My Encounter with Low Back Pain

It was Sunday afternoon (Day 0). I was cleaning up some items in the backyard. I was finally trying to get rid of that heavy (punching) bag that had torn off the hooks several months ago. It had been lying out for the past 5 months or so and had accumulated a good amount of rain. I was attempting to roll it in a vertical fashion (bottom to top, like you would a large tire in a “boot camp” class). Unfortunately, that 70 pound bag had become well over 100 pounds. After one roll and then the next I immediately felt a sudden spasm in my low back. I knew exactly what I had done. I had sprained my back. As I have done this a time or two before, but to a much lesser degree I soon realized, I figured this would resolve in a day or two.

Monday (Day 1 post injury):

After sitting for prolonged periods of time, or having just arisen from bed, I moved around like an old man slightly flexed forward in my posture, walking slowly to avoid excessive movement or engagement of my back and trunk muscles. I had completed one day of work uncomfortably, but successfully. I did find that I was moving much more slowly than before: even climbing the stairs was uncomfortable! (I’m accustomed to climbing steps two at a time.) I proceeded to resume my regular routine of jogging alongside my girls (while they ride their bikes), lifting weights, and stretching. I began to realize my pain was more severe than I had initially thought. My gait (walking pattern) had changed. I found myself adjusting my gait to avoid excessive back movement since every movement of my core resulted in back pain. I knew I had sprained my back worse than before. ‘Oh well’, I thought. ‘I don’t have any numbness or tingling in my legs. I don’t have any incontinence’, thankfully. The pain was isolated to my back: what is referred to as “mechanical” low back pain or an “acute back sprain.” I reluctantly took 1 Aleve (naproxen sodium) with some Tylenol. I say reluctantly because it is rare I take any medication at all. I felt slightly more comfortable but still with significant pain that was hampering my regular movements and daily activity.

Tuesday (Day 2 post injury):

The pain persisted and was even more severe than before. I even did some weightlifting the night before with less weight, as it was back and biceps day. I got through the majority of my second day of work and then went to my office. I knew my patients could tell that my back was hurting. In fact, one of my hospital patients asked me earlier that morning if I had back problems. I mentioned to her ‘ I see you noticed that’ to which she replied something similar to ‘people with back pain can easily recognize others suffering from the same.’ (Had I become one of ‘those people’ with back pain?) Back in the office that afternoon (thankfully my office schedule was light, partially due to a “no-show” and a rescheduled patient), a colleague  (whom I frequently discuss workout and running routines with) noticed my altered gait. I explained to him what I had done. He offered me a Toradol injection which immediately sounded quite enticing. I told him I wanted to try and tough it out since I was getting a taste of what many of my patients experience on a daily basis. I quickly decided, after he offered a second time, to take him up on the offer. I didn’t want my pain to affect my patient care and my ability to take care of my family as I pride myself in being active for my 7 and 8 year-old girls. I was administered 15 mg of Toradol (an anti-inflammatory similar to ibuprofen or naproxen) into my right gluteus region. I knew that since this was an intramuscular injection that the relief would be delayed. I began to feel somewhat more relaxed in my movements over the next few hours. I still had required several minutes upon initial standing from a chair or car before I was able to stand up straight or walk normally but this seemed a bit easier than before. I was reluctant to take another non-steroidal since I had taken Aleve the night before and again that morning and I do tend to experience gastritis (“sour stomach” or “heart burn”) when I take non-steroidals. I took another Tylenol and remembered my rehabilitation protocol on musculoskeletal injury which includes: relative rest, ice, compression, and elevation when appropriate and indicated. I decided to avoid weights over the next few days to prevent additional injury since my body mechanics had been altered by my back injury. I did however remember that before return to play or sport specific activities (lifting weights for me), that cardiovascular exercise is recommended as part of the rehab protocol. I decided I would do cardio (aerobic exercise) the remainder of the week. I would have liked to go for a run however, given the temperature outside (August in Houston), I decided upon spin cycling indoors and swimming laps indoors (at the gym). I incorporated a bit of cycling outdoors as well. I would continue with my stretching, my cardiovascular exercise, with minimal pharmacological intervention as long as i could stand it. I still had no numbness or tingling in my legs or other signs of neural (central or peripheral nervous system) injury.

Wednesday (Day 3 post injury):

I woke up quite sore but managed to crank out 30 min on my spin bike. I stretched and did some push ups afterwards. I stretched after my shower, as I always do. I threw down an Aleve, an extra strength Tylenol and got dressed with discomfort. My gait (walk) was still impaired and guarded (slow and cautious). I got to work a bit late after dropping the kids off at my mom’s . I attended my Wednesday morning conference still quite stiff upon standing. I then went back to the hospital to conduct my patient rounds followed by my weekly rehab team conference. After sitting in a chair for an hour and a half, I was stiff and uncomfortable upon standing. I started to notice, as I walked out to my car, that my gait was returning to normal. When I arrived at my next destination, approximately 10 miles away, I was a bit stiff upon entering the facility but by the time I left there (2 1/2 hours later) my gait had improved significantly. I returned home about 6 o’clock, took my children and their cousins to my home (from my parents’ home) and because I was feeling so well, I insisted they play outside as I returned to lifting weights. It was a leg and shoulder day. I was quite conscious of my form and how any wrong move could result in a re-injury. I felt so good after dinner, my oldest daughter and I went for a nighttime 3 and a half mile bike ride around our neighborhood. I was finally starting to feel myself again. The last medication I had taken was earlier this morning. I finally felt like everything was going to be all right.

Thursday (Day 4 post injury) :

I woke up and stood up still with discomfort upon standing erect but feeling much better. I considered whether I should take an anti-inflammatory but decided to tough it out. I did 30 minutes on my spin bike followed by stretches. I then had a wonderful breakfast with my oldest daughter and took her to work with me. I was able to perform all of my duties without much discomfort. I was moving around more quickly. I was walking without as much discomfort. I was finally starting to feel myself again. Simple tasks were not as difficult. After sitting for long periods of time, or exiting my car, I still felt a slight discomfort upon standing up totally erect. I completed my day without taking anything for pain and feeling as if I was getting close to 90% of my pre-injury status. I was encouraged by how well I felt throughout the day. Everything was going to be OK (I hoped). I did however feel slight twinges in my back with certain movements throughout the day. Was I always going to have to worry about a back injury? Would I be more susceptible to this happening again in the future? Would I be limited in my ability to push or pull things? Would I no longer be able to help people move heavy items? These are all concerns I had as I’ve never felt limited or prevented from doing anything physical. Perhaps I was no longer the “Superman” I had always felt I was.

Friday (Day 5 post injury):

I awoke and rose from bed with minimal discomfort but still aware that my back was irritated earlier that week. I’d still taken nothing for pain since Thursday and wasn’t planning on it Friday. For the most part, my gait was back to normal. No one could see me and tell that anything was wrong. I was standing upright and walking without a limp. Only I could tell that my low back was slightly sore upon initial standing and after prolonged sitting. I even helped my mom move a few items in her house. She had forgotten that I sprained my back but since I was moving around so well (no grimacing or “grandpa gait”) she never even hesitated to ask me to do a few things. Later that day I did a half hour on my spin bike followed by pull-ups and an ab work out. I was

feeling great. ??

Saturday (Day 6 post-injury):

I awoke and arose from bed with almost no discomfort but only the slightest hint that I had pulled my back almost a week ago. I got ready to head out to the hospital to see a

few patients. A sneeze reminded me that I was not at ? . I’d still taken no medication for the past three days. I did my morning stretches with minimal discomfort. At the end

of the day I was able to lift weights with my daughter and then moved a desk up the stairs with her. I  even did some work around the backyard in which I was squatting in the hundred degree heat for over an hour. I felt great even upon standing! Things WERE going to be OK. Nevertheless, occasionally when I would sneeze, I was reminded of the irritability of my low back extensors. This was a reminder to me that I would have to be careful from here on out.

 

Sunday (Day 7 post-injury):

I had a nice uneventful day at Church with my family and didn’t think much about my back.

Monday (Day 8 post injury):

I awoke and arose from bed with no discomfort at all. I showered, did my morning stretches without a hint of back pain. I took my girls to their first day of school and enjoyed some coffee with some of the parents. I had completely forgotten about my back until some of the fellow dads at the school asked me about it. I explained to them I was feeling much better but that I had to be careful from here on out. They reminded

me that I wasn’t a teenager anymore: thanks guys. ?? I completed a full day of work, finished early, and was able to run a few errands. I ended the day by picking up my

girls from my parents’ house, taking them home, and doing one of the things I enjoy most with them: running beside them as they ride their bikes in our neighborhood. After the girls were showered, the Bible was read, we said our prayers and talked about the total solar eclipse earlier today. I then went out to my backyard and proceeded with my nightly weight training: legs and shoulders. My back was feeling great again: thank the Lord!

My encounter gave me the invaluable opportunity to experience what those who suffer with acute back pain and acute on (flare up of) chronic back pain experience on a daily basis. It is humbling. It is limiting. It is anxiety-provoking. The back is to be respected. Proper body mechanics during lifting and bending cannot be over- emphasized. Like I told one of physician friends who also enjoys weight lifting, “you’ve only got 1 back! Protect it.” I’m a person who has worked out religiously, has never been sedentary, and this happened to me! I am a rehabilitation physician who often lectures my patients on proper body mechanics and I let this happen! I imagined what those who are less conditioned and fit must feel when they’re suffering from a back injury. I imagined the disability, anxiety, and fear they must experience. Furthermore, they don’t possess the medical knowledge, training , or experience to understand that the condition of acute back pain due to sprain is self-limited and can respond extremely well to conservative treatment. You just have to be patient, know the “red flags”, and remember: it will get better in time but YOU HAVE TO DO YOUR PART!

“RED FLAGS”

It is important to remember that at no time during my episode of back pain did I experience any symptoms of pain or numbness in my legs. I lost no strength in my legs. I was experiencing no spasms in my legs. I experienced no incontinence (loss of bowel / bladder control). I was not having night sweats or pain worsened while lying down. I had no associated weight loss. These are referred to as “red flags” in back pain which warrant further work up and imaging. If I had any of these, I would have sought the advice of my physician for further work up and imaging.

 

 Summary points:

• Mechanical low back pain, or lumbar sprain, will improve with time, supportive care, patience, and cautious movement.

• Anti-inflammatories (non-steroidals) such as ibuprofen, naproxen, diclofenac,  can help.

• Warm, moist heat can help (I felt much better after spending that hour sweating in the back yard, although it was 6 days post-injury).

• If numbness/tingling or loss of muscle strength in legs, incontinence of bowel and/or bladder, pain worsened by rest and lying flat, weight loss, night sweats

or unrelenting pain accompany your back injury, you need to seek the attention of your physician or urgent /ambulatory care center as soon as possible.

• Remember: the emergency department is not an ambulatory clinic nor does it replace your primary care physician’s office. You do not need to go to the ED for every back injury. Call your physician if you are concerned. The emergency department is for life threatening injuries and illnesses which must be addressed urgently.

• In closing, if you’re in doubt, see your doctor or come see me and together we’ll figure it out! ??

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Dr. Michael