Physical Therapy Ch. 9

Next week, I get to run. Outside. At my full body weight (obviously).

I met with my physical therapist, Cathy, for the first time in more than a month today. My sacro-iliac joint was stable and responded as a healthy joint should to all of her tests. I told her that I am still not pain-free, particularly in the mornings, so she wants me to do a week of heavy ibuprofen and icing. She believes the ligaments and muscles around the joint are still inflamed, despite the stability of the joint itself. She thinks the requirement by my new coach, Darren, that I wait another week to do this first longed-for run outdoors is a good idea. She dry-needled some of the more tender lower back muscles on the left (and yes they do feel much better--I can honestly say I am an advocate of dry needling after these experiences).

Physical therapy isn't over. I have another appointment with her in a month to check in with my pain. I'm going to be religious about the icing and the ibuprofen because it sounds like I may be in for a steroid shot or something equally unpleasant if I'm still in pain by then. If that's what it takes to be pain-free, I'll do the shot.

For now, though, I'm not worried.

On Tuesday, I'll be here:

This is a park in my town that Darren recommended because it's flat and all-gravel but has lots of room--the kind of place where I'll be doing those first few runs. Cathy said to first add slow and easy on flat gravel, then add ups and downs, and then and only then can I add speed. I think this fits in well with Darren's plan for my comeback.

I'm feeling nervous but excited. I can't wait for Tuesday!

Pilates

When I last left you riveted by the Chinese water torture that is the story of rehabbing my back, I was feeling down in the dumps because it still hurts, more than I think it should after almost three months of physical therapy, no outdoor running or spin class and lots of strengthening exercises for my abs and glutes.

It's like one of those never-ending video games, where you achieve a new level or find a new token....only to learn that the ultimate Holy Grail remains elusive.You start to wonder if you'll ever get there, or if you should even be bothering.

Well, no video game addict would ever stop looking....and neither will this running addict. Yesterday I received a new token, a new tool in the quest: a one-on-one Pilates lesson with Patty at Boulder Center for Sports Medicine, who is also one of the physiotherapists who supervises me on the Alter-G. I don't want to be overly optimistic (that's not really in my nature anyway), but I'm feeling good about this for two reasons:

1) Patty is not only the only Pilates instructor that Cathy, my physical therapist, wants me to see, but she is also a Boston Marathon qualified runner, a mom and a recovering sacro-iliac joint issue survivor herself. She understands this problem not only academically, but personally (in fact, she says hers still bugs her if she overdoes it working in her garden). She also has a good sense of humor and hung up my kid's picture of a train at her desk at work.

2) Jessica of Pace of Me and Dimity of Another Mother Runner both say Pilates done right was THE magic spell that freed them from the curse of their own back and hip issues. First-hand endorsements from athletes I respect....you can't beat that.

Patty had me warm up with some Kegals. Pregnant and formerly pregnant ladies will remember those. Apparently, not only do they help with incontinence issues (thankfully I don't have those, though I know some runners do), but they improve pelvic floor strength and thus support the back. I need to be doing them all the time, boosting them as I go by imagining my sit bones moving closer to each other with each squeeze.

As I lay on my back doing Kegals, we talked about which exercises in my current routine seem to exacerbate my pain. This was easy for me to answer: the standing glute exercises and the seated-on-a-Swiss-ball leg raises. Patty counseled me to do only one of the standing glute exercises per day until I identify the one that truly makes my pain worse. She suspects it's the one where I swing my leg out to the side--but time will tell.

She then modified one of the exercises Cathy had given me for my abs. For the "laying on my back marching" one I am supposed to slow down and really concentrate on two things: 1) using my abs to lower the leg as well as raise it (this already makes a HUGE difference in how this feels to my back) and 2) exhaling on the raise and inhaling on the lowering. I'm supposed to do the Swiss ball lifts (carefully) with the same focus. She said to think of there being a puppet string from my lower abdomen to my knee. I have to really concentrate on this--my quads really wanted to help.

Patty also suggested I do this exercise lying length-wise on a foam roller. This makes it harder, but also more obvious when I arch my back.

I also have one new ab exercise: the Pilates Hundreds. If you Google this exercise, you'll see the more advanced "real" version, done with legs straight and elevated. That's not the one I'll be doing. My version has me on my back, knees bent in sit-up position and feet on the floor. I then raise my torso to about bra level and do the pulses. I'm also not doing a hundred pulses. Right now, I'm to do four sets of five inhales and five exhales.

The breathing is key for all of this--and I'm very bad at it. Patty says learning breathing control will help my running, too. That makes me more likely to stick with these latest modifications. I've gotten really good at visualizing finishing a strong marathon, or crossing the finish line in Boston with my new abs and buns of steel. It's still a fantasy, but with each squeeze I feel a tiny bit closer.

Physical Therapy Ch. 8: GOOD NEWS!

This morning, I lay on my right side on the exam table at Boulder Center for Sports Medicine, my right leg bent on the bottom and my left leg straight on top. Cathy, my physical therapist, asked me to raise the left leg just a bit, then told me to do whatever I could to prevent her from pushing it back down toward the table. She pushed. I resisted. And for the first time since I started this physical therapy odyssey she was unable to push past my resistance.

She then ran me through some other tests. I had to jump up and down on a trampoline, monitoring the pain in my sacrum. So far so good. Then she had me jump onto the trampoline from the floor, landing on one leg and stabilizing myself. I did just fine with those, feeling no pain in my sacro-iliac joint and only a little pain in the left hip.

Then I had to do the same thing on the floor, which means a harder impact. Still no pain! I wobbled a bit when landing on the left leg, but I caught my balance fairly quickly.

Finally, she put me on a leg press sled and had me push with my top leg while swinging the bottom leg in a running motion. This actually felt good. I could feel my glutes working, but without any accompanying hip pain. Too bad there's no leg press machine like this at any of the rec centers I frequent.

After I passed these tests, Cathy took me back in to the exam room for some needling (my piriformis, QL and glute medius on the left were really tight).

And when she finished with that, I got my good news:

I'm now allowed to do two sessions per week on the Alter-G--starting whenever I want!

Of course the sessions are limited. I will warm up for five minutes, run for twenty minutes at an easy pace and at 50% body weight, then cool down for five minutes. If I have any joint issues (as opposed to mere protesting muscle pain), I must stop. So most of my cardio will still be on the recumbent bike and walking on an inclined treadmill. But my first appointment for a real run is Monday morning.

I'm nervous. After all, it was just two weeks ago that Cathy said I was probably in for no running until July. And I know these things have their ups and downs. If my SI joint hurts, I'll need to stop.

But for now I'm letting myself be happy.

California Here I Come!

In other good news, I registered for my winter marathon. It will be the California International Marathon on Dec. 2. I will be rooming with Tricia--this will be her first marathon!--and possibly Kathy (if she decides she's OK with doing a winter marathon). Hopefully we'll all be healthy, relaxed enough for some fun meet-ups with other bloggers--and ready to run fast.

I haven't decided how to work this with the Detroit International Marathon on Oct. 21. I may take a step back and run the half-marathon. But I'm not going to make that change until I see how my back is doing going into June.

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.

Cardio

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.

Physical Therapy Ch. 7

Wow, seven chapters on my physical therapy visits! I never knew I'd be writing such a long (and boring) book.

It's about to get longer, too.

Here's the quick and dirty summary of my appointment with Cathy (back from Australia and all tan):

1. No needling today (I'm glad to have had a break from that)

2. My sacro-iliac joint looked good to her. I'm now allowed to remove my SI belt for four hours a day. I still need to wear it at other times, and most especially when I'm riding the recumbent bike, walking for exercise, doing weight-lifting and doing my PT exercises. As I'm typing this, I'm out of the belt. While I don't miss the constant wedgie, I am missing the support a bit. But I figure that's OK. I'm near the end of the four hours so it makes sense.

3. My abs are getting stronger! Cathy thinks I'm close to being able to do those elusive leg lifts on the Swiss ball.

4. BUT...and here's the big BUT (or maybe I should say BUTT)....my glutes are still far too weak to consider running on them yet. She ran me through some tests that confirmed it: I have a serious case of white-girl butt. This explains many things: why my finishing kick in all my post-pregnancy races has been lacking; why it's so much harder for me to power up hills when I'm hiking; why I tended to avoid lunges and squats in weight training class.

Cathy actually quantified what I'm in for thanks to the weak bottom: three more months of no running (though I may get to hop on the Alter-G sooner). I think it's a good sign that this didn't surprise me much. On a trip last week to the park with my kids, I saw from afar as my son fell off his bike. I ran in his direction...or tried to run. I felt it instantly in my SI joint....and at that moment I knew that, geez, if I can't even jog over to help my crying kid, I probably shouldn't be huffing it around the neighborhood yet (even with lots of walking in the mix).

5. I have new PT exercises for homework. They all involve the glutes. I plan to attack those suckers. Buns of steel, that's what I'm going for. It took me six weeks to get my abs to where they are now (and yes, I'm still working on the abs, too). I know I can expect the same amount of time for the glutes.

So here are my priorities, in order:

1) Do everything necessary to rehab my back. This means a) do the PT exercises the prescribed 3-5 times a week, 50 reps each and building, b) learn to sleep on my sides and back, relinquishing forever my beloved stomach cuddle and c) be vigilant about my posture and lifting technique.

2) Maintain my cardiovascular fitness so it's still intact when I return to running (I know the running muscle strength won't be there--nothing I can do about that). This means the recumbent bike is my best friend. I've even named him Pitbull, after the vulgar-yet-charming-and-certainly-catchy hip-hop dude whose music accompanies me on all my "outings" on this bike. Move over, Mario Lopez--I have a new Latin lover.

3) Maintain my weight. So far, so good on this. But I know I can continue tweaking my diet to include even less sugar and even more fruits and veggies. I'm wondering now if I can even lose a few pounds and finally hit the low 120s. I'll be writing more about this later.

4) Improve my sleep habits. More on this in a later post as well.

5) Do upper-body weight work.

6) Remember that these months away, which are crucial to my long-term health and my abilities as a runner, will someday be just a blip in what I hope will be a lifelong relationship with trails, roads and running shoes. I can and will take as much time as this problem requires.

Physical Therapy Ch. 6

First off, congratulations to all of you who stuck it out and made it to the finish line of the Boston Marathon in that heat today. Hearing about the temperatures almost made me glad I wasn't there.

Almost.

Inspired by these marathoners' example of doing what needed to be done when it needed to be done, I went to physical therapy with a spring in my step....and the news after six weeks was good. My joint is still not perfect, but it was better than last week. And Sue took as a good sign the fact that I had less pain all week (even with all the air travel and sitting, cute little baby holding, bag carrying and Saturday's hike).

I had an adjustment (these feel so good) and some needling (this actually hurt a bit, but she got right into the tender spots around my sacrum, so I think later it will help). She also did some intramuscular stimulation with the needles. She'd done this last week, too, but I forgot to mention it. I felt it more this time, though. Here's a definition:

Intramuscular Stimulation (IMS)
Intramuscular stimulation (IMS) is a perpendicular dry needling technique, deep into the motor points and muscular tendinous junctions to release muscle shortening. It is effective but may be painful.

It sort of feels like a dull little pinprick shock. For me, it isn't painful. But it is uncomfortably weird.

Then I got two new exercises, one designed to loosen up my tight mid-back muscles and another to activate my multifidus muscle, which runs along the spine and needs to be doing more of the stabilizing work than it is right now. Yes, yet another back muscle I'd never heard of before and apparently haven't used in years!

It's actually on both sides of the spine, but this gives you the idea.

The best news was that I can now throw in some consecutive days on the recumbent bike....and it's time to start walking, walking fast....AND (drumroll) if all goes well this week, next week could bring walking with running intervals.

I almost couldn't breathe when she suggested that.

I realize it may not happen. You never know when a bad week will hit. Also, Cathy, my original therapist, will be back then, and her recommended course of action may be different from Sue's.

Still, this has given me a new fervor for my PT exercises. After the kids go to bed tonight, I plan to spend some quality time curled up with my stability ball, my foam roller, and my Theraband.

Physical Therapy Ch. 5

It's almost Boston Marathon time, and the happy preparation tales have been out there for several weeks. Which makes the post I did last year even more relevant now than it was then. I wish I could say my character had improved some in a year, but I guess it hasn't.

Sometimes the task ahead of you isn't the task you want to work on. But you have to work on it anyway. And that brings me to......

Two steps forward.....one step back.......

It's now been five weeks since I began physical therapy.

Today, after a two-week hiatus, I had a visit with Sue. It was good timing because yesterday morning (Easter Sunday) I woke up with the worst pain I'd had since beginning the process of trying to make my back better. I don't know what I did to provoke it. I hadn't even been on the recumbent bike in two days due to the holiday craziness at my house (in-laws visiting, volunteering at the church potluck, two five-year-olds with three Easter egg hunts to attend) and the gym having odd hours.

Sue worked her magic with needles, adjustments and some massage-like manipulation, and I feel much better. She also said it wasn't a huge step backwards or anything dire--my sacro-iliac joint had gotten a bit out of alignment again. I don't have to step back my exercises or my time on the bike.

But it's deflating because I had been feeling much better in the days leading up to Sunday, enough that I could honestly have said the pain was the least I could remember having for a long time, enough that simple motions that have hurt for a really long time (like putting my elbows on my knees when sitting down, pushing in the clutch in the car with my left foot and twisting to watch behind me when backing out the car) were starting to...not hurt...at all. The PT exercises were starting to feel easier. The muscles in my lower abs are starting to feel more like muscles contracting and less like the twitch of a dying mouse (this at least hasn't changed!).

I told Sue all of that. She said I still need to take it easy this week, not add anything new, and let the latest issue unwind itself. The only new instructions are to do some mild stretches when I first wake up (knees to the chest, cat/cow) and, because I'm a stomach sleeper, put a pillow under my belly when I sleep to keep my back from arching. Had I come to her without Sunday's flare-up, she said she might have let me add some consecutive days on the bike and some new PT exercises--but now that won't be happening this week. I also asked her about the Bolder Boulder 10K (on Memorial Day) and, alas, it's not going to happen for me this year either.

She did say that we will probably be talking--soon, she said!--about transitioning me back to running. She mentioned the Alter-G and pool running, both of which would be an amazing treat to me. Pool running is the cheaper option since I belong to the rec center, but I might be willing to pay for (or even use one of my precious insurance-covered PT appointments for) a session or two on the Alter-G. It's just so much more like real running than slogging it back and forth in a pool (where music isn't an option).

Thank you all for your thoughtful comments and stories on my last post. I plan to reply to them all in the next couple of days (along with catching up with your blogs). Happy late Easter, everyone! I ate some sweets and I hope you all did, too.

Physical Therapy Ch. 4 and Eating Check-In

Today when I arrived at work around lunchtime (Tuesdays are my night shift), I discovered my awesome co-worker Lisa had left a handmade heating pillow for my back on my desk. I took it straight to the microwave and then sat with it for several minutes while catching up on email ahead of my 1 p.m. physical therapy appointment. Big THANK-YOU to Lisa!

Physical Therapy Ch. 4

Cathy went on vacation last week, so today I had my first of three visits with Sue, another therapist at Boulder Center for Sports Medicine. Cathy and Sue were the two therapists my doctor recommended back when I first went about my back, and after just a few minutes with Sue I felt I was in good hands.

Once again, when she checked it, she found my sacro-iliac joint had stayed in place. She also had me lie on my back and tested the strength of both sides by having me resist as she pushed each leg toward the table. The left is still weak, but things are improving (though, as I told her, I still can't get either leg off the ground during those knee lifts on the Swiss ball that Cathy prescribed last week). Then it was time for needling. Sue ranged a little higher in my back than Cathy had, and I can tell I will be a bit sore, which is good.

The only new thing she wants me to do is a dynamic hamstring stretch. Somehow my hamstrings are still really tight despite three weeks of no running. My main focus remains on strengthening the abs and the glutes with the exercises Cathy had given me. I will see Sue again in two weeks and am hoping to show her some real progress the next time we meet.

There were a couple of pieces of really good news. The first is that Sue said I can start to lengthen my aerobic sessions on the recumbent bike provided my pain doesn't worsen. She still wants me doing it only every other day ("I want the joint to get some real rest for now"), but on the ON days I can hammer a little harder and go longer.

The second good piece of news is that she thinks I can still plan on doing the Detroit Marathon in October. She offered no guarantees, but she said she is optimistic right now. Being superstitious, I'm still not going to add the "In Training" badge to this blog. But I'll admit....I'm feeling better about the fall.

Eating Check-In

Things are going well on the eating front. I weighed in this morning at 127.2, and none of my recent weigh-ins have been over 130. I've gone back to fewer-than-daily weigh-ins. The daily thing was driving me crazy. It swung wildly in a five-pound range (Corey had warned me about this--you were right, Corey), which on the "high" days made me feel bad all day. Silly, I know. But sometimes ignorance is bliss. And since the average looks good after three weeks of no running, I figure I'm doing OK enough to not police myself so rigorously.

My Lenten no-sugar-except-on-Sundays thing has also been successful. I credit it with the good weight maintenance so far. But I've not completely lost the craving for sugar. I took Will and Ruthie to a birthday party on Saturday last weekend, and, boy, did that Harry Potter themed vanilla cake look tasty. When Sunday's sweets-OK day arrived, I dove into a Dairy Queen dip cone (I had forgotten how good those things taste) AND a bag of pretzel M&Ms.

With two weeks to go until Easter, after which the spiritual imperative to self-sacrifice won't be there anymore but the physical need to restrain myself still will be, I think it's time I tried something else to get the cravings in line. So yesterday I began a "cleanse" that, as far as somewhat restricted eating goes, will last four days (I'm on day two) and as far as taking supplements goes will last two weeks (also on day two of that).

Now we're still talking about me, hater of diets, skeptic of plans that eliminate whole food groups (unless there's a case of true allergies), so "restricted eating" in my case means only that I'm trying to eat clean whole foods: no packages, heavy on the fruits and vegetables. It also means restricting my eating to set meal and snack times. It does NOT mean fasting, calorie counting, vegan or vegetarian, no-carb, no-fat, no-dairy or no-anything except refined sugar and fake stuff. I am trying to avoid white flours and cut back a bit on my pasta and bread consumption (I love these foods and easily eat too much of them, which I think does contribute to my sugar addiction), but I don't plan to do that forever.

The supplements I'm taking were recommended by Moutain Kait, from the brand Renew Life (I chose the "First Cleanse" product). I'm still not sure I believe all the claims about these supplements, but I'm willing to try them out for two weeks and see how I feel at the end.

How do I feel so far? Not bad! I noticed I didn't immediately want my morning green tea as soon as I woke up like I usually do, and I'm less gassy. I did get a huge headache last night right before bed, my stomach was actively growling around the same time. And today every time I stand up I get head rushes. But I have only two more hard-for-me days and I can up the consumption a little again (hopefully minus sugar cravings; I'd like to skip the Sunday treat this weekend).

And I'll need the calories for those longer recumbent sessions, right?

Physical Therapy: Chapter 3

The good news out of this morning's physical therapy appointment with Cathy: my sacro-iliac joint once again stayed in place on its own for a full week, and my long-forgotten transverse abdominus muscle, after a week of me attempting to reacquaint my brain with it, appears to be more in play when I lift my legs while lying down.

So....I have graduated to some harder exercises (though I do have to continue with last week's as well). The new exercises include:

1. Sitting Alternating Leg Raises on the Swiss Ball
Cathy, in demonstrating this, sat right down on the ball, knees bent and back ramrod straight, and lifted each bent knee in turn without any sideways movement or any slumping at all. Me? I sat down and could not get ONE foot, or even a heel alone, off the ground without leaning to the side. So while that deep ab muscle is waking up, it's still pretty sleepy and not ready to do its job. I asked Cathy why I can do a two-minute plank but not this. She said most abs programs emphasize the "high-load" muscles but entirely ignore these deeper muscles and the subtle movements they require.

I'd be really curious to hear from those of you who have a ball at home and can try this. I'm betting most of you will wonder what the big deal is, but there may be some of you who (like me) find this hard. Cathy told me she once treated a professional triathlete with back pain who was so frustrated at not being able to do this that she said, rudely, to Cathy: "YOU can do this. Why can't I?" Cathy apparently is a horsewoman and keeping her abs very strong and stable matters a lot. Tough for even a fit Boulder triathlete (with a weak transverse) to compete with that!

2. Rowing on the Swiss Ball with a "Theraband"--arms bent and then arms straight
3. Biceps curls on the Swiss Ball with a "Theraband"
Again, the emphasis is on straight posture, not slumping, keeping those abs engaged (and therefore my angry back relaxed).

4. Standing Leg Swings
This one is for the glutes. Stand on one leg, holding either a pole or a counter for support, and do leg swings to the side with the opposite leg. On the left side, I could not do this without leaning left. The object is to get to where I can stand and do the lifts with my body straight and tall, feeling it in, as Cathy says in her Australian accent, my "bum."

After she showed me these exercises, I got back on the table for some more needling (the QL and piriformis, along with the sacrum, are still sore, though much better than last week). She got right into the worst part of my back this time, and it already feels better. Tomorrow I have another massage with Kate. And I'm still in the belt. Wearing the belt has eliminated my hamstring pain, and it makes all of my pants feel artificially tight, which is helping me rein in the eating (seriously!). However, I'll be glad when I can start going without it for periods of time, because I also have a permanent wedgie whenever it's on.

Tomorrow is my "on" day with my friend the recumbent bike. I'd really like to go longer than 30 minutes for these sessions, but I'm going to stick to that limit for another week before, depending on how my back is after another week of TLC, asking next week for either more frequent outings or longer sessions on it. Or both. Wouldn't both be awesome?

Thanks to the intervals I've been doing (and some good tunes on my iPod), I'm finding the bike much less boring than I did at first. I do a lot of visualization there. During the fast intervals, I like to pretend I'm Desiree Davila hanging on in the Boston Marathon, picking off Kenyons (hey, a girl can dream!). I also like to picture the Boston finish line, which I know many of you will be crossing very soon (luckies!). But I also just imagine myself running, not particularly fast or particularly slow, just running with the wind in my hair, no pain in my back, no pain at all in fact but instead the pleasure of forward motion, freedom, suppleness of limb, the best kind of solitude, good health and a quiet mind.

It *will* happen for me.

Physical Therapy--Second Visit

There was good news and bad news out of my second visit this morning with Cathy, my physical therapist at Boulder Center for Sports Medicine.

The Bad News

1) I'm still exercising too much. Last week I went to spin class or rode my bike every day but Sunday. After yesterday's spin class, my back had had enough and went into full spasm. Getting out of bed and into my clothes was actually difficult this morning, so I skipped spin, but still did thirty minutes on the recumbent bike before going to physical therapy. Recumbent bikes look like this (though the one at my rec center is older and clunkier):

I told Cathy all of this, and she gave me a new exercise prescription. I didn't cry this time because I was expecting it--I knew my back wasn't liking the past week's workload. I am to do ONLY the recumbent bike for ONLY 30 minutes at a time and ONLY every other day. I am also still OK to do upper body weight training and the three exercises she gave me today (see Bad News #2).

2) Cathy ran me through a quick series of tests to see if I'm using the correct muscles for certain movements. The answer was, bluntly, NO. When I do side leg lifts, I'm using my quadratus lumborum (QL) muscle instead of my glutes, which are the ones I should be using. Here's a picture of the QL, and yeah, when she manipulated it, it hurt:

And when she had me lie on my back with bent knees and attempt to lift one leg at a time, I could NOT for the life of me use my abs. Instead, I was arching my poor back and using the QL and other muscles in that vicinity. Basically, my brain has forgotten how to call on the correct muscles for these movements.

Running, as you know, involves a lot of glute action because you're lifting your legs up and down, up and down. And it also requires a lot of stabilization that should come from those abs. I've been using the wrong muscles for these key running movements for five years. Cathy put it this way: "You can't be running marathons right now."

My homework for this is three very basic (as Cathy put it, "piddly") exercises: side leg lifts (NOT using my QL), clams (also not using my QL--I was better at these) and the leg pickups, monitoring my lower back lift with my hands. My goal for the latter? To lift my legs without arching my back at all. It's going to be hard given that right now I cannot do it.

The Good News

1) Over the course of the week between last Tuesday's visit with Cathy and today's, my SI joint stayed in place. When she checked it today, it wasn't out of whack as it had been before she popped it back in. So my belt (which I'm in full-time for at least another week) is doing its job, and I didn't mess that up by overdoing it on the biking. This is a good thing because it means that so far I'm not in the vicious cycle of having her put it back in place only to have it come out again over and over and over.

2) Dry needling: it's not so bad! After she showed me the ab exercises, she broke out the needles. I had about eight of them in various spots on my QL and my glutes (she left the sacral area alone--I later got a cortisone patch for that). Here's a video of Cathy herself doing the needling on someone else (a shoulder instead of a back, but it will give you the idea--think of it as a massage, but at the source of the soreness and with a needle).

What did it feel like? Well, it felt weird. The insertion of the tiny thin needle I barely felt, but when she started moving it around, looking for the trigger point, and especially when she found the trigger point, I could feel the muscle twinge, rebound, constrict--and because these muscles are already sore, it wasn't what I'd call pleasant. But it also wasn't painful. I'm sore now, in exactly the same way I've been sore after deep sports massages.

After it was over, she had me rest for 10 minutes with heat on the spots. I'm now supposed to ice the area fairly frequently. Her advice was to stick a package of peas down my pants and leave it there for 10 minutes a few times a day. She also wants me to take 1200 milligrams of Advil every day for four days to kick the inflammation.

3) I'm going to see Kate for a massage tomorrow. Cathy says dry needling one day followed by massage the next is pretty much ideal.

My Reaction

1) I don't like not being able to exercise, but even my Eager Mind is conceding that my Exhausted Back deserves the upper hand right now.

2) My task for the next few weeks (aside from doing exactly what Cathy says) will be to watch my weight. This I am nervous about. A week ago, I weighed in at 129.4. That's satisfactory. Yesterday after spin class, however, the same scale, same time of day, read 134.6. That's not satisfactory.

I don't like to be obsessive about the scale, and when I'm running I don't really have to be. I weigh myself once a week. But with the exercise cut so drastically, I'm going to weigh in every day. Today's weight was 132.4. Better....but anything above 130 is an alarm bell that we've moved in the wrong direction. I may even check out the plan in Racing Weight again. I don't care if I get down to what I suspect is my actual racing weight, but I want to come out of this process still safely below 130.

3) Between daylight savings time and a week of getting up early, I'm really tired. The recumbent bike, for all its drawbacks, is always there. I don't plan to set the alarm again for a while.

Love the One You're With

On the way to the first physical therapy appointment designed to deal with my unhappy back, glutes and upper hamstrings this morning, I heard the song that's the title of this post. It didn't occur to me that the one I'm "with" for the next six to eight weeks won't be these:

Nope, instead I'm looking at all this all the time:

Yes, it's true. I got the prescription all of us dread: no running. Also no elliptical, no rowing machine, no stair machine, no swimming, no lower-body weight training. Only biking is allowed (but no standing on the bike).

I have sacro-iliac joint instability. According to a good explanation I found online, "under ideal conditions the sacrum is positioned somewhat diagonally between the pelvic bones. With this relationship in place there is maximum stability. With a swayback posture (hyperlordosis) the sacrum tilts downward and forward and becomes more horizontal. The ligaments...are stretched and the sacroiliac joints become unstable and the self-locking mechanism is impaired. The ligaments undergo further stretching, firing the pain receptors. Alternatively, the unstable sacroiliac joints may become locked in an abnormal alignment, maintained that way by resultant muscle spasm producing pain."


The pain described is exactly what I've experienced, on and off, for five years now: "Sometimes the pain goes into my butt and the back of my thigh, but never past my knee.....The pain may involve either or both sides, radiate into either or both legs, usually not past the knee, at the same or different times."

In my case, says Cathy, physical therapist and my new best friend/taskmaster, it goes back to my twin pregnancy--the ultimate time of "swayback posture" for me--and an incomplete period of recovery after it. As you all know, I've mostly ignored my pain because I thought it was just weakness in my core, and that if I could get my stomach muscles back to where they were pre-pregnancy, the back pain would vanish. It was frustrating that core work seemed to make it worse rather than better, but hey! I was running, and the running was going OK, so I just lived with it.

For some reason, it makes me feel better to know that it's not a running injury, that it has nothing to do with bad form or my shoes or how my foot strikes the ground.

But regardless it's not something that I can run through. Running, Cathy tells me, isn't going to help the irritated joint stabilize. Nor can the problem be solved by a cortisone shot or PT exercises. I will probably still have some dry needling done (at next week's appointment) and I will be getting some of that coveted insurance-sponsored massage.

The main tool for this week is this:

The Serola Sacroiliac Belt

During all of my waking hours (and my sleeping ones, too, if I can stand it), I have to wear this little item. I'm wearing it as I type. I'm not going to lie: as soon as Cathy put it on me, my lower half felt about ten pounds lighter. The hamstring pain went away entirely, and the glute and back pain, while not gone, feel much better. It actually takes me back to pregnancy, when I purchased one of those belly support bands and could suddenly walk again without pain.

This isn't to say I felt completely happy when I walked out of the clinic. In fact, I had a good messy bawling session in the car, decided to go to spin class right then and, when I got to the gym where I thought the class was happening and found out it wasn't, broke down crying again at the front desk. I managed to put on my big girl pants and get on the bike for 40 minutes on my own (the equivalent of the 40-minute recovery run I would have been doing today).

Afterwards, feeling sweaty and therefore much better, I apologized to Matt, the guy at the front desk, for breaking down in front of him. Matt is one of those chiseled Boulder types, a coach, triathlete and runner who spends his summers in Kona. He told me he totally understood, that he was sidelined recently himself for a couple of weeks with a freak back injury and had his own breakdown the weekend that happened.

While on the bike getting sweaty, I had decided that my plan for this period of being sidelined will be to stick as close as possible to the workouts in my running plan--but do them on the bike. So, for example, this weekend's 90-minute progression run (first third easy pace, second third medium pace, third third medium-hard) I'll mimic on the bike in both duration and intensity.

I shared this idea with Matt. He said it sounded good. He said the key thing about running is the superior aerobic fitness it builds. "That will be the hardest thing to get back," he said, "so do whatever you can on the bike to get your heart rate into the zone where it's working as close to as hard as it does when you're running. When you come back to running, your legs will feel weak--that muscle strength comes back fast. But the aerobic fitness can take a really long time once you start running again if you don't work hard on it."

This makes total sense to me. So I'm going to dig out my old Polar heart rate strip and wear it on the bike, and work to keep the heart rate above 115-120 (Matt said that's where the benefit will arise, that you don't gain that much more by pushing it higher). I'm also going to stay indoors for this. Biking outside is more fun, but I can't afford any "coasting downhill." Staying inside will assure I'm working hard the whole time I'm at it.

Which brings me to my other issue with the stationary bike: boredom. A 40-minute run outside? Paradise. Too short. But the 40 minutes on the bike today felt like it would never end. So I'm going to do as much of it as possible in spin classes. For the first time, I'm glad that the longest runs planned for the next few weeks never topped two hours.

So, yeah. Add me to the DL list. The half-marathon on April 15 isn't likely to happen.

A good attitude will be really important. I'm cultivating that in two ways. One, by trying to see this six- to eight-week period from the perspective of my 65-year-old self, who of course will be fit and running races and doing all this with a nice, steady sacro-iliac joint. It's best for the long term.

The second attitude adjustment is this: On the drive out from the clinic, I saw a guy running in a Boston Marathon shirt. Cathy agrees with my doctor that fixing this will make me faster. Solid back=solid running. That's what I'm hanging on to.