Jill’s Journey Through Back Pain: A Case Study Part II

In the previous blog post, we introduced Jill and described her journey with back pain. Now we will discuss more specifically the approach we used to help her navigate this complex situation. 

As the Wellness Station is a holistic practice, Jill’s plan of care was based on the biopsychosocial approach. This means that our care integrates factors related to biological/tissue structure and function, as well as psychological and social factors. Our approach is inspired by the Feldenkrais Method of somatic education, as well as therapeutic yoga, mindfulness, and traditional physical therapy.

(For further understanding of the biopsychosocial approach to pain, check out the following two previous blog posts: Does How You Think About Your Pain Affect Your Pain? & A Holistic Approach to Pain Science)

Bio

In collaboration with Jill’s referring provider, we made sure that Jill was managing pain most effectively with the lowest possible therapeutic doses of medications with the least potential for adverse effects. Jill’s goal was to get off medications for good, as she did not want to rely on them over the long term for pain management. 

We also ensured that Jill was consuming a nutritious, whole-food diet to support an internal environment conducive to healing (she adopted an anti-inflammatory diet similar to the Mediterranean diet). 

The bulk of our treatment approach focused on movement patterns that were likely putting additional strain on the injured tissues. Jill was extremely sensitive to bending movements, as well as prolonged sitting. Using biomechanical principles, we broke down patterns of spinal flexion and extension necessary to bending and lifting, and provided opportunities for neuromuscular learning- new strategies of bending that felt more comfortable, efficient, and less stressful on Jill’s back. This generally involved keeping Jill’s center of gravity over her base of support, sending her hips back to counterbalance her reach, and lifting objects with the strongest muscles of her core and legs.

Jill began to practice picking objects up in her daily life using new techniques, and eventually picked up her two year-old granddaughter in her new and improved way! 

We also provided education about posture and the importance of changing position throughout the day, especially during prolonged sitting. Jill found that a children’s ball placed behind her back in her chair was incredibly helpful for back support, as well as performing small, regular movements of her pelvis, hips, and spine known as the pelvic clock. 

See How Your Spine Moves Part I and How Your Spine Moves Part II for some ideas on what Jill learned here.

Psycho

Psychologically-informed care was necessary for Jill’s treatment approach. The grief from the loss of her husband was affecting her more than she cared to admit. She also recognized that a fear of aging and loss of confidence in her own body’s resilience contributed to a sense of hopelessness. Addressing these factors allowed Jill to further align with her goals, and she was able to instill a sense of self-compassion into the rhythms of her day. Combined with education on the psychology and neuroscience of chronic pain, as well as a daily practice of mindfulness meditation, Jill was able to insert a mindful influence on her pain. She recognized that by shifting the way she thought about her pain, her back, and the active role she could have in her own healing, she was able to take control of the situation more effectively. This helped her body and mind to begin to function more as one.

See Mindfulness and Movement for more of an idea on how we integrated mindfulness and self-compassion into Jill’s therapeutic care.

Social

Without others, we are lost. By creating a strong therapeutic alliance, Jill and I were able to work together on an even playing field. Unlike previous therapies she had been to in which an authoritarian figure prescribed what she should do for her back, Jill and I collaborated as a team, along with her physician. This feeling of support improved Jill’s confidence in her providers, as well as in herself as a necessary member of the team.

See Enhancing the Therapeutic Alliance for more information on the importance of the relationship between the patient and the provider.

We also addressed Jill’s social life and relationships with others. We encouraged her to seek support from her daughters and her friends. Jill began to feel more comfortable asking for help. She also began to go on regular walks with her friends, which she realized was very helpful for her back and much more enjoyable than walking alone. 

A Whole New Jill

Clearly, Jill’s issues were not just in the tissues. The tissues in the back are part of a living, breathing, thinking, feeling, moving organism. Any persistent pain or mobility challenge is multifactorial. Throughout the healing process, the biopsychosocial approach was taken in order to holistically Jill’s issues.

As mentioned previously, Jill is now back to rowing, walking with her friends, strength training with weights, and playing on the floor with her grandchildren!  This has further motivated her to continue to stay active and improve her life and her movement capabilities. She feels that she has gotten her life back!

“In the last eight months, I have shared my experiences with friends and shown them some of the simple movements. I have traveled, concerned I would re-herniate a disc. Not. That truly felt like success. I now know that this process takes time and patience but it is well worth the investment.”

Jill will occasionally experience instances of increased pain. However, these instances are drastically different from the flare ups of the past. They are far less frequent and less severe, and do not bother Jill as much emotionally. She also has much more clarity as to why the flare ups are happening, based on what she has or has not been doing.

Jill no longer sees pain as the enemy, but rather as an informant that helps to guide her actions. She recognizes that pain is inevitable for us all, but how we believe and behave relative to our pain can make all the difference.

Jill has the tools to manage and diagnose how to treat her pain, and she still does a monthly check in at The Wellness Station for support and for a review of movements and techniques.

Jill had an extremely active role in her healing journey, which will be a gift that keeps on giving for the rest of her life.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Images: 

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Jill’s Journey Through Back Pain: A Case Study Part I

Who Is Jill?

When Jill first presented to the Wellness Station, she described her life as “a mess” and felt skeptical that another attempt at physical therapy would make any kind of difference. Jill is 75 years old and had stayed generally active with outdoor rowing and exercising with weights. However, Jill has experienced recurrent bouts of debilitating back pain over the last 15 years, which tended to set her back for quite some time. She had been to physical therapy several times, which never made any long-lasting difference for her.

Jill was having an extremely challenging year. She had become more sedentary during the pandemic, as she did not feel as comfortable working out with her personal trainer. She lost her husband, her lifelong best friend. On top of this, her sister also lost her husband around the same time.

While at her sister’s house to support her both emotionally and physically and to re-organize their house, Jill suffered a severe back injury. A herniated disc in her lumbar spine became sequestered, and the sequestered disc fragment led to nerve compression. Jill began to experience severe back and leg pain, which was constant and severe. She had herniated several discs in the past, and she described this pain as far worse.

Jill went through a course of traditional physical therapy and described it as follows:

““It was very modest stuff. I felt like there wasn’t much of a progression, and it wasn’t as individualized as I would have hoped. They might have used the same printable exercises as any other old lady with back pain!” ”

Jill Finds The Wellness Station

Jill was referred to the Wellness Station four months after her sequestration injury, and was still experiencing constant, debilitating pain. In coming to the Wellness Station, Jill hoped for improvement but wasn’t sure what to expect. Her goals were to improve her fitness and build her core strength in order to be active, independent, and play with her grandchildren- however, she was beginning to lose hope that any of this would be possible.

““In the first session, I found Jacob Tyson to be an exceptional listener as I outlined my back pain history, the recent event and goals. The room was calm as was his demeanor that set a relaxed tone.””

““I still was puzzled in the first few sessions that focused on just a few movements or exercises to establish what is called the pelvic clock. But at each weekly session, the new movements built on the previous week, a method I could appreciate as a former newswriting instructor, teaching the basic journalism language and incorporating more concepts and practices as students learned newswriting style.” ”

Jill Turns the Corner, & Beyond! 

As we worked together over the course of weeks to months to a year, we gradually progressed Jill’s home exercise program by introducing new movements, slightly more challenging than the week before. We continued to layer on educational and lifestyle components that were related to Jill’s life, including concepts of biomechanics, anatomy, exercise physiology, psychology, mindfulness, pain neuroscience, and more.  As Jill continued to learn and build her strength and confidence, she has been able to do more demanding physical tasks without any increase of pain.

“ “Through the sessions, I learned how to stand up and walk in new ways, to use my legs and tailbone to shift weight, to improve the flexibility of my entire spine—all aimed at relieving the pressure and weight on the lumbar part of my spine. We also did relaxation and simple meditation to promote mind-body connection. After each session, I received an email, summarizing our activity. I have compiled all those exercises and support into a file that I can use to refresh my memory of exercises—and to see my progress.” ”

““The knowledge and movements I learned gave me a feeling of accomplishment and control over the mechanics of my body. Usually an exercise or stretch would relieve the pain, and I did not take any medication. A triumph!” ”

Jill is doing much better today, and feels that she has gotten her life back. She no longer feels limited by her pain, and feels empowered to stay active and engaged in life. She is now back to rowing (weather-permitting!), going to the gym twice per week, and having no trouble lifting her quickly growing grandchildren!

Jill also improved on the Modified Oswestry Disability Index (a survey used to measure the impact that back pain has on quality of life) from a 58% to a 12% over a period of six months, which is over four times the threshold of clinically significant improvement. 

Stay tuned in to see our next blog post, which will break down more specifically what we addressed with Jill biologically, psychologically, and socially.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Images:

https://www.safetyandhealthmagazine.com/ext/resources/images/2019/10-oct/back-pain.jpg?t=1568903562&width=768

http://balanced-movement.com/2019/02/17/controlling-pelvis-hips/

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Yoga: Like Flossing for your Joints!

For our whole lives, we participate in a daily practice to ensure the health of our teeth, as it is obvious that tooth decay is extremely undesirable. Neglecting dental hygiene can lead to issues far beyond affecting that beautiful smile on your face, including infection, as well as compromised gut and heart health. In order to ensure dental health, we brush and floss daily, and visit the dentist two times per year. We have accepted this as the gold standard practice, and dental hygiene becomes almost an unconscious part of our lives.

What about our joints? We have over 200 of them in our body, and without them, we would be unable to move. Each of these joints desperately need movement, compression, and relaxation in order to stay healthy, mobile, and well-lubricated. Unfortunately, we have an epidemic of poor joint health that is on the rise. In fact, around a quarter of US citizens have arthritis (an inflammatory disease of the joints), and the prevalence of knee osteoarthritis has actually doubled since the mid-20th century.1 This is contributing to extreme rises in healthcare costs, risky surgeries, chronic disability, and unnecessary pain and suffering. Poor joint health is also associated with many other health conditions- depression, cardiovascular disease, stroke, and metabolic conditions such as diabetes.2 There are many theories as to why the incidence of this disease is so high- increasing weight, sedentary behavior, as well as the overall aging of our population. However, there is little discussion about how to address the root cause of this disease through education and prevention.

Why is there not more education about how to keep our joints healthy as we go through our lives? My main takeaways from gym class growing up were pretty much as follows: how many sit ups and chin ups can I do in a minute in order to "perform well" on the presidential fitness test, as well as how quickly can I run a mile in order not to embarrass myself around my peers? However, there was absolutely no discussion of joint health in any of my education up until physical therapy school.

What joints need is movement- movement that goes behind repetitive gym exercises, walking, and running. As joints do not have great blood supply, they are completely reliant on us moving our bodies through our given ranges of motion in order to distribute the lubricating synovial fluid around the joint space. As we move and load our joints through their given ranges of motion, we develop an improved mind-body awareness that helps us control the force we put through each joint through our body's posturing and muscle recruitment/relaxation. By regularly moving each joint, we also build up our injury resistance to both chronic and acute injuries. For example, if you never practice moving your ankle inwards, and then you accidentally trip over a root during a hike that forces your ankle into an inward position, you will be far more likely to sprain this joint compared to someone who regularly practices moving and loading their ankle in this position.

One might be thinking…."Are you telling me that in order to have to have healthy joints, I have to move each and every one of them every single day?? This sounds like a lot of work… I already have enough on my plate, especially with how often I am supposed to floss my teeth!"

Luckily, even a brief mindful movement practice such as yoga can help ensure your joint health! A yoga practice has the potential to move every joint and engage every muscle in your body in a relatively short, continuous sequence. And, you will naturally start to use what you learn on the mat in your daily life as well, perhaps without even meaning to! Rather than a chore, a yoga practice can be fun, and make you feel more comfortable and strong in your body. Yoga can be an excellent supplement to whatever else is in your fitness routine that can actually improve your performance in other athletic endeavors as well.

Written by: Jacob Tyson, DPT - Physical Therapist and Yoga Instructor

References:

1. https://www.pnas.org/content/114/35/9332

2. https://pubmed.ncbi.nlm.nih.gov/31207113/#:~:text=The%20key%20comorbidities%20associated%20with,to%20have%20other%20chronic%20conditions.

You Can Break the Cycle of Chronic Pain!

It’s All In Your Head: Your Brain & Pain

Many of us who experience pain might feel very offended if we were told that this pain was all in our head. However, all pain, as well as any other sensation, is created by the brain. This is because pain is a perceptual process- the experience of the pain is not actually happening in the part of your body that hurts, but rather it is happening in your brain. Sometimes this perception of pain can be a very useful process (Ouch, I just touched a hot stove, let me move my hand away as quick as possible!), but when it comes to chronic pain, this process can severely impact our quality of life.

In cases of chronic pain, the brain tends to get hypersensitized to the pain until we are in a constant state of high alert. A learning process occurs in which neural pathways involved in pain perception of a certain area (the low back, for example) become strengthened. The neural pathways responsible for chronic pain experience go far deeper than our acute pain pathways, such as in the stove top example. This is because over time, the neural pathways related to the chronic pain will be embedded into the memory and emotional centers of our brain, making chronic pain far more complex than pain from acute injuries.

As with any learning process, we form associations, such as... sitting = pain, long car rides = pain, exercise = pain. These associations can contribute to a self-perpetuating cycle in which we avoid certain activities because of the fear of pain, which decreases our quality of life, thereby contributing to depression, inactivity, limited social participation, and other factors that will actually make our pain worse over time.

How do we break this vicious cycle?!?

Pain is our brain's opinion of how much danger we are in, and we have to change that opinion. Our brain was capable of establishing these detrimental neural pathways that contributed to the chronic pain, and it is just as capable of creating new pathways that will help us get out of this situation. This is because our brain remains plastic for our entire lives, meaning we are always capable of learning. We must learn that we are safe, and that movement of the affected body part is safe and beneficial.

At The Wellness Station, we help those in chronic pain learn that they are safe.

By creating individualized movement programs, we help our clients learn ways of moving and relating to the body in a manner that will drive neuroplasticity. We will help to teach the little person in the control room (aka your brain) that movement can be associated with calm, pleasure, and ease, rather than movement = pain. The movements lessons are designed to help our clients move with greater efficiency to make movement easier and to decrease tension and tissue strain. We will also help with self-care tools necessary to calm down the nervous system to decrease pain sensitivity, and provide guidance regarding management of the psychosocial aspects of living chronic pain.

Do not let pain stop you from living life to the fullest. It is never too late to learn!

Written by Jacob Tyson, DPT - Physical Therapist,Yoga Instructor and The Wellness Station Team

Balance Part II: Strategies for Improvement

Last month, we discussed factors that control and impact our balance. Consideration of these factors can help us become more aware of what to do to stay safe and prevent falls, as well as targeted exercises to improve our balance that are based on scientific principles.

How do we improve our balance and prevent falling?

If we recognize the influence that the physiological, psychological, and environmental factors have on our balance, we can be strategic in how we improve our balance and decrease our risk of falling.

• Stay active, making sure you are keeping your muscles strong and healthy for life. Have a movement practice that incorporates functional strengthening and balance challenges.

• Enhance your somatosensory system by regularly stimulating your feet. Think of your feet like antennas that provide messages to your brain about your balance. Massaging your feet with balance pods are a great way to keep the nerve endings responsive. 

  Consider more time spent barefoot, especially during balance exercises. This will allow your feet to feel the ground and your toes to spread out, creating wider points of contact with the ground. In daily life, consider shoes with a thinner, more flexible sole, and a wide toe box.

• Ensure you are taking care of your eyes and vision by regularly visiting an ophthalmologist. Make sure you use a nightlight when going to the bathroom at night, and remove any trip hazards from your path.

You could also consider the role of vision to challenge your balance during exercises. Notice that keeping your gaze stable on an object in front of you helps your balance. Moving your eyes around will make balance more challenging. Closing your eyes will make it the most challenging!

Recall in Balance Part I, we discussed how being overly reliant on vision can contribute to a stooped posture, as many people will look down to the ground with their whole body rather than just with their eyes. When walking, practice looking down with just your eyeballs as needed to see the ground in front of you, rather than with your whole self. If you had a light shining from the tip of your nose, and a light from your chest bone, you should be able to maintain these lights at the level of the horizon while walking, rather than keeping the lights cast downwards. 

• Make sure your vestibular system is healthy, and recognize the impact that vertigo, seasickness, and certain medications can have on your balance.

Likewise, you can progress your balance exercises by introducing changes in your vestibular system. If standing on one leg has become easy, can you do it while slowly turning your head from side to side, or up and down? 

• Optimize your environment: Make sure your environment is conducive to not falling! If icy sidewalks, crowds, or uneven trails are not for you, make sure you modify appropriately, perhaps bringing an assistive device or a loved one to help you stay steady.

You can also use the environment to improve your balance, by intentionally walking on trails and standing on uneven or “squishy” surfaces.

• Train your balance… but don’t overshoot it! A mistake many people make while training their balance is going past their edge. If standing on one leg consistently leads to excessive wiggles, wobbles, and you are unable to find your steadiness, then you are simply practicing being unsteady, rather than practicing finding steadiness. You want to be close to your edge, without going over it!

Find an exercise that feels moderately challenging, but you are able to find steadiness and ease with practice. If not, modify the activity to make it more or less challenging. Standing at the kitchen sink, by the counter, in the corner of a room, or in a door frame are excellent places to practice balance, as you have the option of supporting yourself with your arms as needed. 

By finding this edge and achieving success with practice, not only can we improve the physiological components of balance, but we can also improve the confidence we have in ourselves, thereby decreasing our fear of falling and subsequent risk of actually falling!

Follow along with this video, which incorporates seven balance exercises and strategies, “Feldenkrais style”! It instructs in balance challenges including standing and walking with a narrow base of support, closing the eyes, getting up and down from the floor, dynamic weight shifting, and practice with “falling”. Best to do this video near something to hold on to as needed. 

At the Wellness Station, we can help you recognize and make changes in the factors that could be impacting your balance. We will provide you with individualized recommendations and movement lessons to help you improve your balance, your confidence in yourself, and your ability to continue to do what you love.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team