Friday, May 4, 2012

Oh, Our Aching Backs--Part II

My high-tech system for tracking my physical therapy and other exercise.
Two posts ago, I detailed how two strong runners came back from sacro-iliac joint dysfunction, the injury I'm currently working through. In this post, I'm going to detail my own ongoing program, which I hope will result in my own successful comeback. All of these things, big or small, were either prescribed by Cathy, my therapist, or discussed with her.

Some basics:

1. For the first eight weeks, I wore the Serola Sacroiliac Belt pretty much every waking hour of my day--exercising, sitting at my desk at work, hanging out with my kids, you name it. Its job was to fill in for the support my largely absent abdominal and glute muscles are supposed to render to my pelvis. Here it is modeled by someone much more attractive than I:

No heavy lifting for me!

As of two weeks ago, I am weaning myself off the belt. I find I really need it only first thing in the morning (my back is always stiffest then), when I'm doing my PT exercises and when I'm sitting for a long time in the car or at work. For walking and light work around the house or yard, it's actually nicer to have it off. I consider this a good sign.

2. In the last two months, I've adjusted two other habits that sound piddly, but have made a big difference in how my back feels. First, I have weaned myself off of being a stomach sleeper. This was not easy. I bought a *huge* body pillow (it's like having a third adult in the bed with Dan and me) and at first I couldn't stand it. But now I find I like sleeping on my side if I can wrap my arms around that sucker. I'm still not much at sleeping on my back, which would apparently be even better, but I'm getting there. In addition to my back being much less stiff in the morning, my neck and shoulders feel looser. Making this change has taken me about a month. I'd say it's only this week that I am sleeping well on my side.

The second change has to do with our cars. Dan and I are both standard-transmission people. I've been driving a stick since I learned on my grandparents' dark-blue '69 VW Beetle (God, I loved that car). Both of our current cars are standard, and I still much prefer this kind of driving. But driving a stick means lots of raising and lowering both legs, and that motion *should* be handled by your lower abs--exactly the muscles I had forgotten how to use, to the detriment of my back. Now, when I'm driving (which is far too much, but that's another issue), I pay close attention and engage my lower abs whenever I shift or adjust the pressure on the gas or brakes. I know it sounds miniscule, but believe me, it's helping.

The Exercises:

This list includes all the exercises I'm doing now. I didn't start out doing all of these. In fact, the first week, when my back was really bad, all she wanted me to do was wear the belt and get the inflammation down (more on how below). But gradually over the weeks we've added these, and this is my current program. More may come later, too, but I feel I'm in a good groove.

Equipment needed: Swiss ball, Theraband, Bosu ball (I don't own a Bosu ball--I use the ones at my rec center)

Abs (mainly targeting the transverse abdominus)

1. Knee lifts--I lie on my back with my knees bent and feet flat on the floor (traditional sit-up position). Engaging my lower abs (usually I put my hands on them so I can feel them contracting), I raise one foot off the ground, lower it and then raise the other, alternating legs, keeping my low back flat on the floor. I'm up to 50 of these now, and I feel the contraction in my abs quite strongly. When I began, getting 10 done without arching my back was very difficult, and the motion of my transverse was more like a twitch than a contraction. This was the very first exercise I was given.

I now also do some step-outs, one leg at a time, where I start from the same position, lift the knee in the same way, but step out with my heel three times, then step the leg back in. I still sometimes feel a back arch creeping in with this, but it's getting better.

2. Bicep curls & rowing on the Swiss ball with a Theraband--A Theraband is a stretchy piece of latex. I got one from my PT. For this exercise, I sit upright on the ball, feet flat on the floor, back straight, abs engaged. I hold each end of the Theraband, and my husband holds the middle so that it's stretched taut (if you have a stable pole or bannister, you can also wrap the band around that and pull it out). I then do baby bicep curls and rows. The object isn't arm strength. It's stabilizing with your abs while you do the exercises. I try to do 3 sets of 10 of each.

3. Kneeling twist--Do this one next to a wall or table in case you need some support. Kneel on the floor in genuflect position.

Tebowing works too, except you hold your torso straight instead of bowing over your leg.
Engage your lower abs, then put your front foot (the bend in the leg should be at about 90 degrees) more toward the mid-line of your body, deliberately making yourself unstable. You will wobble a bit (if you don't, move the leg further in toward your other side). Once you can stay upright, up the ante by lifting your arms straight overhead. And once you're stable with arms raised, slowly rotate your torso from side to side.

4. Swiss-Ball Knee Lifts--I still can't do this one unassisted, but I'm a lot closer than I was. Sit on the ball as you did for the biceps/rows. Make sure your back is straight, and rest your hands on your thighs. Engage your lower abs and raise one knee straight up WITHOUT leaning to the opposite side (leaning even a bit means you're using your back, not your abs). Right now, I do this one next to a table or wall, using the pinkie of the hand on the same side as the lifting knee to give my abs a little help. I'm hoping this week that I'll finally get the knees up at least one time without the assist.

Glutes (baby needs back)

For the first seven weeks, I did side-lying leg raises and clamshells only. Once I could do these without increasing my back pain, I graduated to the following exercises.

1. Side kicks with support--Stand straight up, engaging your lower abs. Hold a tall ski pole or other pole in one hand for support. Plant the leg opposite that hand firmly into the ground--don't lean or hike the hip. Then take the leg on the same side as the pole hand and do side leg raises with it. Do not lean to the supporting leg side. You want that leg's glutes doing the work of keeping you straight. I do 50 of these on each side.

2. 45-degree kicks with support--Same set up as above, but instead of kicking out to the side, you kick behind you at a 45-degree angle. I like this one. You really "feel the burn" in the kicking glute as well as the stabilizing leg. Again, I do 50 on each side.

3. Running kicks with support--This is my favorite glute exercise because it's the one that gets as close as any of my exercises to actual running motion. Set up like in number one, but instead of kicking to the side you lift the pole-side knee in a high march motion, then swing it back behind you in a runner's kick. Be very careful with your back on this one. Your range of motion may not be great at the beginning. Remember NOT to hike the hip on the planted leg or lean that way--this strains your back (and is apparently what my body was doing when I was running because my glutes weren't doing their job). I'm supposed to do 50 of these, but that's hard. I often have to break it up to rest the supporting leg.

I see this exercise as super-important. Cathy (my therapist) told me she wants to see me to do 100 of these WITHOUT the supporting pole before I'll be able to run again. You can imagine how I attack this one.

4. Mini squats on a Bosu ball--Stand on the flat side of a Bosu ball. When you've got your balance, lift your arms in front of you so they are straight out and parallel to the ground. Then do mini squats. You don't have to go low (and at first you shouldn't). Squeeze your glutes on the up motion. I do 3x10 of these.

5. Supported mini lunges--Rest the ankle of one leg on a small step or other support behind you. Place the other leg in front of you. Do mini lunges with the front leg. Don't put that leg too far in front (you will be able to move it out later when you're stronger), and don't go down too low. Squeeze your glutes on the up motion. I do 3x10 of these, too.

Also in my repertoire for glutes are the leg press machine at the gym and step-downs (I don't use a step as high as the guy in this video--Cathy told me no larger than the Boulder phone book--nor do I use weights--yet). Again, when I do these, I do 3x10.

How often do I do these exercises? I try to alternate days so that one day I do all the ab ones and the other day I do all the glute ones. I also do the lying-down knee lifts and/or step-outs even on glute days, and I try to do at least one glute exercise on the ab days.


I'm still doing the Pete Pfitzinger plan that I think I linked early on in this process. I'm currently on week seven. It's really for water running, but I apply the durations and intervals to the recumbent bike (hoping to graduate from that soon, too, maybe to a stair climber or elliptical-type thing, but I'm waiting for Cathy to suggest that). I watch my heart rate the whole time I'm on the bike, making sure it stays above 120 for as much of the time as possible (I prefer the 130s and 140s). My average HR at the end of a session on the bike seems to be around 130.

I freely admit I can't face the days when I'm supposed to just go steady for an hour or more on the recumbent bike. The intervals go fast, but I get really bored doing one pace or heart-rate range for that long. So on days when I don't ride the recumbent, I always take at least a 30-minute walk that incorporates hill climbing of some sort, and when it's possible I do an hour walk or at least one 30-minute walk while at work and then another after the kids go to bed in the evening.

Supplemental Therapies

My back is responding well to all of the above, but it still gets sore if my form slips during the exercises or if I tweak it bending down. And sometimes my glutes or legs feel tight for reasons I don't understand. So here's what I do when that happens:

Massage--At the beginning, when things were very sore, I saw Kate for a 45-minute massage every week. Now I'm spacing these out more. I'll probably do them on the weeks where I don't have PT with Cathy, and only when I need them.

Dry needling--Cathy didn't do this the last time I was in because I was feeling good and she didn't find any tight spots. But when needed, it really helps, especially my piriformis and my quadratus lumborums (QLs).

Ice--The first couple of weeks I iced a lot. Now it's on an as-needed basis. I keep a bag of frozen peas just for icing my back. I stuff it in my pants right over the SI joint when needed. Sexy...and effective.

Heat--One of my wonderful co-workers, Lisa, made me a special pillow that I can throw in the microwave for two minutes. When it comes out, it's toasty warm but not burning to the touch. I can stuff it in my pants above the SI joint just like the ice bag. I often do this after needling or massage, and also right before I go to sleep at night to loosen up the back before rest.

Ibuprofen--The first week, when I was really inflamed, Cathy had me take 1,200 mg of ibuprofen for four days straight. Now I take it on an as-needed basis. I haven't needed it at all in recent weeks.

Tennis ball (for the piriformis) and foam roller--These implements will probably always be part of my post exercise stretching routine. They hurt so good.

Hamstring stretches--The hammies get tight with the glute exercises and the walking. I realize now I wasn't nice enough to them when I was training for races. I won't make this mistake again.

Where Will I Go From Here?

I've already mentioned I'll be doing some running on the Alter-G. I will also be doing Pilates! Cathy calls Pilates an "end of therapy modality." I'm not strong enough yet, but she says it's really great for people in my state once the necessary stability is in place (Jessica in the prior back post swears by it, too). When Cathy tells me I'm ready for Pilates (and she has a teacher in mind for me already), I'll know I've reached the end of this tunnel.

And now you've reached the end of this massive post. If you're still with me, your back must bug you often enough that you feel you need some help. My advice? Don't ignore it! See a therapist or other practitioner you trust! I wish I had done all of this before beginning my BQ quest. But better late than never.