Chronic Back Pain - Triathlon Training - Help

[SigMik]

Drekkly, well done in performing the slump test on yourself!

It was about as I expected. A skilled therapist, familiar and comfortable with the test, would probably be able to confirm your observations as he/she could change sequence, add rotations and adequate overpressure to the right places and so on.

This suggest that you have a neurodynamic (neuro = nerve-stuff / dynamic = movement) component to the pain in between your shoulder blades. Your nervous system is in reality one continuous structure, almost like a tree (spinal cord) with bigger and smaller branches (peripheral nerves, eg. the sciatic nerve). The whole nervous system is enclosed in protective sheets, and talking specifically about the spinal cord - the outermost protective sheet is called the dura mater. When you do any movement, obviously the nerve and its protective sheets moves with you, smoothly within the spine and extremities, elegantly adapting to the surroundings. Any structure/swelling that interferes with this nerve movement, can potentially make the nerve increasingly sensitive to movement = mechanosensitive. The most classic example is a lumbar disc interfering with the sciatic nerve and that's why a straight leg test could produce shooting pain in the leg/or back, similar to the test you did on yourself.

I'm not suggesting that anything is interfering with your nervous system (ie. no neurological issues), but I am suggesting that something might be interfering with the sensitive protective sheet around your spinal cord. It does not necessarily have to be the disc, it could be any structure that lies close to this sheet, or swelling from any of these structures. I am, as Damien, quite sure that you do not have a herniated disc, but maybe a structural change to the outer parts of your disc (annulus fibrosus), or a small injury to the upper or lower endplates of the disc where it attaches to bone, or a small injury inside the disc. A MRI-scan could potentially confirm/disconfirm this, but I don't think that is indicated at this point. Personally I'd might order a MRI if you did not improve with treatment based on my hypothesis.

My hypothesis is that when you do reversed dips, you put traction through your spine due to the weight of the lower body. This traction will have a pivot point, somewhere in your upper back where the spine is supported with your upper arm muscles. I think the triggering injury is located at that pivot point. The opposing forces at the pivot point would be increased if you (most people do) have a small jerk at the point where you push yourself up from the dips. As Damian says, it could be perpetuated or in combination with a sprained/torn spinal ligament, making that pivot point more unstable and vulnerable to withstanding the opposing forces I'm talking about. Probably we'll never know.

You should have a thorough examination of your thoracic spine, not only the simple plane movements as forwards/backwards bending, rotation and side bending, but any combination of these to explore every possible movement combination of your thoracic spine. I would also recommend a thorough palpation examination where the therapist puts pressure to different parts of your thoracic spine, again in every possible direction, preferably when you lie/sit in a neutral position compared to when you sit in your most uncomfortable position. This will not tell you if its a disc or not, but should give the therapist a preference on what type of treatment to give you, and also physical reassessment markers he/she could retest directly after giving you a treatment to see if it was beneficial to your or not.

You could try to treat yourself a bit. Sit straight, chin towards chest, notice amount of discomfort between shoulder blades. Maybe even try rotation. This is your reassessment marker. Do the slump test fully, straighten both legs 10 times, retest yourself in straight sitting position. Do 10 reps about 3-4 times or until you don't get more improvement. This is to treat the sensitivity of that protective sheet I talked about.

I'm personally not too familiar with McKenzie exercises for thoracic problems, but google it. I would think the exercises done in front lying with upper body extension could potentially be of benefit to you. Try them, reassess yourself directly afterwards! Sit straight, chin towards chest and so on.

I think any therapist you see should reason along the ways you've been given here. The initial questions asked by Damien are CRUCIAL for any therapist to understand your symptoms. If you don't get this form of communication and reasoning from your therapist, ask for it, if he/she is unable to reason, move on.

Kind regards,
Sigurd Mikkelsen

[drekkly]

Dear Sigurd

Thankyou for your very detailed response - a lot to take in there. I am seeing my GP on Monday and need to figure out what pradctical help the NHS can give - can you confirm - do I need an MRI scan at this stage? Do I need an X Ray?
I think I can take what I know now to my exisiting therapist and see what they can do for me or try another physio centre.
Are you saying that undertaking the slump test repeatedly would help the condition? I will certainly google the other exercises you mention.
Would you recomend avoiding any particuar sports until I fix the problem - if indeed it is fixable at all? Would it just be a case of mitigating the effects?

Thanks again

Nick

[Dr Damien]

Dear Dekkly/SigMik

I would trust the response from SigMik, as nothing occurs with the resisitance tests rules out a muscular issue. SigMik has given a plausible reason for your chronic pain. The graded exercises using the slump test deriatives should impove your symptoms for as long as you do not over do it. Primarily because it can easily be irritable (causing more inflamation). Your thoracic spine needs a thorough examination as suggested by SigMik, It might be a good idea to combine your self treatment with heat or a contrast treatment if you do not have a heart problem to get muscular relief and enable better movement. A visit to your doctor for some anti-inflammatoies should be helpful as this will reduce the inflammation furthermore in preparation for your self treatment as suggested by SigMik.

To SigMik, i do not feel a mckenzie approatch will help this situation primarily because like you say it sounds like a tethering of the dura matter. The Mckenzie approach purely looks at derangement from disc issues. If that is unlikely here, I think going through those principles will not make a difference. I agree with you that using graded neurodynamic exercises should be the way to go first.

To Dekkly/SigMik
A visit to the chiro maybe needed once more. Not to take anything away from the chiro as im sure he knows exactly what he is doing, logically speaking...it is perhaps better to use gentle mobilization of the vertebrae above and below to help stretch this tethering and perhaps gentle mobilizations to the tranverse processes of the involved vertebrae.

An X-ray will confirm that you might have a degenerative spine, it will unlikely show this problem, as SigMik rightly said your best bet is with the MRI and I agree its not necessary yet unless the problem is not getting solved, best to avoid unnecessary radiation/investigation if the problem can be solved clinically.

Cheers to you both and thanks SigMik for helping us narrow this problem further.

[SigMik]

Yes, Nick, I do think in your case that it is "fixable" and there is a lot of things you can do to help yourself. I often find it is a question of doing more of the good, and less of the bad, and a skilled therapist can help you with identifying relevant factors that can contribute to your recovery. I often say that it's not about what you see (osteo, physio, chiro, etc), but WHO you see. Personally, I'd recommend you to get a referral to a musculoskeletal ESP (extended scope practitioner) clinic or look for MACP-members (manipulation association of chartered physiotherapists). I'm maybe contradicting myself a bit here, but at least I know the criteria they've been trough to get to where they are. My point being, a skilled person practicing chiro, osteo, physio, would probably be skilled no matter what profession that person would become - it's more about personal traits (I believe) than what is being taught in the different schools........

I've become quite careful with advising anti-inflammatory drugs, as resent research suggests NSAIDs to delay healing processes. Another important aspect is that your pain being of 6 months, the chances of any inflammatory mediators being active is less than likely and that the pain now has a bigger component of inadequate pain-processing issues. Anyhow, it's all about overall net-gain or net-loss, and for your part, I'd say IF you can manage without, let it wait so you can monitor the effect of the interventions this communication might trigger.

Damien do bring up a technical point to the McKenzie approach, but taking it into a functional light rather than structural (derangement), my impression is that forward bending makes it worse - intuitively one would try to see what happens if you do the opposite - backwards bending. As long as you reassess the before and after effect, you'd be the one to tell if its meaningful for you.

The slump test as an exercise could potentially help the condition, but as Damien commented, "neural" issues can tend to be a bit irritable, a bit easy to flare up with a tendency of latent pain, so take it easy. It's purely hypothetical, but moving the nerves is thought to make its "fluid" flow better as it has thixotrophic factors, potentially improving nutritional conditions within the nerve, making it less sensitive to mechanical movement...

A few points that I forgot to mention in my previous post, was how a disc issue could produce symptoms in the situations you describe. The MAIN thing you mentioned, was the difference when swimming. Swimming is a non-weightbearing exercise, potentially causing less pressure to your disc and therefore potentially less tethering to the dura mater. It does also involve a lot of repetitive movements which could irritate minor "mechanical dysfunctions" in your upper back. This together with the transition to weight bearing out of the pool could explain why you feel sore after swimming in contrast to the other exercises you do.

Also, you mentioned that its worse while cycling. First of all, cycling is a forward-bending positioned activity, also not extremely far from a sloppy slump . Second, it could also potentially challenge this pivoting point as I spoke of earlier, as your upper body will absorb much of the torque (rotational forces) when you work with your legs and hold on to the handlebars. Personally, I'd use components of this exercise in tailoring a rehab-programme for you.

As you suggested, bring some of this info to your existing therapist or even better, ask them to read this post . I'm sure your therapist might also appreciate some input and will be able to use some of this constructively.

Best of luck,
Sigurd Mikkelsen

[drekkly]

I would just like to thank you both for the information you have given me - I feel much more informed as to what the condition might be - I don't mind so much carrying an injury or condition as not knowing what it might be and why it might be happening!
I can go back to my physio with some specific requests now and hopefully we can get my back fixed - that would be so good.
Can you just confirm what this meant

"It might be a good idea to combine your self treatment with heat or a contrast treatment if you do not have a heart problem"

I am not familiar with contract treatment and why would this effect the heart.


Finally nothin either of you say suggests that I should rest the back in order to get it better - I am ok to carry on training without the risk of worsening the condition? That was what I was worried about - training through the pain and doing myself permanent damage. In both your opnions this is not likely?

Thankyou once again and enjoy your Sunday

Kind Regards

Nick