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Bulging Discs & Pain #2: February-March 2021

Bulging Discs: The Short Story
Based on my recent experience, suspect that you have a low back/lumbar disc injury if:
..you have muscle pain in the lower body that doesn’t respond to usual muscle treatments
..standing and walking with good posture is fine; bending over, especially when reaching, isn’t
..there is severe shooting pain with a sudden onset or recurring pain over months or years
..you have episodes of unexplained, deep, fatigue with any of the above

Relief from disc pain sometimes can be attained in a day and they can be repaired in 7-10 days by:
..doing yoga cobra pose push-ups in reps of 10, every 2 hours
..scrupulously avoiding bending forward or lifting
..using a lumbar roll to support your low back when sitting
..maintaining good posture when sitting or standing

I recommend seeking professional help from a physical therapist rather than a doctor or massage therapist if you suspect a disc issue.

Bulging Discs: The Long Story
Non-Existent Mobility: The Missing Piece
Two physical therapy (PT) appointments clarified that the source of my chronic buttock muscle pain was displaced or damaged discs in my lower back, not issues with the muscles themselves. I dutifully performed the prescribed backbends in the form of the yoga cobra pose hundreds of times in sets of 10 since my first diagnosis in mid-October 2020. I was definitely improving but I wasn’t fixed and the 2 PTs I worked with expected me to be fixed long ago. The buttock muscle pain slowly improved but persisted and, then dramatically worsened, in mid-January without an obvious reason for the change.

Three weeks after my 1st coronavirus vaccination and when the Palm Springs PT’s office reopened after a virus-prompted closure, my 4th PT consult in recent months and the third for buttock pain, yielded the fix. The “Eurkea!” moment settled into my mind by the end of the appointment and it partially took hold in my body the next morning. I wasn’t 100% cured but I knew I eventually would get there. It felt right in my body and made sense to my mind. It snapped into place. It was “the button,” the single control point, I had hoped to find that would free me from chronic, sometimes, excruciating, pain.

My persistent buttock muscle pain issue was due to a lack of vertebral mobility causing disc “derangement” and injury, but the fix could not be attained with the standard do-it-yourself backbends prescribed by both PTs and echoed online. My lowest vertebrae were stuck and could only be mobilized with excessive, almost ballistic, force delivered by someone else. Disappointingly, there was no self treatment substitute in my case.

Bill had graciously honored my request to do the hands-on mobilizations like the PT had done in December, with obvious effect but confusingly, his efforts fell short of the cure. He watched the PT at my second appointment, in February, and probably blanched. The large, tall, PT slid a 10” high exercise step-bench next to the treatment table, stood on the bench, put his hands on my lower vertebrae with straight arms, and began a pumping motion like CPR, with perhaps all of the force that he could generate.
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A simple rigging system vastly reduced back strain for both of us when moving our heavy bikes in & out of the trailer.

Bill had been administering the treatment while standing beside me with me lying on the bed. Observing the PT, he presumed that he’d been delivering a fraction of the force required for mobilization of my vertebrae. He had been cautious, not wanting to damage me, but had used enough force to feel some yielding in the tissues. That night back in the trailer, he modified his technic but realized he still wasn’t robust enough. The next morning, with me on the floor and him kneeling over me, he was able to replicate the PT’s effort, working up a sweat along the way, and feeling greater mobility in my low back under his hands.

The mobilization was a 2-staged process: the slow, jack-hammer-like motion by my assistant and the 10 reps of cobras, of backbends, by me afterwards. My backbends also needed strong countering from my assistant. The do-it-yourself remedy of back-bending without assistance was insufficient for my stuck vertebrae, I needed a substantial counterweight on my pelvis.

Back in December, Bill had suspected as much, and he would flop a 10 pound, sandbag-styled ankle weight on my bum. Now, with a better understanding of the forces involved, he sat on my pelvis and also pressed down with the weight of his upper body through his hands to provide an unyielding fulcrum that I pushed against with my arms while back bending. It was stunning how much force was needed by both of us to restore normal mobility between my lower 2 vertebrae and at how quickly I felt improvement once the treatment matched the condition.

Field Testing the Treatment
That day, after my first Rambo PT treatment by Bill in the morning, I cautiously headed out on the Pacific Crest Trail for what became a 14 mile hike, not knowing if I’d be instead sitting in the truck all day. It would be the 5th longest hike I’d done in the last year and with my standard 10 pound pack which I hadn’t carried in a couple of months. I had no buttock muscle pain or spasm on the hike. I couldn’t remember the last time I’d gone for even a neighborhood walk without buttock pain—a year? Or years? I still had abnormal sensations in the buttock where the pain had been, but not pain.

I was delighted and amazing but not totally surprised to do so well because in the morning, after Bill mobilized my lower vertebrae, I could sense that my body had crossed a threshold: the critical, missing bit of lumbar mobility was returning. It wasn’t a 100% restored but it clearly didn’t need to be 100%; it was good enough for now. What an absolute joy! Less than a month before, walking flat city streets would trigger pain and dysfunction after 2 miles, enough so that I might struggle to make it back to the trailer.

In a quick comment, the PT had said mobilizing these lower vertebrae would fix my painful shoulder muscle caused by neck disc damage diagnosed the week before by the virtual PT. Not intuitively obvious as to why, but I believed him. A truism in the body is that “it is all connected” and that is especially true of the 2 ends of the spine. I’d started the hike with some lingering shoulder pain and restricted head movement, which all gradually improved throughout the hike. Any movement during the day would have helped it but the extent of the improvement suggested my neck vertebrae were responding well to the lower back mobilizations: another confirmation of the pain syndrome being on its way out of my body.
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Bill’s custom trailer hitch dolly eliminated the need for both of us to lift it, further sparing our discs.

We guessed Bill would need to perform at least daily, if not twice daily, ‘mobilizations’ for weeks to keep the newly released vertebrae mobile, to interrupt the pattern of muscle tightening and over-tensioning of the joints and to modify scar tissue formation. I would continue doing the cobra pose reps after each of Bill’s treatments and would continue them at least twice daily for the rest of my life, but the buttock muscle problem that haunted me for years and had become a crisis this last year, was resolving.

Ultimately, the treatment was simple but it must be highly unusual for disc injury sufferers to require such intense, frequent, hands-on treatment; cobras are supposed to be enough but they fell short in my body. Perhaps it was because my unusually high spinal flexibility allowed the stiffness between the lower vertebrae to escape detection. Or perhaps it was the 18 months of deliberately restricting my back movement in 2015-16 to allow my left sacroiliac joint to heal that laid the foundation for this problem. Regardless of the cause, it would take weeks of Bill’s hard work before the yo-yo-ing between mobility and immobility stopped and mobility persisted. There was still more disc healing to occur after that, but sustainable mobility was a critical step in the process.

The day after the hike, everything in my body fell into place. The seemingly weird and exaggerated posture the PT had me striking to be well aligned 2 days before no longer had to be extreme and felt natural, felt right. Even after an abruptly harder, 14 mile hike, there was little to tend to in my body the next day. Clearly, my body was properly aligned, balanced, and symmetrical and could once again function smoothly. My efforts to maintain my fitness and tissue health while navigating around the pain and limitations had paid off: my body was willing and able to go, go, go like before.

For years, I had averaged 1-2 hours per day tending to my soft tissues: to my muscles, fascia, tendons, and ligaments. It seemed an inordinate amount of time and yet it was what was needed to keep me active. It was like I had to put everything back in its proper place every day. My dreamed-of state of being appeared to be around the corner: light touch-ups rather than major reorganizations might be all I needed. It sounded suspiciously normal. And the bonus would be ridding myself of vulnerability to these ‘snowed brain’ episodes of nerve pain.

Another exciting prospect of the impending cure was the chance that ancient, puzzling asymmetries in my body would melt away. They weren’t important functional issues, they didn’t limit me, but they were telling markers for imbalances. My right big toe always had a thicker caucus on the outer bottom edge than the left. I always suspected it was due to an imbalance but changes elsewhere didn’t reduce the callus. The toe callus observation fit with the pattern of being a little tighter on the inside (medial) leg muscles on one side of my body and on the outside (lateral) of the other. Both suggested a twist or tilt somewhere. A particular asymmetric seated yoga position was always harder with my legs to the left than to the right. I hoped that my lumbar vertebrae immobility had a little lopsided quality to it and that these asymmetries would melt away in 6 months to a year while the mobilization work integrated.

Cervical (Neck) Disc Injury & Shoulder Pain
“Joint derangement” was my new, recurring diagnosis delivered by my virtual PT, so I decided I’d better get used to it. When in the spine, that means that the joint isn’t working properly because the disc or its gel is out of place. She skillfully extracted me from buttock muscle pain in mid-October and I called upon her services again in early February when I had a 10 of 10 event on the pain scale from a shoulder/back muscle.

When I somewhat glumly asked the virtual PT “Is having severe pain from 3 damaged disc in a little over 3 months a function of aging?” she responded with what felt like uproarious laughter compared to my pessimistic mood. She said something like “No, no, it’s just because you are active! It will keep happening. It’s great!” She considered me really lucky: at my age the spinal discs are usually all dried out, causing people to lose inches in height, and there is nothing left to rupture. My discs obviously were still soggy enough to get damaged. She went on to tell me she recently had another old lady patient who was in her 90’s and also had a ruptured disc. In her mind, we were the lucky ones!
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Maintaining the protective, upright posture on the trail was challenging for both of us.

Bill gave a nod to her comment: it fit with my observation that I was lagging behind in my expected loss of height with aging. I hadn’t checked my height during the pandemic, but at last look, I’d lost ¼”, not the 1.5” inches predicted by my age.

Ever the cheery one, the PT suggested that the source of my current pain was probably the bottom cervical (neck) disc, C7, impinging on a ligament, which refers pain to the scapula (shoulder blade), to the back and to the right of my spine. The specifics didn’t matter in her mind, resuming my active lifestyle was all that she cared about. With her simple exercises, she expected a 90% improvement in symptoms in 5-6 days. Given my pain was in my back, closer to source of injury in my neck, predicted a faster recovery than if it had been in my arm.

Her treatment regime had 3 parts:
..pushing the jaw straight back 10 times to improve alignment (https://youtu.be/PU96JF3DFi8)
..doing 10 controlled head tilts backwards to move the disc back into position (like with the low back)
..doing 10 head rotations and 10 head side tilts to test for pain reduction

The details all mattered, especially keeping the shoulders and chest still throughout the movements so as to isolate the neck.

She concurred that the injury was probably cumulative, both from increasingly, suboptimal posture from chronic pain and an inappropriate pillow. I’d struggled to find the right pillow for years and, for my side-sleeping position, she recommended one filled with torn foam pieces and a forearm-diameter rolled towel on the pillow to support my neck vertebrae. I eventually found an inflatable pillow with a depression in the middle to prevent it from sliding, which functioned as a welcome “ear well” for me. Being inflatable, it had the advantage of being easy to tweak its firmness.

Other Lessons: Nerve Pain From Disc Damage
The Anatomy
The nerve bundle is biggest when in the spinal column and as the bundle moves away from the spine, nerves on the outer layers peel off, heading to their target tissues. The diameter of the nerves get smaller the farther away from the spine they are.

At a given level in the body, nerve pain more lateral or at the outer edges, indicates more injury of the disc than pain more medial or central. For example, buttock pain that occurs closer to the mid-line indicates less damage than when the pain is out to the side. Likewise, pain in the shoulder area or upper back reflects less disc injury than pain part way down the arm.

The pain tends to be concentrated in one area, like the shoulder or buttock, rather than along the entire tract of the nerve from the spine, which adds to the confusion for some of us. It feels like the pain is being caused by a specific muscle because it is confined to an area rather than being a long, continuous swath of pain from the disc. This is because the nerve endings in the muscle, or other tissue, are what transmit the pain signal. The nerve is wrapped in a protective sheath from the spinal cord to the target tissue, which lacks pain or other sensors.

Making Sense of It
Suddenly, the excruciating pain episodes I experienced 6 months ago made sense. In August, I had had 2 episodes of “white out” pain in the Serratus anterior muscle below the shoulder blade on my right side and a less severe episode in my buttock, also on the right side. All of my current pain problems were also on my right side. It was a perfect fit: I’d been having increasingly significant, though intermittent, pain from irritated or injured discs for months, if not years. I was so alarmed by the pain in August that I bought a massage gun and a TENS unit for treating pain because I feared pain was a new and unpredictable companion in my life.

The Treatment
Usually, the treatment of disc issues is so simple and yet so tedious: extension of the spine. Exactly how one needs to extend varies with the region of the spine that is injured, but the theory is unwavering.

The biggest drawback of this incredibly simple treatment strategy is that the patient must be motivated to heal themselves. Pain is usually a good motivator but for people who expect to be fixed by a pill or a procedure or another person, it’s problematic. I am a very high complier and, even though I find it boring and tedious, I am gifted with enough discipline to do self-treatments, so it works for me.

Oh, By The Way: Pain Goes Both Ways
Coincidental with being forced to “get it” that the painful muscle in my shoulder was painful not because the muscle was damaged but because the nerves in my neck that feed the shoulder muscle were being irritated by a disc, I learned something about gut pain. It was hard to get the new model to stick in my brain: a damaged disc intrudes on a nerve and the muscle controlled by that nerve hurts. My neck didn’t hurt and the length of the nerve between the disc and the shoulder muscle didn’t hurt, only the isolated muscle at the far end of the nerve hurt. There was an equally bizarre lesson to be learned about my gut pain.

I’d suffered miserably off and on for 3 years with brain fog, depression, and general distress from high blood pressure medications. I assumed that my misery was due to the direct effect of the drugs on my brain, but a significant portion of it apparently was because of their potent effect on my gut.
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Watermelon belly: a difficult episode of distention at the PT’s office.

The medications irritated my gut and one of the symptoms of that irritation in me was massive distention or bloating. My gut literally can inflate faster than I can blow-up a balloon. There are receptors in the gut that function like a switch: the switch gets flipped at a certain point of expansion, which activates ‘visceral pain receptors’ that then send alarm bells to my brain, which then shuts my brain down. I rapidly become lethargic, have to sit down, have to be still, and I can’t think. There are such receptors in the chest and pelvis as well as the abdominal area.

Lucky for me, because of the medication I take (amiloride), there was a way to sometimes short circuit this cascade, which was to shovel in Imodium, the anti-diarrheal, loperamide. I’d been using Imodium, one tablet at a time, in response to worsening abdominal cramping from the high blood pressure medication. Many days, I was taking 4 tablets by noon to control the cramping but it didn’t eliminate the malaise and brain fog. Once learning about the visceral pain receptors, I immediately switched to the ‘hammer’ approach, with good results in the early experimentation.

The moment I saw my belly swelling like a watermelon, I’d pop 2 Imodium. If I didn’t see improvement in 30-40 minutes, I’d pop another one. And when, an hour later, if my gut started to rumble and cramp, I popped a 4th tablet. By noon, I’d taken 4 tablets like on days when I employed my ‘onesies twosies’ strategy, but I skipped the the malaise and brain shut down by aggressively controlling the distention.

I struggled to change my thinking about my gut-brain issues in 2 ways. One was that the sooner I interrupted the visceral pain receptors being triggered, the sooner my head would clear. And the second point was that it wasn’t the abdominal cramping that knocked me off of my feet like I thought, it specifically was the distention. The cramping and distention were intertwined, but the distention was the symptom that should trigger my action, not the cramping.

After becoming convinced of the relevance of this visceral pain receptor model to me, I finally caved-in and starting taking Imodium at bedtime as well. Enough of waking up at 1:30 am every night with gut pain and being groggy in the morning from lack of sleep. Some days, I was taking 7 Imodium to manage my medication side effects.

Part of my reason for doling out the Imodium a half and whole tablet at a time, was to prevent constipation. The good news-bad news was that 5-7 Imodium a day didn’t trigger constipation in this situation. My gut was so agitated from the direct effects of the medication on it that I was still at risk of 3-4 bowel movements a day. The effectiveness of Imodium for controlling my brain fog was highly specific to my medical situation but it is a nifty example of how convoluted controlling pain can be—pain isn’t always as straight-forward as it seems.