pages 23-27. https://doi.org/10.1016/j.sleep.2004.06.003