My experience with hydrotherapy

I have not blogged for a while whilst I have been trying new things, doing lots of research and trying to make progress on reducing my pain and increasing my ability to cope with day-to-day tasks and activities. It has been an interesting voyage where I have become clearer that there are many paths to recovery – and no-one has the universal answer, so you have to try lots of things! With this in mind, I thought that I would share in a few blogs over the coming weeks some of my recent experiences.

Hydrotherapy was one of the things that was suggested after each of my surgeries. It is 45 mins drive to the nearest hydrotherapy pools and there are none in my local authority area. Plus you have to have a medical referral form and go through some extra checks to get access, so it all took a bit of organising. But I think that is was well worth it, as I think that it reduced pain in the short-term and had an incremental improvement in the Range of Movement (RoM) in the scar tissue and the affected muscles.

What is hydrotherapy?

The hydrotherapy pool is kept at 37 degrees Celsius, which consistently feels very pleasant and after 30 mins of doing structured exercises feels positively hot!

It is about shoulder depth and about 10m across, so it is easy to get the benefit of the water resistance as well as the immersion.  There is also easy access, including a hoist so that you can get in and out even when your body is not working well. Given that there is only space for a small number of people, it is key to reserve the slot and be there changed and ready in time.

You can work with a physio in the session, but once you have a routine it is relatively easy to work through the exercises on your own. There are ‘weights’ made from floats to create additional resistance by pushing them down in the water and inflatable ‘noodles’ for support.

How is it better than a normal pool or hot tub?

I had tried both the normal pool and hot-tub, and would say that the hydrotherapy pool is much better.

Doing my exercises in the pool was hard work (remember that 1 litre of water is 1kg – so there is lots of weight in the water resistance), and the cooler water temperature that makes it suitable for swimming means that there is not the therapeutic benefit of the muscle release that helps with RoM and probably with the pain reduction too.

I had also used the pool to try a little aqua-jogging with the float-belt (as shown in the photo). This is used a lot by elite athletes when they have injuries and it is claimed that you can keep 80% of your running fitness if you put the same hours in at the pool. This should work really well for lower limb injuries where you need to keep the muscle memory, but avoid the impact (especially in stress fractures and some soft-tissue overuse injuries). But given that for me the inflammation affects the movement pattern, I found that it was too tough at this stage.  

The aquajogging float belt clips around you to keep you upright without your feet touching the bottom of the pool (you need a pool deep enough for this!) and you can add difficulty by holding a waterbottle in each hand and changing the amount of liquid in it for more difficulty.

The hot tub is useful for me for the muscle release and for managing some of the pain. But it is not deep enough or large enough to do all of the exercises, so it is not as good as the hydrotherapy pool. I think also that the 30 mins slot, where everyone else is also working on their exercises, brings a level of focus that really helps.

Did it make any difference?

My own experience was that it was a very supportive environment – everyone there is working on getting better and is very willing to share what they have had success with.

In terms of the physical impact, the warmth definitely had a positive impact in terms of reducing pain for a few hours (just like hot water bottles etc when at home). My understanding is that this is not universal – some people find that the pain is reduced with cold, others with warmth.

Plus, I found that 30 mins of hydrotherapy definitely improved RoM for a period of 24-48 hours and if I did it 3 times per week, I saw real progress on my land-based exercises. That said, it was positively hard work – after 30 mins the combination of the temperature and the hard work was very tiring and I was keen to get out and have a nice drink of water! And the travel on top made it quite a bit harder. So, I would say that if you have a hydrotherapy pool nearby, do make use of it in your recovery and rehabilitation.

Learning to dance in the rain

One of my best friends, Liz, has a quote on her wall saying “Do not wait for the storm to pass, instead learn to dance in the rain”

It’s a concept that I love – and my husband and I have talked about it over and over across the last months. But I have been struggling with it too; constantly asking myself whether this level of acceptance is giving up on the goal of getting better. Like so many aspects of recovery, I have had lengthy internal debates about it and not reached any clear conclusion. Then this week I came across this very impactful TED talk from the amazing New York Times writer Suleika Jaouad; it has given me another perspective and perhaps helped me to slay a dragon and move forward some more.

It is a talk that applies to everyone – not just those struggling with injury or illness. Do watch it for yourself here (just 17 minutes of beautiful and impactful viewing): https://www.ted.com/talks/suleika_jaouad_what_almost_dying_taught_me_about_living

Living well ‘in the middle’

She challenges us to think again. Her premise that the separation between being sick and being well is not the simple, binary divide that we often paint it as. But that the border is porous. And that with the increased life expectancy of today, most of us will spend much of our lives travelling back and forth between the situations of being sick and being well, and living at least some of the time in the middle.

She finishes with the powerful thought that every single one of us will have our life interrupted… by something that brings us to the floor. We need to find ways to live in that in-between place managing whatever body and mind we currently have.

Powerful thoughts for ‘in-betweeners’

There were a number of themes that struck me as very powerful. But a few stuck out:

  1. The power of connection and shared experiences – her example of the prisoners in solitary confinement calling out their moves for the board games that they had made out of torn pieces of paper. It made me realise that the shame and inadequacy that we feel about not getting better and not keeping up is a dark shadow that we can (and need to) chase out with the bright light of friendships and fun.
  2. The importance of dreaming big on plans for the future – her example was the girl in Florida who plans someday to go camping in spite of her fear of bugs. When the whole world seems to be turned on its head, all dreams evaporate in the face of survival. But holding on to some things and keeping dreaming about them, and knowing that one day you will do them is a shining ever-present beacon of hope.
  3. The importance of taking the risk of opening up to new things – her example was the retired art history Professor in Ohio living through a lifetime of constant pain and disability, who in spite of all of the uncertainty of his health got married, had Grandchildren, taught, and danced with his wife every week. In spite of a situation that could have gripped him with constant fear and worry, he found meaning and built a beautiful life encapsulated in love.

Thank you Suleika for sharing your wisdom. And here is to learning to dance in the rain, through the different stages of the storm – in the eye of the storm, in the pouring rain and on the days where the thunder & lightening start to recede.

I hope that you find this as inspirational as I have – even if it took a few months for me to go the journey!

My Saturday night at a ‘Psoas Release Party’

There have been many firsts since I got injured, but spending over 4 hours on a late Saturday afternoon and early evening at a ‘Psoas Release Party’ is one that I thought you would all like to hear about!

The workshop was led by Jonathan FitzGordon, who started out as a yoga teacher in the USA but now works on rehabbing people in terrible pain. He freely admits that most people come across him at 3 in the morning, when they are at the end of their rope and don’t know what to do to get out of pain. This is exactly how I came across him.

What is the psoas?

Jonathan’s theory is that the illiopsoas is the most important muscle in the body. The ‘psoas is a really interesting compound muscle, as it is very difficult to reach and touch, as it starts deep in the back (up near the ribs) and loops around the inside of the hip before attaching at the front top of each of the legs in the groin area. For all its inaccessibility, it is a large muscle and is one of only 3 linking the front and back of the body, and attaches in 6 places – so pretty complex. It is often simply called a hip flexor, but it has a role in much more than this. Jonathan attributes the majority of long-term pain in the hips and back, plus the knees and feet, and even the shoulders to how the psoas is behaving.

I read Jonathan’s book ‘The Psoas Release Party’ and was struck with some of the concepts and case studies. I tried some of his stretches and releases and felt that I had started the journey. Then I saw that he was coming to the UK and was doing a workshop…

The description of the workshop said: “The psoas is the most important muscle in the body acting as the main hip flexor and the engine of walking. A free and happy psoas allows the body to move with peak efficiency and little strain. Issues with the psoas can lead to any number of problems throughout your body—both physical and emotional. Lower back pain and other joint discomfort as well as disturbances to the nervous system can be linked to the psoas. This is not a yoga class. You will spend the afternoon awakening, learning about and releasing the Iliopsoas muscle group and understanding its core function within the body.”

So that is how I ended up being one of 16 people crammed into quite a small yoga studio just near to Wimbledon studio on a late Saturday afternoon. It was mainly women, with a few men and the ages spread from early 40’s into 70’s – and every single person in the room was in pain, and wanted to do something about it.

How did the party get going?

Jonathan did an amazing job of making the anatomy really interesting and memorable, and before long we were all evaluating our dominant muscle patterns when standing still. He looked especially carefully at the balance between the front and back muscles, and the angles down the body: from head to shoulders, from shoulders to the lower thoracic spine at the bottom of the ribcage, from this point to the hips and from the hips to the ankle and into the foot.

He had a wonderful manner of wandering around and gently pointing out individual muscle patterns–for instance, the level that each of the hips were in the sockets, the level of internal/external hip rotation playing into the weight distribution in the feet, overall muscle imbalances and the level of tension in the glutes (butt) and rib-cage.

And what was interesting, was how we all had to be coached for the tell-tale cues and signs – even though almost everyone in the room (other than me) had a yoga or dance training, making them very body aware and elegant in their movement (but still in pain!)

What were the tell-tale cues?

Overall, the biggest message that I took from the workshop was that we all hold too much tension in the wrong places. Given that as soon as one muscle is tight, the opposite (antagonist) muscle simply cannot do anything until the first muscle releases. And this is important because some of these muscles (like the psoas) are large and connect with key processes like breathing, staying continent(!) and movements like sitting, walking and standing.

So stay loose and relaxed!

To do a body check yourself and see whether there are any ah-ha moments across the day:

  • Think about your butt when you are standing and walking – are the muscles tight? (if so, the psoas cannot do anything). A friend of mine tried this for a week and was stunned at how often across the day she found that all of the muscles in her butt were tensed up!
  • Think about your rib cage – if you sigh out a deep breath does the tension change? (if so your latissimus dorsi may be overworking)
  • Are your hips forward and your thighs extended when you stand? (if so, your hamstrings are constantly short and may get persistently tight)

Was there anything practical?

It was pretty much all practical! The four hours simply flew by – we did not stop for any breaks, and yet there was not a moment where I was not learning, making notes, trying different movements and learning more about the cues and signs of my muscle patterns.

The last 90 minutes was spent on 8 gentle stretching movements – most of which were held for a very long time (we did some for 15 mins, and Jonathan can recommend an hour or more at times!) in order to allow the psoas to truly let go. Whilst I had tried almost every single one of these from the book, the specific tuition on the important points of form was incredibly useful and I understood why I may have been missing out the benefits through simply trying it on my own without perfect technique. And the good news is that they are very easy to do at home (indeed one we even talked could be done in a break at the office, if you have a role that requires sitting at a desk all day – which of course is very bad for the psoas due to spending so much time in hip flexion).

Overall verdict – worth the money!

I have to admit that I thought about whether to attend for weeks before I committed – the hassle of a 45-minute drive to get there, no parking at the location and the £65 workshop fee. But my husband was kind enough to drive me and drop me off at the door, and benchmarked against other treatments that I have had, it was worth the money.

And like all of the best parties, with the late finish we were locked in!

I would strongly recommend Jonathan’s book – but the workshop took it to another level for me in terms of the personal insights and advice, plus the detailed coaching on the correct technique for the exercises. If you are not able to get to a workshop, Jonathan does do Skype consultations and I cannot over-emphasise the level of knowledge that he brings to your personal situation and his commitment to getting you out of pain. I am not at all surprised that he has helped and supported so many people to incredible recovery and rehabilitation.

And there is even a summer retreat in Italy…

Fascinating reading, with useful explanation and practical exercises

What I learned from going to see a nutritional therapist

I had to go back into hospital for some manipulation under anaesthetic due to the limitations on my movement from the scar tissue after my hip surgery. I had been dutifully massaging the scar tissue on the outside but came to realise just how much scar tissue there was on the inside that was reducing my range of movement and potentially one of the causes of pain. This led me into a journey to look at what I could do with nutrition to try to help my recovery.

So, for the first time ever, I went to see someone for dietary advice – with the specific question of whether I should be taking supplements to help my healing, and if so, which ones.

Layering the different aspects

I had previously thought that nutrition was mostly common sense, but I learned a lot from the way that Saffron (the nutritional therapist) layered what I needed:

  • Starting from a well balanced diet – with 7-a-day vegetables and fruit, plus a good split at each meal of complete proteins, good fats, and wholemeal carbohydrates as well as maintaining good hydration. She also specifically asked about how often we eat fish, and especially oily fish – as apparently the British are standardly very short of the long-chain omega 3 fatty acids. The ideal is apparently at least two portions of fish per week, with at least one oily fish.
  • Then looking at my age and lifestyle to get a sense of the hormonal pressures and tensions, as well as the aging factors on all of my tissues.
  • Whether I have had any blood tests to give information on nutrient shortages. These are very useful for things like anaemia (shortage of iron) and vitamin D shortages (common in Northern Europe, especially in winter or for people who stay inside a lot).
  • Checking for any food allergies or intolerances, or specific dietary requirements. I am very lucky with the robustness of my digestive system, so it means that I can draw on most foodstuffs – I just need to be organised enough to plan the right meals, shopping, and preparation! (I am sorry – I realise that some of this advice is not going to be so helpful for vegetarians, but a nutritional therapist will work with everyone’s dietary requirements).
  • Building from there to the current medications that I am taking – and talking me through the receptors that these medications block and hence what dietary changes and vitamin supplements may be needed to reflect this. For instance, the need for extra fibre for the constipation from painkillers, sulphur if taking ibuprofen, and extra B-vitamins (B6 and B12) when taking muscle-relaxants and antidepressants.
  • Then looking at the injury and the surgeries to understand what tissues are trying to heal – in my case covering bone, joints, cartilage, muscles, ligaments, and fascia, as well as scar tissue.  She talked about the importance of protein and zinc to help the muscles and ligaments repair. So a quality protein with each meal, and a wide range of pulses, grains, seeds, and nuts for the zinc. Getting nutrients to the bone and joint is more challenging – so I will come back to this theme below.
  • From the symptoms that I am still experiencing what extra may be needed. For instance, Magnesium is the mineral involved in relaxing muscles (whilst Calcium is involved in muscle contractions), so extra Magnesium can help with the muscle spasms and cramps. Magnesium-rich foods include spinach, avocado, seeds, nuts, yoghurt, banana and best of all: dark chocolate!
  • Then we talked about inflammatory foods, vs anti-inflammatory foods. Whilst inflammation is an important process in the initial weeks after the injury and surgeries, now months down the line there is a chance that swelling and inflammation is getting in the way of healing. Hence foods can help as one of the factors that can reduce inflammation. Overall, processed foods with high fat and processed sugars are inflammatory, plus fizzy drinks and nitrates, and nitrites in processed meats like smoked bacon and ham (you can buy nitrite-free versions), and of course, mild toxins like caffeine-based drinks and alcohol. The anti-inflammatory foods include tomatoes, leafy greens, olive oil, nuts, fruits, and oily fish.

Reducing scar tissue

As I said, reducing the scar tissue internally is a big goal for me, as I think that it will improve my mobility and potentially reduce the pain.  Saffron recommended proteolytic enzymes which are supposed to help minimise and reduce scar tissue after the surgeries.  These need to be taken away from food for best impact (either 30 mins before a meal, or an hour after a meal). Natural enzymatic foods include pineapple and papaya (yum!)

Rebuilding the bone

Of all of the injury and surgical aspects, we spent a lot of time talking about how to get blood flow and nutrients to all of the damaged tissues. Obviously, the bones are one of the most difficult to reach and the only access in the joint is via the synovial fluid. This points to the importance of movement in healing, as this only happens with movement that increases both blood flow to carry the nutrients around the body, and synovial fluid movement and regeneration.

The nutritional advice is to bring bone broths into my diet – using them instead of stock.  She counselled that it might seem weird to begin with but that you can get bones from butchers – they just give them away (I think that they normally assume they’re for a dog…) https://wholefully.com/bone-broth/

Normally your body will synthesise the necessary building blocks itself for bone synthesis and (to a certain extent) repair but it does get more difficult as we get older and we have less of the ‘whole’ ingredients in our diet such as animal skin (like on chicken etc), marrow, offal etc.  So this is where a supplement may be easier. 

Dealing with continued inflammation

Turmeric has become one of the anti-inflammatory supplements of choice for athletes. There is a lot of discussion about the format, and whether it is needed to be activated with black pepper or not. There is not a clear answer. The focus is probably best on getting one with sufficient amounts of the curcuminoids that create the reduction in inflammation. It needs to be taken with omega-3s for impact, which given the frequency really means using a good quality supplement.

More that we could have talked about

I have to admit that there was so much more that we could have talked about – and maybe I should go back in a few weeks once I see the impact of a few changes.

For instance, many people say that having had 7 general anaesthetics, rebuilding the gut fauna with a good probiotic is a priority to ensure good absorption of nutrients.

In summary

I came away with a much clearer view of what I should be doing in my base diet and the things that I should be eating more of and the things to avoid. I also finally answered the debate that I had been having with myself about supplements – and decided that the extra demands of this recovery phase meant that a few specific supplements would really help me.

But more than this, it was a real wake-up on the complexity of nutrition and how everything works together. It has been a great insight at this stage of injury, medication etc. But when life changes again, I think that there is a real value from getting expert insight on the body’s nutritional needs and how to meet them effectively. I really hope to be back to sport and when I start training would definitely go back again, plus at different physical lifestages as hormones change, or lifestyle changes. I had not previously realised the benefit that one can get and I would recommend it to others.

Affirmations and Mantras for healing

Self-talk is known to be one of the most important parts of mental strength. Athletes consistently use it (often together with visualisation) to help with performance under pressure. My suggestion is that it is just as important when you are injured and facing the challenges of recovery and rehabilitation.

Are you wondering what is self-talk? I define it as the voice in your head that chatters constantly, about all kinds of things and at times can escalate to a full-on internal debate. But there is good evidence that the mind takes these messages and images very seriously, driving changes in the hormonal system and the nervous system which in turn have very significant physical impacts (as well as changing your thought patterns going forward).

Affirmations or mantras are usually short, pithy phrases to insert positive messages into the mind. I would also be remiss not to mention that in the Hindu faith and yoga mantras are chanted, with specific mantras to generate powerful sound waves that promote healing, and the relaxation from the ancient practice of gong therapy or ‘sound bathing’.

This is something that many people write about. I especially enjoyed Carole’s blog from 2014 where she talked about Dr Coue’s mantra (or autosuggestion as he called it) where in conjunction with their medical treatment, they would say over and over to themselves 20 times in the morning and 20 times in the evening ‘Every day, in every way, I am getting better and better’. Read more on this inspiring story from over 100 years ago, plus some great tips and book recommendations in Carole’s blog:

What kind of mantras help?

When I was running ultramarathons and doing Ironman triathlons, I used mantras a lot and found:

  • It needs to be positive. I had a spin teacher who used ‘mine is the power and the glory’ as a mantra, and I know that many people find these universally positive exhortations very useful– hence the Ironman slogan of ‘Impossible is Nothing’.
  • It needs to be realistic at that moment! For instance, telling myself ‘I love to run’ is true, but in the final stages of ultra-marathons or long-distance triathlons the voice on my shoulder would scream back ‘I don’t right now – I want to stop!’ so I would use simple exhortations like ‘run for home’ or ‘nice and steady’.
  • It is better when it is process-based.  There are times in a long race where the final finish line seems too far away to engage with, and so process-based mantras worked better for me. This seems a strong parallel with the uncertainty on outcomes in recovery and rehabilitation. So just as I would focus on technique points in races like ‘keep my rhythm’, ‘nice and light’, which brings the benefits to keeping good technique at a time when tiredness can reduce form. In the same way in the tough part of recovery focus on the exercises, release work, nutrition, hydration and sleep patterns can reinforce the positive habits that will make a difference.
  • It is not helpful to set specific goals that you then miss. Whilst I have spent many races setting myself a challenge for the next split time, or the person that I would overtake, these are only useful when you hit the goal and then set the next goal. Missing them really can really drag you down, as it allows the internal critic to keep saying that today is not your day and you may as well just give up.

How do I apply that to my recovery?

It is really useful to reaffirm your strengths and the resilience that you bring to this situation: from the factual such as ‘we have a good plan and next steps with the medical team’ or ‘we are focused & determined and will get to the bottom of this’, ‘I have what I need to get through this’, ‘all of this strength and conditioning will make me a better athlete’ to the more aspirational ‘we will beat this’, ‘I’ll be back’, ‘my body is amazing’ and ‘I’ve come through tough times before and I will again’.

Also to recognise all of the people on your side and rooting for you: ‘I am in great hands’, ‘I am surrounded by love and support’, ‘I stand shoulder-to-shoulder with my team’, ‘I am enveloping my body in love and kindness’.

Reaffirming the sense of progress – even when it is too small to see: ‘every day of careful nutrition and good sleep helps my body to rebuild’, ‘little by little my body is healing itself’ and ‘every step towards recovery helps me’, ‘cell by cell my body is rebuilding itself’.

Some people find perspective very useful – for example: ‘whilst this is tough, people are facing much worse than this and getting through it’.

Some inspiring quotes

This link includes some inspiring quotes for injured athletes that could be used as mantras:

https://www.theodysseyonline.com/25-quotes-inspire-injured-athletes

So why not try it?

How about choosing a favourite mantra and use it every day for a week – repeat it under your breath over and over at key points in the day, write it on a post-it and put it on the bathroom mirror or under your pillow, close your eyes and smile gently as you visualise it… the mind is a powerful thing.

Your body and mind are amazing – ‘Every day, in every way, you are getting better and better’

Another self-help technique for back pain – the McKenzie method

I had lots of people getting in contact after my blog earlier this week on back pain, so wanted to quickly share this additional technique that has brought relief and recovery to many. I hope that some of you find that it helps.

For a lot of people (especially runners and cyclists it seems) back pain comes and goes episodically. For most the issue is a disc bulge (most people over 25 or 30 years-old seem to have them to some level), and the disc bulge moves slightly, compressing one of the 4 key nerves at that lumbar vertebrae level and sends white-hot pain, pins & needles and/or numbness down the leg, sometimes with symptoms in the bum cheek or hip as well.

Each nerve has a role for areas of the body and internal organs. If you are interested in understanding the link between the level of the spine (which vertebra) and the body, have a look at the spinal nerve chart: https://millerchiropracticclinic.com/spinal-nerve-chart/

A lot of people have found great relief through the McKenzie method

First of all, take this simple self assessment – answering yes or no to each of the questions:

  1. Are there periods in the day when you have no pain? Even 10 minutes?
  2. Is the pain confined to areas above the knee or above your elbow?
  3. Have you had more than one episode of low back pain or neck pain over the past few months or years?
  4. Do you feel worse during or immediately after prolonged bending or stooping; as in making beds, vacuuming, gardening, concreting, etc?
  5. Do you feel worse when sitting for prolonged periods or on rising from the sitting position, ie after watching TV or working on the computer?
  6. Do you associate your pain with any one particular activity but are generally pain-free when not engaged in this activity?
  7. Do you feel worse when inactive and better when on the move?
  8. Does your low back feel better when lying face down? (You may feel worse for a minute before the pain subsides, in that case, the answer to this question is yes).
  9. Does your low back pain feel better when you are walking?

The McKenzie Institute claims that if you have answered yes to more than 4 questions, your chances of gaining benefit from the McKenzie method is very good.

They say that if you answered yes to 3 or fewer, then you may require specialised assessment and treatment.

The McKenzie method is built on gentle spinal extension exercises

The theory behind the method is that most discs bulge out backwards, and therefore gentle extension exercises encourage the disc to change shape with more of the disc-matter at the front and take the pressure off the nerve that it is compressing.

Robin McKenzie’s book ‘Treat your own back’ is inexpensive and practical – giving a do-it-yourself plan for relief of lower back pain through postural changes, ergonomics, and simple exercises. It also provides a clear understanding of the causes and treatments of persistent back pain.

One last key tip

I think that anyone who goes to a physiotherapist with back issues is given spinal extension exercises. But I am not sure that everyone talks about technique, and it is really important. If you simply move into the spinal extension, then all of the muscles in the lower back shorten as you peel up. But if you engage your abdominals (especially the deep Transversus Abdominus) and then do the back extension, then the same muscles go into extension due to the reciprocal inhibition of the muscle pairing with the abdominals. This is what you want.

Back Pain? You really need to read this book before you do anything at all!

I challenge you to find better explanations and practical advice on back pain management anywhere!

Even though the pain can be so bad that you may not be sure that you can live through it, do not panic! Back pain affects 80% of UK adults at some stage in their lifetime (and usually in mid-life) and for the great majority of them, this passes within a week. For the 10% that it lingers more than a week, the scans and the words used by consultants can seem very scary.

I remember my Dad impressing on me the importance of avoiding spinal injury when I was a kid who loved climbing, abseiling and mountain biking. He was right that the back is a complex mix of bones, tissue, and nerves that drive everything, and the challenge is that the central nervous system is not very good at healing itself (medical experts are divided on what is possible vs impossible).

And back problems are not the end of your sport. 85% of male gymnasts, 80% of weightlifters, 69% of wrestlers, 58% of soccer players, 50% of tennis players and 30% of golfers have had back problems and the large majority of them have come back to their sport – albeit, for some of them, this has taken a little time.

Crucial advice for you before you go to any health professional!

This book ‘Back Mechanic’ by Stuart McGill claims to be ‘the secrets to a healthy spine your doctor isn’t telling you’. I would suggest that every athlete with back pain needs to get it and read it cover-to-cover twice before they take any action. It is very readable and contains truly excellent explanations, evidence-based plans, and case-studies from athletes where he has led their rehabilitation.

In the ‘Back Mechanic’ book, he explains why:

  • your pain may worsen after trying physiotherapy, especially with significant manipulation
  • why you can seem to be OK and then try to do something and be knocked out for 3 days straight
  • why it makes sense if you find walking faster is less painful than dawdling
  • why you may get told that the pain is in your head (which he completely refutes)
  • why just keeping a diary of your pain levels and painkillers is not enough
  • yoga and pilates may be recommended to you but may increase your pain
  • and many more questions answered!

A structured self-assessment and practical toolbox

The mid-section of the Back Mechanic book leads you through a highly diagnostic structured self-assessment of your back pain in static and dynamic movements.

From this, you can build up basic movement tools for simple, small, pain-free movements.

Then he moves into spine hygiene so that you can expand your pain-free abilities, with further sections on building a resilient back and restoring the hips, as well as specific conditions.

Will this help me avoid surgery?

There is a whole section on avoiding surgery, and the key decision points that will lead you to build an evidence base that suggests that you may not be able to move forward without surgery.

How to recover and trust your back

Many athletes who have come back from back problems say that one of the biggest challenges is regaining confidence in your spine. The second book – ‘Ultimate Back Fitness & Performance’ (which is more expensive and you may have to order from Canada or USA) gives a really excellent guide on building up from the end of the first book into using your back in performance situations but is a longer and harder read.

In summary

The message is – do not panic, don’t rush to the Doctor yet – read the ‘Back Mechanic” book and create a plan that you believe fits with your specific symptoms and responses to the static and dynamic tests in the book. It may take some time, but a good path to take given that 40% of people after surgery have ongoing pain and often end up having second and third spinal surgeries (each with considerably lower probability of successful outcomes).

Surgical skill or bedside manner?

We had a great debate over breakfast the other day. The question was –  if you had to choose, would you prefer a surgeon with great surgical skills and average bedside manner, or average surgical skills and great bedside manner? Of course, one hopes that you never have to make this choice, but it was a good debate!

My argument was that I wanted great surgical skills, given that I am unconscious at that point and once you are opened up they need to deal with whatever the situation actually turns out to be (which may be rather different from the best guesses on the scans). Having seen how incredibly thin and fine things like nerves are in many places, the fine-motor skills of dealing with this feel very important (and obviously in things like arthroscopy are one-step removed like a computer game!) I have to admit that I was only conscious once as I got wheeled into theatre (the other 6 times I was in a small ante-room with just the two anaesthetists) – but I was completely stunned to see 10 people and realised what a team leadership role the surgeon has!

But the counter-argument for the importance of bedside manner was a great one. The sad statistic is that many people continue to have pain after surgery (for instance, failed back surgery is said to run at about 40%, according to Penn Medical in the USA). So what you most need is to find a person who has the depth of skills to really understand what is going on in your body, and what interventions are most likely to help the situation. Therefore, someone who has a good ‘bedside manner’ to truly understand what is going on and whether surgery is a good option is what you most need. It can save you a lot of trauma and uncover a much better path.

The argument goes further. If you do have the surgery, the recovery phase is critical. Being able to explain what recovery and rehabilitation approach works best, and adaptations to make really increase the chance of recovery. Not to mention the softer factors, such as the level of trust and belief, which many would argue also play a key role in the mentality of the patient and therefore their biochemical make-up during the recovery phase.  

Supporting evidence that bedside manner may be much more important…

Having had four male surgeons, I was somewhat stunned that there was a statistically significant difference in the outcomes by the gender of the surgeon in this British Medical Journal comparison of postoperative outcomes amongst patients treated by male and female surgeons via a population-matched cohort study. It showed that fewer patients treated by female surgeons died, although there was no statistical difference in the proportion that were re-admitted to hospital or had complications within 30 days, compared to the matched group treated by male surgeons. If everything in your mind is screaming out that this cannot be true, then I will leave you to read all of the statistical analysis in the paper (including the interesting finding that the same pattern was true in emergency surgery, where the patient did not choose their surgeon):

https://www.bmj.com/content/359/bmj.j4366

But perhaps more interesting is the why’s, which the paper says need more study. But they already suggest that there is a gender difference in how male and female physicians practice medicine, such that it can affect patient outcomes.

They say that there are 4 core components of surgical practice:

  • Knowledge
  • Communication skills
  • Judgement and
  • Technical proficiency.

Obviously, post-surgery there are more people involved in the care so there are more factors too – and a previous study of beneficiaries of US Medicare that were treated by female general internists in hospital had lower rates of 30-day mortality and readmission than those treated by male internists (Tsugawa et al), which they attributed to female doctors being more likely to:

  • use a patient-centred approach and
  • to follow evidence-based guidelines

So what could this mean for your surgery?

Having never been in this surgical world before it was thrust upon me, I had no idea how to move forward. So here are a few tips that I would say now:

  • If you have Medical Insurance, ensure that it allows you access to the maximum pool of consultants (they generally operate in a number of different hospitals and each of them is self-employed, so worry about the surgeon access, not the hospitals)
  • Always try to find a surgeon who has worked with sports people.
  • Get recommendations from people in the know. There is no meaningful data that you can access on the outcomes by different surgeons, but nurses and people in the hospitals know it. Call on your network shamelessly to try to understand the real story. Take time over this – for all that you probably feel that you do not have time on your side in your situation, it is really worth doing lots and lots of investigation.
  • If you have to wait, it is a good sign. Whilst none of us want to wait when we are in pain, it is much better to be seen by a surgeon with a full plate and lots of patients, rather than the one with lots of gaps. Firstly, it is an indication of their reputation. And secondly, if they are busy, human nature suggests that they may be more balanced in whether surgery is the best option for you.
  • Don’t be afraid to ask for a second opinion. Many people say always go for a second opinion before surgery, and that surgeons should not be offended as they should also recognise that it is a big decision. I would say that if what they say doesn’t seem to fit, or you want to have more comfort before making a big decision like a second or third surgery, then a second opinion really helps. They say that the key is not to tell the second person what the previous diagnosis is so that you get a genuine fresh pair of eyes on the issue.
  • Go into the appointment with a list of questions and a second person in support. My experience is that almost all of the surgeons that I have met are extremely introverted and tend to say very little. Therefore it is down to you as the patient to elicit responses, and to keep asking the questions until you feel that you have understood the answer adequately. This is why I always take someone else to the appointments who also has the list of questions and understands what we are trying to understand from the appointment, as I have felt quite intimidated and not managed to get all of the responses that I was looking for when I was alone.
  • Always go to another medical specialist too. The old saying is that when you have a hammer in your hand, everything looks like a nail. So the surgeon is always likely to come back with the choice of wait and hope it gets better, or do surgery. Hence getting an alternate view of how another specialism would approach your issue is very useful – go to:
    • a good clinical physiotherapist (one who has done cadaver work, reviews scans, and works across a range of techniques that are not just manual therapy and strengthening exercises),
    • a chiropractor with a good track record (who again reviews scans and uses more approaches beyond the classic ‘twist and crunch’)
    • a sports rehabilitation specialist (who again reviews scans and does screening to present a treatment plan that shows clear milestones with review points for reassessment and case studies of where this has worked before with/without surgical intervention)

So I changed sides on the debate

Through the debate (and long after I had finished breakfast), I realised that the core of the issue for me is that I was falling into the trap that I think many of us fall into – the idea that surgery is a quick intervention that creates an instant fix.

Once I articulated that I believe that surgery is sometimes one step in the rehabilitation path, it becomes clear that the communication skills to make the right decisions with the patient are much more likely to get to a better outcome. And since communication is a two-way street, we as patients also need to do lots of work to make sure that we communicate and understand well through the process.

“You just fight with your brain, to get the body ready to fight against the illness”

I am not a big Formula 1 fan, but I do listen to a lot of radio at the moment. And so I came to understand a little more of the amazing story of Niki Lauda, who passed away yesterday, aged 70.

Niki Lauda was Formula 1 world champion three times (1975, 1977 and 1984).

“My brain was the only thing that I could control”

But in 1976 he had a crash at 150mph on one of the bends at the German Grand Prix and suffered third-degree burns on the majority of his body. He was rushed to hospital, technically ‘died’ twice before being resuscitated each time and had a priest read him his last rites.

His mental toughness is credited for not only keeping him alive, but also getting him onto the start-line at the Italian Grand Prix at Monza just 40 days later (in incredible amounts of pain, but still contesting the world title race which he had been leading by some margin).

You can hear about it in his own words on this video:

https://www.theguardian.com/sport/video/2019/may/21/niki-lauda-looking-back-at-the-life-of-a-formula-one-legend-video-obituary

“The mind leads and when it can the body follows”

For an injured athlete who is having a hard time, this may sound corny – like one of those motivational posters hanging on the wall of the gym such as “your attitude defines your altitude” or the like. But there is not only Niki Lauda’s inspiring story, but the increasingly considered ‘BioPsychoSocial Model’ in medicine which shows how interlinked all of these aspects are.

So even if your body is not responding to therapy for you right now, keep working on your mind. Amazing things are possible. You could be back in the fast-lane sooner than you think!

Good luck to all, and of course RIP Niki Lauda