Read time 5-6 mins - Audience-> Anyone with an interest in low back pain.
During this strange time that we find ourselves in, I find myself having more time to reflect on my own practice; my strengths, my biases, areas to improve upon and my own thoughts and beliefs around why I have chosen to be a physiotherapist.
Like many of us, I suffered greatly from the Dunning-Kruger Effect when I began studying physiotherapy. The DKE (see chart below) suggests that beginners have more confidence in their ability than many experts with many more years experience and competence. This confidence usually takes a nosedive after you encounter your first failure. In physiotherapy, this usually happens when you are unable to help someone to get better. More specifically, in the management of chronic low back pain, this occurred for me when I was forced to challenge my own beliefs on the issue following unavoidable evidence to the contrary.
Dunning - Kruger Effect
My area of “expertise” when I started studying was low back pain. I had been struggling with my back for the previous 2-3 years and once I learned the basics in the first few months of studying in UCD I was sure I had all the answers. I would tell my lecturers that I may need to get out of my seat during lessons because of my back. They were polite and listened to me even though I’m sure they had seen it all before. I would volunteer as the patient in practical sessions because of my back. I even debated with a guest lecturer who presented evidence that sitting posture has much less significance than was previously accepted.
Thinking back, I am unsure when it all began. I’m pretty sure my first significant episode was in late 2011/early 2012. I was working as a strength & conditioning coach in professional sport just out of college. While the athletes were doing a gym session I sneezed and suddenly I was unable to stand up straight. There was plenty of experience of back pain in a rugby squad so I was not short of advice on what to do and opinions of the damage I had done. I had no medical training but I was sure I had a ruptured disc and that surgery was the best option. I must have improved very quickly because I can’t remember being absent from work at all. Despite the quick recovery, the disk problem was firmly planted in my head. This was strengthened the following year when I found myself doubled over after trying to predict the bounce of a rugby ball had me stretching outwards. Once again, I heard an intervertebral disc as a possible cause of pain. I was now fully wedded to the idea that I had a “bad back”. It was now affecting my everyday life. I found myself struggling to get around a hurling pitch. My athleticism was my only strength on a hurling pitch so once that started to fail me, I found hurling very demoralising.
The pain was never severe apart from the 12-24 hours after the two incidents mentioned above. Rather it was the lurking presence of pain in the background of my thoughts that was the biggest problem. Any discomfort I felt in my back when exercising was further proof that something was wrong. In actual fact, it was probably a normal physical sensation you get when exercising. I had learned to associate this sensation with physical damage being done to my back. You might know this as “wear and tear”. That pain you get when going up the stairs must be as a result of the bones rubbing against each other and that means you’re going to get arthritis before the age of 40. This is very rarely the case. Pain does not mean damage. After treatment from an osteopath was unsuccessful, he recommended an MRI to help with an accurate diagnosis. The consequences of the MRI were significant.
The radiologist’s report mentioned mild disc space narrowing at the L2-3 level along with a mild disc bulge at the L4-5 level that was not impacting any nerve roots. I was terrified by these results. Here was proof that I had a bad back. I stopped playing sport because of my back pain. It was at the front of my mind before I did anything. I would be suspicious of times when I wasn’t feeling pain and would assure myself that it was a false dawn and that pain was just around the corner, waiting for me. I knew that the symptoms of disc issues in your back can include altered sensation in your legs such as pins and needles, numbness, and tingling to name a few. I was hyper-vigilant for anything that could be identified as a symptom. It was the opening of most conversations I had with people who were unfortunate enough to know me because I would have already told them all about it and even showed them the images of my MRI if they were one of the lucky few to be near me when my laptop was open. (I have since deleted the files from my laptop last month when finding myself with time on my hands due to self-isolation). I went to an osteopath, a physiotherapist and eventually got an epidural injection from a well-renowned orthopaedic surgeon. The reason I got the epidural injection was because physiotherapy was deemed to be unsuccessful. The lack of success of the physiotherapy intervention had nothing to do with the physiotherapist. She was excellent. The problem was my lack of participation in the process. I just thought I was being lazy but there was an unseen resistance towards the rehabilitation. All in all, my low back pain had consumed my life and my identity. It was almost a safety net; a get-out-of-jail-free card for any situation that I didn’t like the look of. Once I got better, I would have to regain my fitness, get back up to match sharpness and regain my place on the team.
MRI findings very often will show up a number of issues, even in healthy individuals
Prior to this decline, I had made it on to my hurling club’s senior championship panel which was a relatively big deal for me. I had worked hard for years to get there. Now I found myself 2 years out of sport, studying a full-time Masters in another city and had just started dating my future wife. If I didn’t even try to get back playing sport at that level, then I didn’t really fail did I?
A Homer Simpson quote comes to mind. “You tried your best and failed miserably. The lesson is: Never try.” I gave in to my back pain. I was now part of the exclusive club of former players; cruelly stopped short by injury in their pursuit of sporting excellence. I almost wore my back pain as a badge of honour. I wore this badge on my sleeve through my early days of physiotherapy. No need to ask the rest of the class, I could answer all your questions on back pain. I would always seek out the latest research on back pain management. I would dismiss interventions that didn’t provide a clear blueprint that was to be followed afer you’ve pigeon-holed your patient into a specific sub-group of low back pain. Everything has a place and everything in it’s place. I believed that there was a set of exercises out there, waiting to be discovered that would cure me of my affliction. I was seeking out the Holy Grail. The more I searched, the more I realised that my cure wasn’t in the form in which I had hoped it would be. There would be no magic bullet in the guise of a new stretch or strengthening programme. I needed to challenge my own biases and beliefs towards back pain and take in what the best evidence available was telling me. The evidence was telling me that my back was structurally fine.
The MRI findings were completely normal. The symptoms I had were so sporadic and mild that they were not indicative of any damage. I had chosen to believe that I had a bad back. Now all the evidence was telling me that my back was normal and that most of the trouble I was still having was because I was grossly unfit afer a few years out of regular exercise and was adopting certain postures/actions to avoid back pain which were probably exacerbating symptoms. An analogy from the guest lecturer that I mentioned above has stuck with me since I first heard it 5 years ago. It goes something like this: If you were to look in a restaurant filled with 100 people and told that one person in there has back pain, you would be able to pick them out because they would be sitting taller than everyone else, bolt upright with no slouch in their back. I know this to be the case because that’s how I sat for a few years as a way I thought would protect my back. All it did was strengthen the belief that my back was weak and needed protecting.
Gradually I began to trust myself and my body’s durability. I began to exercise more regularly. I took up running and got more consistent in going to the gym doing strength exercises because I enjoyed feeling strong and fit. I made an effort to think less about my back. I told people that there was no problem with my back anymore. It took some time but eventually I began to believe it myself. Now I know this to be true. Today, there is nothing I wouldn’t do because of my back. Yes, it gets stiff from time to time. It even gets painful every once in a while. But I don’t have the same fear that I once had. I don’t over-react to what is happening. I take a minute, think about why it’s sore or stiff and take actions to remedy the situation. Sometimes I do nothing but go about my daily business and sure enough, the back pain usually goes away too. Ignorance is bliss sometimes.
Even though I would not consider myself to have a back problem anymore, I never returned to organised sport despite it being my only past time prior to everything starting. My life circumstances had changed greatly during these years also, making time for sport scarce. I flirted with the idea of going back to sport and I did make a few cameo appearances on the hurling pitch, but a concussion in late 2016 was the last time I put on a hurling helmet. I wish someone could have convinced me to keep playing from the very beginning. More importantly, I probably needed to convince myself! If I had never stepped away in the first place, I would most likely still be playing today.
This pathway has led me to the point where I am today. I understand back pain and the role it can play in your life. My own experience has definitely helped me and shaped my treatment of low back pain.
My special interest is most definitely in helping people to avoid the pitfalls that swallowed me up. Low back pain is a very complex issue for a lot of people. It can take over your life. It can be all consuming. However, It doesn’t have to be this way. There is help available but like a younger me, you might find that it is not in the form which you imagined it would be. Sometimes you need to think outside the box.
About the Author: William is a musculoskeletal physiotherapist with a specialist interest in low back pain. He has undertaken a wide range of post graduate training in the area of low back pain. William is currently working with the Laois senior hurlers and has previously worked with Munster rugby and the Chief in Super rugby.