Ask a Therapist - MRI & Low Back Pain

This week's question is an excellent one and a common issue for quite a lot of people.  The question is, how do I know if I need an MRI or other advanced imaging (such as a CT scan) for low back pain?  People may understandably assume that more pain equates to a more serious issue but this is not backed up in the medical literature.  The medical establishment actually has a guideline for when advanced imaging is appropriate.  Unfortunately, these guidelines are often not followed by medical doctors as demonstrated by this survey given to 579 VA doctors.

“Our study showed that almost all clinicians were aware that an imaging test was not indicated for a patient with low back pain without danger signals of severe spinal problems and agreed with the Choosing Wisely recommendations to not do testing,” Sears told Reuters Health by email. “Instead, clinicians worried about not having sufficient time to explain the risks and benefits of testing to patients, were concerned over medical liability if tests are not ordered or rare diagnoses are missed, and noted that they cannot refer patients to specialists without first ordering imaging, even if they think the imaging will not change patient management.”

So what's wrong with getting an MRI or CT scan if it is not really needed?  Aside from the cost of such procedures, they may lead to addition unnecessary tests/measures which could delay proper treatment and potentially result in worse outcomes.  Perhaps the co-author of the study says it best.

CT scans expose the patient to radiation, which can add up over time, and even without inherent dangers an unnecessary test could reveal an unexpected finding that may be insignificant to a patient’s health but lead to more testing, and sometimes complications, Sears said.  “Patients should first have a thorough history and physical exam to rule out presence of ‘red flag’ symptoms and are often first referred to physical therapy in the initial treatment period,” she said. “Because low-back pain tends to come back, staying active, through activities such as walking, yoga, and supervised training, is key to warding off recurrence.”

Sometimes what we get is a super scary and expensive picture of our insides and it doesn't actually do anything to help us get better.  In general, degenerative disc or joint disease can be likened to getting wrinkles on your skin as you age.  It's natural to some degree.  Sometimes an expensive picture IS appropriate but there are some pretty clear indicators which your healthcare provider should discuss with you.

Understanding this "up-to-date" summary of Low Back Pain is invaluable if you have any consistent back pain.  It reviews the rare but serious conditions that may exist as well as the utility of imaging and when it is or is not appropriate.  That said, we know in medicine that no series of questions will be 100% accurate for everyone in every given circumstance.  The key is to look for the big issues, listen to your body, and visit a healthcare provider who has the training (and the time) to address your issue as well as if it is or is not improving.  How you symptoms change can be just as important as what your symptoms are in the first place.

Therapists are trained to screen for the major problems and if it's the kind of back pain that's not due to a scary cause, we are trained to help you improve symptoms, mobility, and other factors that may have led to your episode (i.e. muscle imbalances for examples).  Check out these articles/studies on this topic here, here, here, and here.  It's also true that people can spontaneously recover from back pain with time and as long as they remain active.  Our bodies are pretty smart.  That said, some people have a more difficult time than others and might benefit from getting professional help.  In the end, therapy seeks to improve movement and quality of life whereas an MRI or CT scan seeks to find out if you're a candidate for spine surgery (or other serious treatment such as chemotherapy if your pain is caused by a tumor).

Thanks for the thoughtful question this week and keep them coming.  Please share our Facebook page and this blog with friends and family.  Submit general questions by Facebook messaging "Natural Performance Rehab, LLC" or via email at npremail@naturalperformancerehab.com

Ask A Therapist - Pelvic Floor Dysfunction

This week we received a great question about pelvic floor dysfunction in women.  There are many manifestations of this problem, not the least of which are episodes of incontinence.  Did you know that pelvic floor dysfunction is very common in female athletes?  Did you know that pelvic floor issues can occur in men and that women who have not had children are also susceptible?

Conventional medicine often treats this problem with Kegal exercises, which may have their place in certain circumstances.  Kegals are designed to "strengthen" the pelvic floor through contraction of the group of muscles that stop urine flow.  That said, the issue is more complex than simply strengthening a muscle or muscle group.  Consider how incomplete a rehabilitation program would be if we only strengthened the quadriceps muscle for everyone with knee pain or the hamstring muscle after a hamstring pull.  Rehabilitation for those issues requires us to look at flexibility, muscle balance, muscle control, and even other areas of the body to ensure the pain isn’t due to a compensation for something else.

Contracting the pelvic floor muscles repeatedly (i.e. kegals) might "strengthen" the muscles supporting our abdominal contents but it does not teach them "how and when to fire" and it does not improve local flexibility if that is an issue.  Thus, kegals alone may not provide relief or improvement of pelvic floor dysfunction.

In the same way, pelvic floor dysfunction may come about for a variety of reasons that are unique to the individual.  There are two excellent articles below to learn the basics as well as helpful exercises to consider if you suffer from any sort of pelvic floor dysfunction.  The articles are concise and to the point, well worth a short amount of time to read if this topic interests you.  Also be aware that there are physical therapists who specialize in women’s health and pelvic floor dysfunction.  If you don’t see results on your own these specialists are well trained to give you individualized attention.

Runner's World article with background and helpful exercises.

Breaking Muscle article on why kegals are not a comprehensive program for pelvic floor dysfunction (and what to do instead).

Thanks again for this question and keep them coming!  Please LIKE and SHARE our page so your friends and family can benefit from our weekly Q&A!

2016 Spartan World Championship Recap

 With increasing age I find great benefit in occasionally appealing to my former childhood self.  Remember how you thought in your earliest days as a human being?  I think we all do this from time to time, perhaps parents much more so.  For me it seems to be an incredibly helpful exercise to combat my 90-year old self that is already enjoying a static knowing of the world.

So when it comes to something like a Spartan Race, the geriatric adult in me wants to be practical and tactical, and that is fine to a degree.  For my adult-self there is the training, the nutrition, the taper, the pre-race, and intra-race, the obstacles, the lanes, the footwear, the equipment, and the competition.  For my child-self, there is the experience of camaraderie, the joy of new experiences, the thrill of challenge, the humbleness of learning, the excitement of engaging in physical obstacles, and the anticipation of the unknown.  And while my adult-self certainly has a voice in all this, the entirety of Spartan Worlds would mean nothing without the contribution of my child-self commentating every step of the way.

Nicole and I were quite pleased that the start of the race was slightly warmer than last year.  There were no less than four opportunities in the race to get soaked with frigid water so we were hoping for the warmest possible temperatures.  I’m guessing now it was low-30’s to start and the temperatures climbed up to 55 degrees or so that day.  However we would all contend with a stiff wind varying from 10-20mph sustained.  No way around it.

Neither Nicole nor myself were able to get a good place up front at the starting line, so when the race officially began we found ourselves quickly trying to run around women jogging at a much slower pace.  Thankfully the initial portion of the course was wider than last year and we ran on pavement and dirt for a long period of time.  Last year we started through a rutted grassy field with a healthy appetite for twisted feet and ankles.  The first obstacle was the “over, under, and through” wall which is simply an obstacle that slows you down.  It was quickly followed by three waist-high dunks into water.   Spartan places a thick plastic sheet into the holes they dig to keep some integrity in the muddy floor everyone plows through, but it makes it difficult to climb out of the water (that’s also its purpose).  So I was very irritated to find women cheating at the 2^nd obstacle and getting out of the water from the sides of the obstacle where it was much easier.

Dude jumping into the water pit.

The course was different this year and laid out with two big climbs, the latter of which was twice the elevation gain of the first ascent.  Following a triple drunk we began our first climb.  My weight training and high-intensity training had been nearly zero for the past several months as I prepared for and recovered from the Leadville 100.  I knew that I would be asking a lot of my body to push into the realms of high-intensity when I hadn’t gone for so long.  Like all the women around me, I wanted to have the best possible outcome but I knew in order to finish in a reasonable place I would have to check my ego.  I did a lot of power-hiking up the climb and passed several women who were already wheezing.  I calmly said to most of them as I walked by, “It’s okay to slow down, it’s early.  Get your breathing under control.  When you can breath you’re at your perfect pace.”  Having competed last year I knew how hard just a single obstacle could be late in the race (i.e. the half-mile bucket brigade).  If these girls were blowing up already they wouldn’t have anything left for the real work ahead.  A few women passed me up the first climb but I paid no attention to their pace.  I noted that some seemed to be able to run up a very steep incline with tiny steps and a good rhythm.  If I could have done that I would have as running can often give you a little energy return.  I tried a few different techniques and found that power-hiking was the most efficient way for me to move uphill.

Olympic Village at Squaw Valley

There were a few easy obstacles along the first five miles.  I decided I would slow down before all the obstacles because I didn’t want to fail anything if I could help it.  Successfully getting each obstacle would save me a ton of time and energy in the long run.  Last year I failed the monkey bars early in the race.  It was a disaster really as the obstacle is pretty easy for me.  This year I slowed to ensure my hands were dry and I cruised right through it.  As I ran from the obstacle I saw a lot of women doing burpees off to the side.  I was so happy it wasn’t me again.

Shortly after the monkey bars we began our first big descent.  It was steep and the fine dirt made for a fair bit of dust.  My legs were under me very well and I was able to move quickly down the mountain.  I did have a slight hang up as I ran down the road towards the water station for a drink.  There was a ski resort pickup truck also coming down the mountain road (really, you have to drive on the course of the World Championships?).  The guy driving was probably trying to stay out of the way but ultimately he was slowing down many of the runners because many of us were trying to get out of his way.  I balanced this issue as best as I could and ran to the side of the road when I could safely do so.  It was much rockier around the edges though so occasionally I would jump towards the center of the road.  It was so steep that you really couldn’t slow or stop easily.  I was annoyed by the truck for these safety reasons (and he was kicking up all sorts of dust).  Despite the transgression of the truck, I knew that the only thing that mattered was that I stay focused on not tripping and not wasting energy being angered by something I couldn’t control.  I passed the truck again and took off down the hill.  We were running down such a steep decline, the pace was quite fast.  A lady in front of me accidently dropped a GU packet and I stopped to get it for her.  I had to turn around and run uphill to retrieve it but I was much closer to it than she was.  She stopped and said, ‘that’s okay, I’ll get it” but I already had it and was bringing it to her.  Technically we can be disqualified from the race if we litter and the organizers asked us to not drop trash and clean up what we found.

The first big descent I think.

The rest of the downhill portion went smoothly as the course made its way back towards the starting area.  At the bottom of the hill sat the new “thigh master” obstacle and the inverted wall.  I wasn’t too worried about the thigh master obstacle, which is a series of punching bags you have to navigate without touching the ground, as the rules stipulated that you could use the chains.  After hitting those two obstacles I thought there would be another water station but I didn’t see it.  I was starting to get dry in the mouth.  The course then became single-track again and we began our second, bigger climb up the mountain.  It was then I saw a friend of mine, Becca Clifford, hiking up ahead.  She is on the Spartan Pro team and the Army team and I met her last year after the race.  She happened to be staying at the same lodge last year and we all met at the outdoor chimney after the race (smores and beers).  She’s a very strong and down-to-earth athlete, early-20’s, and now a nursing-school student.  I felt bad for her because she has dealt with several back-to-back injuries over the past couple years (been there, done that).  I knew when I saw her ahead that she would not be able to race her full potential at Worlds.  She was still trying to build back from an injury earlier this year.

As I hiked up the mountain and tried to keep my breathing consistent, I thought about all the athletes who were braving the course.  Most of us would never podium or be considered a real Spartan-Elite.  That didn’t stop us from striving for better things.  I felt in my heart that despite the places we occupied, we were equals on the course.  To finish we would all have to complete the obstacles or the penalties (except for a few people who sadly cheated on the course).  But as a whole, we would all give ourselves to the course, as fearlessly as we could in that moment.  We would all demonstrate the kind of person we were.  I realized in that moment, that although I would love to finish in a higher place in the race, my character was far more important.  We train our bodies to complete difficult physical challenges, but it was just as important to train our hearts and minds to meet those challenges with grace, gratitude, and a belief in self.

Some of the switchbacks

My legs were burning and I wished I felt a little better going up the mountain.  I knew that finishing Leadville and doing well in Spartan in the span of 5 weeks was ambitious.  I had just got my running life back and I was already pushing my limits.  I had also set a precedent for myself by placing 12^th last year in only my 2^nd Spartan Race.  But this was different I knew.  I didn’t fear the outcome anymore.  I just wanted to do it, to live my life, and I would let the chips fall where they may.  Who was I to say this or that should happen? asked my inner-kid.  I checked my ego again and slowed to a controlled pace.

The climb temporarily leveled out at a cargo-net and an A-frame obstacle.  It was near the A-frame that I finally caught up to Becca.  I was feeling dead-legged even though we were less than half-way through the race and I was ready to see, say, or think something positive.  From this position on the A-frame we had a full view of the bucket brigade (a half-mile hike up and down hill with a bucket full of dirt and rocks).  As laughed as I said to Becca, “I did NOT just notice the bucket bridge…”  She acknowledged me but I could tell that she was trying to maintain focus because this would not be an easy race for her.  When you’re on the Spartan Pro team I think you feel the pressure to perform no matter how levelheaded you are.

Becca remained a few strides ahead of me as we started up switchbacks again on single-track.  We were catching up to more and more guys and most were gracious and stepped aside to let females pass.  Whenever I started to feel extra-tired and my brain started to complain from my effort I would say to a nearby racer, “they sure don’t make this easy.”  By acknowledging the fact that this wasn’t supposed to be easy, my thoughts were less critical and more practical.  I could focus on what I needed to do in the moment to have the best outcome instead of how much the current situation sucked.  Once the race starts, “if’s, and’s, or but’s” no longer matter.  You learn to deal with anything and everything that comes your way.  You adjust.  You bend and mold.  You swallow your pride.

“How are you feeling today?” I asked Becca as I gained more ground.  “Legs are heavy and tired,” she said.  I knew exactly how she felt, “Me too.  They sure don’t make this easy.”  I passed her shortly after that and gave her what encouragement I could.  I felt like I was passing my sister even though I’ve seen Becca on only two other occasions in my life.  Part of me wanted to slow down and do the race with her since it would have been a heck of a lot more fun.  But considering that I was sponsored by and representing the Army, I was not about to slow down in the name of having more fun. 

As the course neared the peak elevation, we began to hit more obstacles.  It was very windy at the top and the dust blew so thick many of the racers began coughing.  Getting dust in the eyes and inhaling it when you’re breathing hard is a super not-fun experience.  Most of the obstacles near the top were relatively easy (low failure rate) and my grip strength held very well.  I still missed the spear throw and had to do burpees, although my throw in the howling wind wasn’t embarrassing, if anything I overthrew the spear as it hit the top of the target and bounced off.  I had expected to miss the spear (it’s one of the more variable obstacles) so it was not an emotional hit to do burpees.

New obstacle that wasn't hard (thankfully).

That said, I hit a low point a short bit later at the Tyrolean Traverse when my foot accidently touched the ground.  This was one of the easiest obstacles on the course so I was devastated to have to waste time and energy on another 30 burpees.  Funny enough, the volunteers at the traverse didn’t actually see my foot touch the ground.  When it happened I looked at the only volunteer nearby to share my disbelief and disappointment.  It was then I noticed she wasn’t even paying attention to me as she yelled directions at the incoming Spartans.  Despite my disappointment, I did not feel tempted to cheat.  It would have been disgraceful to do such a thing on so many levels, not the least of which I had U.S. Army on my jersey.  I dismounted the rope and went to do my penalty burpees.  They were painful as the wind picked up kicking dirt in all our faces.

The very next obstacle was the barbed wire crawl in which everyone suffered greatly crawling and rolling over rocks with dust flying in our faces at 20+ mph.  There was no mercy anywhere to be found on this course.  The very next obstacle was the notorious Ape Hanger.  It was a new obstacle for the Spartan Race and most of us had never done it before.  Moving on from the barbed wire crawl I was feeling quite nauseated from all the rolling.  I gathered myself briefly before the Ape Hanger as I watched a few racers make it and many more drop like flies.  It’s entirely over a trench of water, so even if you successfully complete the obstacle, everyone gets wet.  To complete the Ape Hanger you have to climb a rope to the top of the obstacle and then do a version of monkey bars to the bell.  All bells had to be touched with your hand.  The bars were metal but they were suspended by rope and you were either ascending or descending in elevation as you went across (i.e. the bars were not perfectly horizontal).  This was very roughly the halfway point in the race so everyone was feeling a bit tired.  I nearly lost one of the rungs as I had to do a half pull-up, then swing to get momentum with my elbows bent at 90 deg in order to reach the next bar.  I caught the bar with the fingers of my left hand and was able to get a grip.  I finished the rest of the bars as quickly as possible, hit the bell, and dropped 5 feet down into the cold water.

The Spartan Ladder, Tyrolean Traverse, Barbed Wire Crawl, and the Ape Hanger (note the dust!)

So much dust!

The Ape Hanger.  Everyone gets wet.

I had somewhat studied the course map the night before so I knew that we had the log and sandbag carries next before the alpine swim.  I was surprised to have made the Ape Hanger so I tried to focus on that positive energy as I grabbed a sticky log and began the carry.  Based on intra-race chatter, I figured I was somewhere close to top 20 in the race but really didn’t know more beyond that.  I focused on pacing during the carries and tried to minimize stopping.  Still I could feel the overwhelming lack of power in my legs as I took my baby steps.

By the time I had finished the carries I was almost looking forward to the swim (not really though).  I jogged to the pile of life jackets and grabbed a big orange rectangle.  I was able to jog as I fastened the straps.  There were racers standing dumbfounded at the water entrance.  I shot past them knowing that staring at the water wasn’t going to make it any easier.  It was as cold as I remembered from last year but mentally I was able to catch my breath more quickly.  I started with a backstroke which worked alright except that I started to deviate off course.  There were two buoys we needed to swim around and I was on course to go between them.  I switched to a side stroke so I could see my way and found my pace improved slightly.  I looked with horror halfway through the swim at a small baggie of Cliff Blocks floating away in the water.  There went my fuel for the rest of the race.

Swim out and around the buoys!

SO COLD!

As I exited the lake I thought back to last year and how disoriented I felt after the swim.  To my surprise I didn’t feel so foggy-headed as I began running again.  I was still very cold and visibly shivering and yet this time the cold numbness I was experiencing seemed to make me feel a little less pain and muscle fatigue.  I jogged down the road at a controlled pace knowing that after another mile of running or so we would be doing the bucket brigade.  I had to save something.

We soon hit single track and not surprisingly I found myself held up by slower runners.  I had been running mountain single track all summer, so this wasn’t to say they were bad runners, I was just well-versed in moving quickly down a mountain.  All the way to the bucket brigade I was caught behind a guy who was kicking up dirt and rocks (and dust) and fell twice in front of me.  Despite all this, he was hard to get around running just fast enough to prevent me from safely passing.  I watched many other runners fall along this section and I communicated with those I could.  I politely told the guy in front of me that I had been watching him run for a while and he really needed to pick up his feet.  As we neared the bucket brigade the trail opened up and I passed him.  He smiled and said, “Hey, thanks for the tip!”  He wasn’t kidding.

"She'll be coming around the mountain when she comes..."

The bucket brigade is not a technical obstacle, it’s simply meant to be a suck-fest.  Today it would be a half-mile, first uphill and then back down.  Could they have made it worse?  Yes.  But during the race one does not look at a half-mile hilly bucket carry and think, “Whowza, this looks easy!”  I overfilled my bucket to account for any settling that might happen and went on my way.  I needed fairly frequent breaks but I tried to keep them to 5 seconds or so.  For some reason I decided this would be a good time to cheer on the women who were kicking my butt…so as I hiked up with my bucket I congratulated the women coming down the other side on being badass.  Somehow it helped me feel a little better about my own situation; I certainly wasn’t the only one suffering.  My back tightened substantially on the descent but I managed to pace myself well enough to prevent cramping.  Finally it was over and we only had a big descent and one more cluster of obstacles to finish the race.

Half-mile bucket brigade.

I took off down the mountain with what I had left in my legs.  As I closed in on the final set of obstacles I saw volunteers diverting the elites around the balance beams.  My initial thought was someone must have fallen (in which case it would be entirely easy to break a bone).  I was happy to skip it in my fatigue but the race wasn’t over yet.  The Hercules Hoist was next and I knew it would be heavy.  The ropes were smooth and easily slid out of a tiring grip.  I grabbed the rope as high as I could reach and threw myself back to the ground.  Unlike last year the weight actually moved.  Great!  I was able to move it about halfway before I encountered too much difficulty.  The weight was very heavy and my grip was tiring quickly at this point.  I had to step on the rope to maintain my progress and many times the weight dropped lower.  Upon getting it ¾ of the way up I had to take a prolonged break.  My grip was on the verge of giving out completely and I had invested quite a lot of time and energy in the obstacle.  I leaned against the railing shaking my hands and forearms to try to get two more solid pulls.  I was able to do it but it was truly a Herculean effort and I ran into another water obstacle feeling less sure about the rig coming up.

Following my last dunk in the water we hit the slip wall and I was happy to see my grip was intact enough to get me up the wall.  I then ran through the courtyard area of the ski resort where a crowd was standing and cheering.  Up and over an easy framed structure and onto the final two obstacles, a rope climb and the multi-rig.  The rope climb was easy and I seriously thought I could complete the multi-rig considering how it was set up (it wouldn’t require as much grip as previous multi-rigs).  But I failed miserably making it to the end of the rings and losing the grip on my left hand.  30 burpees to the finish.  It’s never fun to do burpees right at the finish line with a crowd of people watching.  Still that was the least of my concerns, my quadriceps began cramping and locking up after about 10 burpees.  I tried to keep them clean but the quads were really slowing me down.  I took a few short breaks in an attempt to maintain voluntary muscle control.  When I completed my final burpee I turned to sprint but instead staggered my way across the finish line.  I could walked with nearly locked out knees as my quads began cramping with wrath.  But it didn’t matter anymore, the work was over and any pain I felt now would pale in comparison to what I had felt on the course.

A pretty awful photo!

Easy Bridge Crossing between Hercules Hoist and the Rope Climb.

I found the Army guys quickly after the race but I could not see my results.  Nicole finished shortly after in good spirits.  I awkwardly walked with straight legs to the team vans to change into dry clothes.  It wasn’t terribly cold anymore but the winds gusted enough to make it unbearable to stay in wet clothing.  Eventually Liam was able to look up the race results using his phone.  After some jockeying of places due to burpee penalties, I finished 19^th place for the women and Nicole 33^rd.  I digested this for a moment, not knowing how I felt about it.  After some time I decided it was good.  I hadn’t really done much weight lifting or high-intensity training this year.  This was a performance based entirely on slow endurance running and a moderate level of grip training (I kept a gripper in my vehicle and often used it on long commutes).  Despite all this I had managed to find a spot in the coveted “top-20” which affords me the benefit of a small monetary prize and free Spartan races for the next season.  But that’s only the adult-Sam analyzing the results.  Kid-Sam was excited to have finished the race without injury.  Kid-Sam was pumped she made the Ape Hanger and was mentally stronger on the alpine swim.  She was also extremely grateful to have been sponsored by the U.S. Army.  Kid-Sam had the right idea.

"You'll know at the finish."

Our top guy, Robert Killian, won the Spartan World Championships last year in his first season of OCR.  He also won the coveted Best Ranger Competition earlier this year.  He had a good race overall but stubbed his toe pretty badly in my understanding and ended up in 3rd place (still amazing).  Our Army guys in general had a good showing and placed first in OCR teams.  Unfortunately our women’s team was short one, Maggie Smith, due to a nagging knee injury.  I know she will heal but we were all bummed she wasn’t able to race the championships with us.  Had we kept a full female team I think we would have dominated.

All in all, the Spartan World Championships was a truly great day.  I always feel honored to represent the U.S. Army in sport and it is awesome to watch so many other athletes rise to the challenge.  Now my friends it is on to new adventures and challenges!