Where's Doc been, and what's he been up to?

[Jungledoc]

It may be presumptuous of me to even think that this questions has been on anyone's mind, but I'm going to answer it anyway!

Those of you reading this who have been around this forum a few years may remember that I did not start exercising consistently until I was in my early 50s. 52, to be exact. 2005. I started because I'd had arthroscopic surgery on my right knee, had not done any formal rehab (long story, blame me, not my surgeon, who is friend) and had got stuck on a steep hillside in the high mountains of north-central Papua New Guinea, too weak to take the next step without stopping to rest literally every step or two, thinking my national friends would literally have to carry me up the mountain to the village. I eventually got there under my own power, and as soon as I got back to Kudjip (the place where I live), I went and looked at the little weight room that some of my fellow missionaries here had set up. It had a multi-station lever and pulley machine that looked intriguing. With no more knowledge than faint memories of college PE, I started doing every exercise on the poster that came with the machine. Browsing the internet and watching fellow exercisers in the gym lead me to start trying free weights, eventually abandoning the machine almost entirely. That browsing lead me here, and people like Tim, Ironman, Stu and a handful of others started teaching me. Of course I read other stuff, tried out a lot of different approaches. I had fun, got stronger, got healthier.

Pain, similar to what I'd had in my right knee for a long time gradually started showing up in other places, including my low back. I self-diagnosed the spread of osteoarthritis to my spine. Remember what they say about he who is his own doctor having a fool for a patient? Or maybe it's the other way around. I keep thinking, hoping that if I found the right combination of stretching, activation, good form and good luck, I could exercise the pain away.

About 3 years ago I was in the US, traveling around, speaking in churches and attending meetings, and spent a couple of weeks in the Indianapolis area. Jason Nunn, who was (probably still is, though not active) a member of this forum invited me to come to his gym to work out. What I definitely didn't expect, but what happened is that I got several one on one training sessions with him. Jason has his MS in exercise science, is CSCS, is very smart, very strong and one of the world's nicest guys. Not only did he work with me one on one for those sessions, but he offered to continue helping me with distance training. He took over all of my training programing, which was a huge benefit. You know what they say about he who is his own trainer has a fool for a client? That had been me. I'd read about some exercise that I really should do, I'd try it, wouldn't like it, abandon it and go back to the comfortable and familiar. Under Jason's guidance I gave up back squats ( ) and started front squatting. I stopped (temporarily, I thought) DLing from the floor, substituting high, but gradually lowering rack pulls. He gave me lots of mobility work, especially ankle, hip and shoulder mobility.

He would write a 4-workout program, I'd do it, then email him to report how it had gone. I felt that I had some latitude to change things on the fly as needed, but I basically stuck to what he gave me. Then he would email me the next 4 workouts. We'd correspond in between when I had questions.

Finally, about a year ago I started questioning my medical diagnosis. My hips were more and more limited in extension ROM. My theory was that that put my L spine into hyperextension, and made the pain worse. If I could just increase the hop mobility, the back pain would go away. It didn't. About a year ago I was at a medical meeting and talking to a rheumatologist. After I'd asked him some questions, he asked me if I'd taken any x-rays of my back. Embarrassed, I confessed that I hadn't. I just work in a tiny hospital where my office is about 20 steps from the x-ray room, and I can go there any time I want and they'll take any views I want, and no cost to me. But, no, I hadn't.

When I got home from the meeting, I got the x-rays. The moments immediately after I put the first film on the view box were shocking and life-changing. There where the lowest 3 vertebrae and discs should be was a hunk of crap. Severe arthritic changes in the joints, and badly degenerated discs. Honestly, my weight training friends, my first thought was about squats and deadlifts. I nearly cried. Then my friend and co-worker came up behind me, looked over my shoulder and asked, in an incredulous tone of voice, "Is that YOU?" And then started laughing. There I was with my heart breaking, and my friend was laughing at me! It was really what I needed to keep me from taking myself too seriously at that point. The next day I passed the same guy who was standing at the view box with a medical student. I heard him say, "At least it's not as bad as Andy".

So, I wrote to Jason, he complete changed my program. No axial loading with added weight (eventually I would add in light goblet squats). Step-ups, RDLs, etc. Bench, chins, pull-ups, various rows, core stuff.

For a while after I started working with Jason, I would cross-post my reports to him in my log here, but eventually forgot a couple of times, then was so far behind that it was too much work to catch up. There comes a point where who would want to read about months and months of my workouts. Maybe the same people who would read this far into this? I got busier with some other things as well, and had less time to browse the forum, so eventually pretty much dropped out of sight. Then a couple of weeks ago I got curious how y'all were doing, and came to check. So I'm back.

When on home assignment this past year, I saw 2 orthopedic surgeons, a cardiologist, a pain specialist, a family doctor, a dentist and an optometrist. Only the latter 2 did me any noticeable good! :) Well, the last 3. The FP got my paperwork in order for coming back to PNG, and prescribed my meds. I'm glad I saw the others--seeing them represented some steps that I needed to take. I got an MRI scan along the way, which was necessary, if not earth-shakingly revealing.

I had an epidural steroid injection, which felt wonderful for a few hours (they mix the steroid in local anesthetic, so I basically had epidural anesthesia like ladies have in the US for childbirth), but after that wore off and it was time for the steroids to "kick in" no improvement. Doctor said that that should be tried first, though he warned me that the chances of great help were small. Then I had a radio-frequency ablation of the nerves that supply feeling to the facet joints at 3 levels in my L-spine. Nothing. I discovered, accidentally, how much help my anti-inflammatory med is, when I missed it 3 days in a row, then woke up unable to stand up.

In January of this year, we had a rheumatologist volunteer at out hospital. I decided to talk to him about my arthritis, not thinking that there was much he could do about it. In just a few questions, and a couple more x-rays, he gave me a new diagnosis, both troubling and hopeful. He concluded that I met the somewhat complex diagnostic criteria for a condition called spondyloarthritis. This is one of a group of diagnoses that includes the dread ankylosing spondylitis, but is not that. The bad news it that it can get really bad. The good news is that there are a lot of additional potential treatments, including some of the "biologicals" or monoclonal antibody drugs. More bad news it that you shouldn't take those drugs if you live in an area endemic for tuberculosis. I diagnose and treat tuberculosis many times a day, almost every day of my life. Good news is that there are some immune suppressant drugs that you CAN take in such places. Bad news is that they usually work best for the peripheral joints, and not so much for the axial pain. I've started one of those, and if it helps will take it until I retire, or am reassigned to a place that doesn't have TB. Later I'll try a biological, if I can afford it on medicare! :)

One feature of all the AS-related diseases is fatigue. One very discouraging, draining, frustrating feature. I used to be a person who did OK with 5 or 6 hours of sleep a night. Now if I don't get at least 7 I'm in trouble. It is now 11:30 PM, so if I'm to get up by 6 AM, I'll be hurting before the day is out tomorrow. That has presented a huge challenge with taking night call. For one thing, I am very stiff when I first get out of bed, so jumping up to go deal with an emergency is difficult. Plus, I don't sleep very well when I'm on call, so it increases the fatigue for the next few days. Fortunately, my colleagues here have been very understanding in helping to adapt how we handle call so that I can do a fair share, but less of it at night.

Another problem that is part of this is proprioception, and thus balance. Sometime if I just turn suddenly or bump into something, I lose my balance briefly and stagger around. Haven't fallen, but look funny sometimes. Another is urination. Hard to get started, and it isn't my prostate. Finally, posture. I look funny because I tend to lean forward a lot. When I think about it, I can correct it to some extent, but that hurts, so when I'm real tired I just give in and lean. I guess that eventually I'll walk all hunched forward, but I'm trying to postpone that.

Gradually, I've resumed managing my own training. Jason has gotten very busy, and it was getting harder for him to answer my emails quickly. He actually does the figuring for the progression of undulating periodization on a spread sheet which had always been part of what he would email to me each time. With a little instruction from him, I learned to substitute the next progression in the spread sheet and adjust the index weight from time to time, then the proper reps and sets show up on the part that I print out and use as my training record. He's still available to answer questions and give advice.

Right now, my "big" lifts are flat bench, incline DB bench, step-ups (sometimes holding a light weight) and goblet squats (with about 20 pounds). I do chin ups or pull ups every workout now, doing sets to failure, or my favorite sets-across approach. Accessories are things like light shoulder raises (3-dimentions), planks, Pallofs, half-kneeling lifts and chops, band curls or pull-downs, pull-aparts, calf-raises, band walks, plus a mobility-oriented warm-up. Thanks to Jason I know about and have experience with a bunch of other things that I can cycle in from time to time.

I won't give up on training. I've often told my patients, "It's better to be strong and in pain than to be weak and in pain." So I'm sticking with it no matter what. Some days I cut down on some things, mostly on the volume of accessories. I need to lose some weight, which should help everything. I'm obviously less active than I used to be, which makes weight more of an issue.

So that's it. You've had the story the rest of the story and a bunch more. As one of my colleagues here likes to say, "I've already told you more than I know."

[stuward]

Andy, That's a great story, and I'm glad you shared it with us. One of the things that attracted me to this forum was that there were people going through stages I could relate to. Everything is not a straight forward "do this, that happens". Your experience will help me with my own trials as they come alone in very short order, and I thank you for that.

[Llemna]

Sorry to hear about your back problems. Good that you are trying to work your way around things and not just surrendering to the couch and ice cream as so many people would do when given your diagnosis.

L~

[Jungledoc]

What I've been puzzling over lately is whether or how much strength training, especially heavy axially-loaded lifts have contributed to my current woes. What damage have they done? I'm not the only person in the world with this diagnosis, and surely most of the rest of the other people have backs that are as bad as mine, and probably very few of them have ever done a squat or a deadlift.

So, the big question is whether I really should avoid such things. It's not likely that there is any good research evidence one way or the other. It is likely that any doctors who I'd ask would have little or no experience with strength training, but have strong opinions against it, or at least be unwilling to advise someone to lift, for fear of potential liability claims. So, it's a decision that I'll have to make all by myself.

If I do take up the "big lifts" again, it will also be hard to gauge effect, to tell the difference between ordinary fluctuation in the severity of symptoms and pain being caused by the lifting. So I'd be guessing, experimenting.

So this past week, I did 5 sets of DLs, very light. The heaviest set was 112 lb. I'm not claiming cause and effect, but the next morning was one of the best mornings in recent months, in terms of pain. I've been doing light goblet squats. This week I plan to start pushing the load up a little on those.

[stuward]

Doc, I'm on my way to work so I have to be brief. My wife had degenerative disks in her 40s without any lifting but on the other hand, Ronnie Coleman just had his hips replaced. Certainly heavy lifting can make things worse or it can help, depending on the situation. There have been people come by hear in the past that seem to have done very well, Bill DeSimone, Steve Proto, Raold Bradstock, etc. Kenny Croxdale can probably make a good argument for lifting in senior years. I think that the direction of stress is very important. Squats and deadlifts are heavy in compression and that needs to be balanced with tension forces. That's very simplistic but I think that core and back strength can be developed without heavy reliance on compression. It's all about balance and adjusting to your own body.

[KPj]

Andy - sorry to hear about the problems you've been having.

Been a while since I posted, I check in from time to time and have a scan through the forum but times gotten away from me recently.

I don't have any experience with your condition but recently have worked with or currently still training clients with some pretty messed up spines (and hips) - I get referrals from a few physios and a few docs.

Anyway, it doesn't surprise me that you felt good after training. Could of been the fact you grooved a hip hinge, or just moved in a different way that felt good. I don't think there's any definitive research on it, but I use deadlift and squat variations with (almost) everyone. I don't "strength train" them like a powerlifter, i'd use a goblet squat before a back squat (and most likely wouldn't use a back squat at all), and the goblet squat could be limited depth, too (depending on current ROM, pain, etc). Their deadlift could be as simple as slightly elevated KB deadlift.

Basically prioritising "sparing the spine" as Mcgill puts it. "sparing the spine" could be seen as a very ambiguous term, you could argue we shouldn't do anything. However I believe you actually have to train to spare the spine. Our lifestyles don't feed those spine-sparing-movement-patterns, for lack of a better term. Therefore, we need to train them. Groove the pattern, and add strength in whatever way is appropriate for the goal. In your case I think a big challenge will be making the goal the movement, rather than the goal being the exercise in itself. So, you need to think about improving your hip hinge, rather than adding pounds to your deadlift. That may well result in using more weight but the priority needs to be on technique and control - smooth fluent motion with good bracing and breathing patterns.

By the sounds of it you're doing this already. Again, no experience with what you have, just reflecting on the experiences I have had - clients with pretty degenerated spines and hips, lots of disc/nerve problems, but obviously all cleared to exercise. I was pretty nervous about some of the clients i've been sent, but by being very strict with pain (if something causes pain or makes it worse, we stop doing it), and most of all screening clients prior to choosing exercises, i've not had any problems. The improvement in symptoms when they start training is pretty remarkable.

I think if you are monitoring everything you can, it can only be a good idea to keep training, but the mindset switch from "exercise" to "movement" oriented may be tough.

I've been back and forth through loads of different "channels" for info in terms of dealing with clients with bad spines, but the Gray Cook, coupled with McGill approach has easily served my clients the best. Both parties already do, but Id add a big emphasis on breathing and bracing patterns, as understanding this more has probably been the most significant thing to happen to me over the last few years.

As an example, I'd always consider the following before someone deadlifts,

Can they do an ASLR, both sides, pain free?

Can they touch their toes correctly, and pain free?

Can they take a diaphragmatic breath whilst bracing?

My point is more about making sure you qualify yourself in some way before doing exercises, particularly those that cause or worsen pain. This is just what I relate to dead lifting - I also make sure clients monitor how they feel the rest of the day and the next morning. As you'll know, you don't always find out until the next morning that what you done the day before was a bad idea. I very rarely have a client who doesn't feel better for it.

I know in your case it'll be difficult to gauge the cause of pain fluctuations, but keeping a close eye on things like your ASLR, Toe Touch, B/w Squat, lunge, etc may help, if you don't do this already. I've had occasions when clients come in and I know from their warm up that their movement quality has decreased, so I change the plan, and I monitor it as we go through the session, and I believe this is why it works so well, and I believe the improvements they feel is because they will move more efficiently, taking some stress off the spine, in every day life (without consciously having to think about it). As I know you know, your spine is pretty much alays under "stress", and I believe the only choice we have is to manage it as best we can, with the spines we have, and training, i think, is a solid way to approach that.

Way longer post than I intended, just like old times!!! Hope it makes sense and helps.

[Jungledoc]

Yeah, both Kenny and Stu--like old times! Now it's "really old time"!

I think I'm going to go to bed and answer this later, both my observations and some questions. Fatigue is a big symptom of spondylo
arthritis, and, much to my surprise and dismay, lack of sleep makes the whole thing worse. So my 5-6 hr/night sleep habit is changing into 9+ hr/night. So, I'll come back to this tomorrow.

[Jungledoc]

Doc, I'm on my way to work so I have to be brief. My wife had degenerative disks in her 40s without any lifting but on the other hand, Ronnie Coleman just had his hips replaced. Certainly heavy lifting can make things worse or it can help, depending on the situation. There have been people come by hear in the past that seem to have done very well, Bill DeSimone, Steve Proto, Raold Bradstock, etc. Kenny Croxdale can probably make a good argument for lifting in senior years. I think that the direction of stress is very important. Squats and deadlifts are heavy in compression and that needs to be balanced with tension forces. That's very simplistic but I think that core and back strength can be developed without heavy reliance on compression. It's all about balance and adjusting to your own body.

Thanks. My feeling is that core (as I understand the "core" at least") and the back can and should be trained in concert. Some degree of compression is needed (heck, you need some just to stand up, and I want to stand up well). I believe that it is very important that any compression occur with the spine in a neutral position. The role (at least one of the roles) of the core is to stabilize the spine in neutral. I think that excessive flexion OR extension with loading are potentially harmful.

For many years, based on reading and information on websites, etc, I was so afraid of lumbar flexion that I fell into the trap of lifting in excessive flexion. All the warnings are (at least all the warnings I saw) against "rounding", with instructions to have a good concave curve in the L spine for squats and DLs. So I worked hard to make sure I had a tight lumbar curve. I now think that that wasn't so good for me. I would notice that if I tried to stay in a neutral alignment, but stayed real tight, my back wouldn't hurt as much after a heavy squat session. In recent months I've noticed the same thing about things like roll-outs. I"ve come to actually like this exercise, and have gotten fairly good at it. When I was first doing these, I wasn't in good alignment, low back hanging down. I started getting immediate pain from that. I discovered that if I really concentrated on a more straight L spine, and a really tight anterior core, even to the point of thinking about a slight posterior pelvic tilt that I could do roll-outs all day without pain. Well, not all day.

Pull-ups and chin-ups are obvious things that I can concentrate on safely. Or that should be safe. But even with those, I found that I was getting more pain. I, like a lot of people tend to flex and extend my back while doing these. At first I tried to do the same thing as on the roll-outs, maintain slight posterior pelvic tilt, but that's hard to do on chins. My best cue is to just keep everything still, try to keep my knees slightly forward. Once this became habit I could do chins and pulls without a problem.

In the arguments about whether direct core training is necessary, or whether just doing heavy lifts are sufficient, I've decided (as I mentioned in my previous post) that it's not either one. Every lift should work the core, and direct core work is very important. By core work, I mostly mean stability work. So half-kneeling chops and lifts, planks (boring as they are), roll-outs, Pallofs, TRX fall-outs, etc., etc, are essential, I believe.

So, Stu, what are you thinking when you say, "Balanced with tension forces", and developing back strength without heavy reliance on compression?

[Jungledoc]

Kenny--thanks for this thoughtful post. I'll quote parts of it and respond and ask questions.

I don't have any experience with your condition but recently have worked with or currently still training clients with some pretty messed up spines (and hips) - I get referrals from a few physios and a few docs.

I'd think training for me would be very similar to anyone with a severe arthritic back and/or degenerative discs.

Anyway, it doesn't surprise me that you felt good after training. Could of been the fact you grooved a hip hinge, or just moved in a different way that felt good. I don't think there's any definitive research on it, but I use deadlift and squat variations with (almost) everyone. I don't "strength train" them like a powerlifter, i'd use a goblet squat before a back squat (and most likely wouldn't use a back squat at all), and the goblet squat could be limited depth, too (depending on current ROM, pain, etc). Their deadlift could be as simple as slightly elevated KB deadlift.

Of course, it was just that one time. This week I had a very average pain level for the next day or 2 after DL.

I'm still doing goblet squats, but intend to work toward front squats. Jason had me doing those. Haven't back squatted now for almost 3 years. Depth is limited by my hip flexibility. I can go as deep as possible without any pain, but it's just not as deep as it used to be. If I were to compete in power lifting ( ) I doubt I could get to a legal depth.

Basically prioritising "sparing the spine" as Mcgill puts it. "sparing the spine" could be seen as a very ambiguous term, you could argue we shouldn't do anything. However I believe you actually have to train to spare the spine. Our lifestyles don't feed those spine-sparing-movement-patterns, for lack of a better term. Therefore, we need to train them. Groove the pattern, and add strength in whatever way is appropriate for the goal. In your case I think a big challenge will be making the goal the movement, rather than the goal being the exercise in itself. So, you need to think about improving your hip hinge, rather than adding pounds to your deadlift. That may well result in using more weight but the priority needs to be on technique and control - smooth fluent motion with good bracing and breathing patterns.

OK. That all sounds good, but I think I need to know a lot more about this. I have paid a great deal of lip service to movement, and Jason did a brief (I think modified in his own way) FMS on me when I was at his gym, but I'm still pretty slow on this. I read one of Gray Cook's books a few years ago, the one that has the self-assessment version of FMS (I think it's on my now-defunct Kindle). I believe that at that time the ASLR was a fail for me. Trying it now (not remembering all the "rules" about how to do it and measure the results) I could get either leg to about 70 degrees keeping my back flat.

So I don't really get "making the goal the movement". Can you say more? Or do I need to come to Scotland for a real assessment? (Oh, that's a great idea, now that I think about it.)

And about the hip hinge. I guess I've always thought that you either hip hinge or you don't. If I can hip hinge, how do I improve it? I mean, what about it would be different? How would I know if I'd improved it?

By "good bracing and breathing patterns" you mean maintaining the brace while breathing? Exhaling on the concentric, inhaling on the eccentric?

I think if you are monitoring everything you can, it can only be a good idea to keep training, but the mindset switch from "exercise" to "movement" oriented may be tough.

Yeah. Tough mentally, especially.

I've been back and forth through loads of different "channels" for info in terms of dealing with clients with bad spines, but the Gray Cook, coupled with McGill approach has easily served my clients the best. Both parties already do, but Id add a big emphasis on breathing and bracing patterns, as understanding this more has probably been the most significant thing to happen to me over the last few years.

And probably the biggest area of learning that I need.

As an example, I'd always consider the following before someone deadlifts,

Can they do an ASLR, both sides, pain free?

To what level? Pain-free, yes, but my ROM is limited.

Can they touch their toes correctly, and pain free?

Correctly? I.e., flat lower back, straight legs, rounded upper back OK?Yes I can, just. If my toes were just a little further away it would hurt.

Can they take a diaphragmatic breath whilst bracing?

I can.

My point is more about making sure you qualify yourself in some way before doing exercises, particularly those that cause or worsen pain. This is just what I relate to dead lifting - I also make sure clients monitor how they feel the rest of the day and the next morning. As you'll know, you don't always find out until the next morning that what you done the day before was a bad idea. I very rarely have a client who doesn't feel better for it.

I guess I worry less about pain that shows up the next day (thinking DOMS) than what makes it hard to walk home from the gym!

I know in your case it'll be difficult to gauge the cause of pain fluctuations, but keeping a close eye on things like your ASLR, Toe Touch, B/w Squat, lunge, etc may help, if you don't do this already.

I'm sure I don't do it very well. Maybe those things should be part of my warm-up every time I work out.

Way longer post than I intended, just like old times!!! Hope it makes sense and helps.

Yeah, it really does. Thanks!

[Jungledoc]

And, by the way, when you say that you don't have any experience working with my condition, I'd guess that you actually do, but that the clients have carried a different label, like "arthritis of the spine" or "degenerative disc disease" or something. The "spondyloarthropies" are a group of diseases that are actually quite different from each other, but have a few things in common. Psoriatic arthritis, arthritis with ulcerative colitis, reactive arthritis (still sometimes called by it's old name "Reiter's Syndrome" and the dread Ankylosing Spondylitis (which may just be a common final pathway of all the others), are all part of this group. Spondylo arthritis is the other disease in the group, having all the arthritic features, but not the other involvements of the other diagnoses. That's me.

The diagnostic criteria have become more refined in recent years, and with that has come better recognition. If my own relative ignorance is any evidence, many doctors are unaware of the recent changes in thinking about this group. I learned about all of this when we had a rheumatologist come and volunteer at our hospital.

The among the features that all these conditions share, and that you can easily ask people about are, 1) pain in the sacroiliac joints, 2) morning stiffness, and 3) fatigue. Not that you need to diagnose them, but those are all things that have practical implications in training. For me the fatigue is probably more likely to be career-ending than the pain. Morning stiffness is just what it sounds like, and usually occurs for the first 10 to 20 minutes after getting out of bed.

The official criteria include that if a person has x-ray evidence of arthritic changes in the SI joint, and onset of back pain before the age of 45 they are in this category. If the pain starts later then the diagnostic criteria are much more complex. Other criteria include enthesitis (pain at the insertion of tendons or ligaments), swollen inflamed fingers (dactylitis, or "sausage finger"), and some laboratory findings.