Where to next? (Medical practitioner question)

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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Tue Mar 06, 2018 4:30 pm

I'd go with the conservative approach - the muscles take a long time to knit, even when a simple separation. Glad to hear the leg is appearing better!

I'm coming along "nicely", I can walk without my limp being too apparent, but can't run... even if the spine allowed it. Much work underway on core strength, but it's pretty obvious that my left side isn't working all that well, balance and ability to exercise is limited down that side. But my L/R power on the bike is O.K., it's gone from 48/52 to 47/53 and I can live with that.

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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Tue Mar 20, 2018 9:39 am

Still alive - the physio is happy with the progress, but I've worked out that I can compress the left S1 nerve by standing a particular way, which takes a good day to get over. One of the guys at work, who's had back issues for year, has been off work since Christmas. He's too sore to get himself into a doctor for a referral for an MRI, and his chiro told him that it was probably ligament related. Given he can't stand for long without spasms and can't sit for more than about 15 minutes, I reckon it's a bit more serious than "ligaments" - which is also what *my* chiro told me years ago was the cause of my back issues. There's a lot to be said for scans and serious physio intervention prior to niggling issues become chronic disease or medical emergencies.

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Tue Mar 20, 2018 2:39 pm

Sounds like things are moving along nicely Rhapsody. Hopefully the left S1 nerve improves over time.

I am 3 weeks after surgery now, so about half way through the 6 weeks of rest. At about 10 days after surgery I developed a tightness down the back of my leg similar but much less to what I had in the first place.... but it is more constant an not much effected by my leg position. I was told by the surgeon that I may get some nerve pain for a few weeks about a week after the surgery, so I am hoping it will go away in a week or two. Not sure what would cause that, but I assume it is something about the repair process with nerves.

Other than that, things are progressing OK. The tightness is a little annoying but not really noticeable most of the time. I am walking a fair bit now, and making efforts to do lots of walking up flights of stairs at my work to strengthen the Glutes. The surgical pain is subsiding slowly, but is still quite limiting, and it feels right to take it easy for a few weeks still. At least I can sit in a chair at my desk for a few hours now... not comfortably... but bearable.

I did a bit more research on the surgical technique for a Schwanoma. I don't know if it exactly the technique used with me. The peripheral nerve has an outer skin which contains lots of nerve fascicles. Typically a Schwanoma will develop on just one fascicle, and the surgical technique is to clear that one from the others and then snip it on each side of the Schwanoma. So they are completely severing one fascicle. I am not that aware how nerves work. I assume that fascicle is associated with certain functions that would be effected. I read that nerves can grow back at 1mm per day and I am not sure if the severed fascicle can rejoin and function again... or whether the nerve functions rewire through other paths... or you just permanently lose that function. I expect that things will improve for many months and then I will be just stuck with whatever is left. Having said that, the nerve pain now is a minor thing compared to what I had.
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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Wed Mar 21, 2018 11:56 am

Hi Adrian - see here. I'd be expecting nerve budding/sprouting to come to the rescue.

I'm at 3 months, I'll be surprised if I get any more functional improvement in the calf, which is still weak. But good enough for riding. It's just my back which is limiting me now. :(

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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Tue Apr 10, 2018 4:50 pm

My first ride back yesterday. So far my bilateral symptoms are unchanged which was to be expected since I had surgery to one side. I am hopeful that I can start some rehab soon that may help bilateral symptoms. On the side of the surgery, the pain in my butt is much improved... I really only have the residual surgical pain on that side in the butt. Also the pain when I stretch the hamstring is much improved, but I still get a feeling of tightness down the back of the leg that is worsened with activity but there all the time. It is different to before surgery where the pain would build up until I had to move to prevent it. Now it is just like the muscles are tight. The surgeon says it is likely scar tissue around the nerve pulling on it from the surgery that will dissipate over time and helped my movement and activity. I hope he is right. At the moment my most troubling symptom is bilateral numbness/pain in the arch of my feet. As Ckinnard has said.... I think I have some sort of central stenosis that is likely causing that, but as yet not identified. I am seeing a different neurologist soon that I hope can find out what that is.

On the bike, I felt pretty good. I did quite a bit of fast walking while not on the bike, and also some short runs over the last 2 weeks. I was surprised that my fitness was not that much worse from the break. I was able to ride at a good pace and felt pretty good. Pain in the butt did not get worse. I was feeling tight down the back of that leg as explained above, but more of an inconvenience than pain. I started with about 20 minutes of cruising, but went up a hill that got the HR up, and felt fine so kept the effort up for half an hour and felt great! Rode to work today, but just slowly. Will resume normal commuting!
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queequeg
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Re: Where to next? (Medical practitioner question)

Postby queequeg » Tue Apr 10, 2018 5:58 pm

vosadrian wrote: I started with about 20 minutes of cruising, but went up a hill that got the HR up, and felt fine so kept the effort up for half an hour and felt great! Rode to work today, but just slowly. Will resume normal commuting!


Welcome back. I just started riding again last week myself. My left leg is still recovering from the DVT, with my Left External Iliac Vein still near-occlusive, but with a spider web of collateral veins developing. My left leg is visibly larger than my right leg, from about 5cm above the knee where there is a large step up. You wouldn't really think anything of it unless you saw it next to my good leg.

The main impact I have noticed is that while the right leg is cruising along, the left leg gets fatigue because the venous return is restricted. Presumably this means the de-oxygenated blood trying to get back up to my lungs and heart is pooling like a partially blocked drain. I suspect that this will reduce over time as my External Iliac vein recanalises. It's been slowly shrinking in size, so I am hopeful that my body just chips away at reabsorbing the hardened clot and eventually the vein opens up again.
'11 Lynskey Cooper CX, '00 Hillbrick Steel Racing (Total Rebuild '10), '15 Cervelo S5

vosadrian
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Wed Apr 11, 2018 11:25 am

All the best with your recovery Queequeg! I don't plan to hit good form at the moment if ever. Just enough to commute to work and do some fun social rides at the moment. Hopefully some miracle happens and my issues go away and then I would plan my big comeback!! :D
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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Tue Apr 17, 2018 2:19 pm

I threw myself sideways off the TT bike at 16kph this morning when the chain skipped on the cassette. My first actual ride of the TT bike since before surgery...

Elbow, knee, sore ribs - but my back is no worse! Hence avoiding a difficult conversation with The Minister for Finance, Household matters and & Health services.

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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Thu Apr 19, 2018 1:12 pm

Ouch RhapsodyX.... be careful mate! Don't set yourself back months with a fall! Maybe stick to the road bike!!
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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Fri Apr 20, 2018 8:15 am

It's all good - I was back on the roadie the next day to deliver replacement first aid supplies to my coffee shop. A few sore spots, and it only hurts when I breathe deeply. My wife is non-too impressed though, and my physio reckons the ribs & shoulder area are going to be sore for a while.

And... physio has noted that my left glute is visibly smaller than the right, and it's the left side that often says "enough!" these days. Yet, left/right power balance on the bike is still pretty much the same (47/53), and on efforts it goes to 50/50. And even though I feel like my life is on hold, possibly never getting back to some semblance of what I consider "normal", he reckons I've actually made more rapid progress than he expected.

RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Mon Apr 30, 2018 10:03 am

Onto the serious exercise/core stuff now. School holidays gave me a lot more flexibility with my time, so I got out more to try things out. 250+km cycling last week, mostly without side effects. I'm very weak down the left hand side, glute exercises and side planks really show up the asymmetry - which the L/R power on the bike doesn't. I'm still not doing any serious hill work, but I am doing some VO2/MAP level efforts from time to time. Basically - all going well.

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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Mon Apr 30, 2018 11:23 am

Physios etc. tell me my right leg muscles are noticeably more developed than left, but my power meter typically reads within 2% of 50:50... mostly being bang on 50:50. Also the other cycling dynamics parameters are very close left to right.

I think I am fairly quad dominant in my cycling and the muscles that are different in size are glutes/hamstrings which I do not use much in cycling. I am trying to strengthen the glutes at the moment, but I think for me it is more than strengthening. I have to teach myself to activate them for normal activities as I think I largely have learned to use other muscles instead.... in fact I think that could be a large part of the cause of my issues.

I am currently seeing a Chiro (that works more like a Physio) that does Active Release Technique... That is why I wanted to see him as that technique has a lot of success in lengthening hamstrings. But so far we have only been doing release and strengthening work to address a twisted pelvis. I don't feel I am making any ground, but only 2 weeks so far. I feel once again like I am doing the same things that have been unsuccessful in the past. Would really like to find someone with a proven track record in fixing pelvic muscle issues, but not having any luck. My hamstrings are ridiculously tight, and I am not sure if that is a cause of my pelvis issues or the other way around. I initially went to this chiro to address the hamstrings to find out, but it has not gone the way I thought it would.
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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Tue May 29, 2018 1:41 pm

Still not dead. I'm pretty functional these days, unless I (1) over-do it or (2) make the mistake of trying to rotate the spine. I'm back at about 80% fitness (FTP 310 down from 370W)... and I've decided to be happy with that. I try and get two short HIIT sessions (seated repeats at > MAP) and two LT1 longer rides a week, along with as many pool sessions as I can squeeze in and daily core work. Still no TT bike as yet, I just can't get my head around riding in that position (fear factor).

It's pretty good as long as I'm not stupid, but it only takes a bit of sitting the wrong way or a bit of rotation before I end up with numbness/tingles in left leg or both legs. The core work has really shown up the weakness on the left, even if the L/R power doesn't. But I can see the (smaller) light at the end of the tunnel now.

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Re: Where to next? (Medical practitioner question)

Postby foo on patrol » Sat Jun 02, 2018 8:30 am

8)

Foo
I don't suffer fools easily and so long as you have done your best,you should have no regrets.
Goal 6000km
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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Mon Jul 09, 2018 1:03 pm

Still alive, but some of the muscles in the calf don't fire properly so my left foot rotates outwards if I try and engage the calf muscle when climbing. Float has been locked out, so now I have to re-strengthen the VMO because I've allowed it to de-train. And the left side lower back is still weak - it's a lot closer to the right side than it was, but on the left I can only to a plank to the knees as going to the feet causes instant pain (and not down the leg).

And the left side nerve is still trapped, despite surgery - I still fail the "slump test". But it's only triggered if I rotate at the lower back when I've been over-doing it. And apart from numb toes on the right foot, no real sign of the bone spur.

I highly recommend daily core strength activities. Stuart McGill is my go-to.

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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Fri Sep 21, 2018 10:27 am

Well... the challenge for the Physio was the AG Fondo 2018. I rode in Rec 2, kept it easy and completed in 4:02 after stopping for food and a nature break. I'm classed as DNF because I lost my timing chip coming down from Tanybryn, but my time would have put me around 50'th fastest out of 1,022 male finishers for Rec. The only time I drafted was between Deans Marsh and Forrest, and truth was I could have ridden faster on my own, so apart from energy conservation it wasn't an advantage.

The left leg balance is still down (47/53 instead of 48/52), but apart from the weaker leg and numb toes... it's pretty good these days. I call "really lucky" - I didn't think I was going to come back from the level of impairment. The left calf/ankle is still weak comparatively, but not enough for me to notice unless I'm walking fast or doing calf raises - but I still move faster with a walking stick. But I won't be doing the next editions of Bowral or Orange - "bridge too far" at this point.

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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Fri Sep 21, 2018 2:35 pm

Well done RhapsodyX!

The main thing is that you are happy and satisfied with the progress you have made. That you can be competitive in competition is icing on the cake.

My situation is that I had surgery to remove a small (benign) tumor on my Sciatic nerve in late Feb. I started riding at a low level about 2 months after that. The surgery was worthwhile because it did dramatically improve a major symptom I had in that leg where I would get fairly intense buttock pain that radiated down the back of that leg that was aggravated by cycling. If I did too much it would limit me as the pain got too much. Now that symptom is mostly gone. I can also stretch that side hamstring better and with less radiating pain. However all my other symptoms are no better, and some have progressed worse (but probably nothing to do with the surgery). Also, the actual surgical site is still very tender and sore despite being over 6 months after surgery. They cut deep into the glutes, so I expect it could take years for that to improve a lot. Currently very hard scar tissue in there. I foam roll it, but not sure if that helps break it down.

Lately, more central pain around the middle (laterally) of my lower back has been troubling me. I have been getting into riding again working up to around 250kms a week. Last year the limiting factor was the left buttocks/leg. This year it is my back. There is a limit to how long I can ride before the back pain is unbearable. I have made some ground though. Some changes to bike fit have helped to try and lessen hip angle, and also think the increase in cycling is adding strength in the area, and it is gradually improving (can go longer before unbearable). I could probably push myself to get through a 100k ride if I managed it well. I am riding OK... at about 90%. I have achieved 10 min powers within 5% of my best, and I am aiming for some PBs on some 10 minute climbs near me this season. I am about to take a week or two of rest as my left anterior knee is a bit sore. Think I ramped the training up a bit quickly. I was working towards a race that was this morning (first race in years), and I did OK in that so now a bit of recovery time, and then build up to peak in summer.

In the meantime, I have tried a number of treatments that made no noticeable difference. Actually mostly it was testing. I went through a suite of tests around various neural disorders. They all came back clear, but the lumbar puncture really knocked me around. Severe headaches when I was upright for several days, which then cleared so I went for a slow ride with my son, and developed a niggling headache accompanied by fuzzy sight and weird skin sensation on my scalp that lasted for around 6 weeks (but varied with intensity). The end result of that was that the Neuro thought I had Lumbar Sacral Plexopathy. This is basically saying the nerves of lumbar-sacral plexus are irritated by unknown cause. One possibility was autoimmune, so I was on a 3 day infusion of high does steroid. That knocked me around a bit also (and was when I was also suffering after the puncture). Again, there was no benefit... so I probably don't have a autoimmune issue... or the damage is done and can't be recovered.

So now I start in a week with a new physio and I expect this will include a back extensor strengthening program. This physio is pretty big into a piece of equipment that can isolate the deep back extensor muscles for strengthening and also strength testing. I have done lots of core strengthening in the past with little benefit, but mostly abdominal core. I have done little with the deeper core muscles on the back of the spine which is closest to where my pain is and also where my scans show issues. I like the idea that they can rate my strength there and compare it to what it should be and monitor progress as I attempt to improve strength. At least I will be able to know if core strength in that area is an issue for me even if it is not contributing to my other issues. Another attempt and fingers crossed for a positive result for something for a change.
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Fri Sep 21, 2018 4:37 pm

vosadrian wrote:This physio is pretty big into a piece of equipment that can isolate the deep back extensor muscles for strengthening and also strength testing.


which piece of equipment is this Adrian?

not this?
https://www.ebay.com.au/itm/Chattanooga-Stabiliser-Pressure-Biofeedback-by-Chattanooga-Shipping-Included/183300024788

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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Fri Sep 21, 2018 6:54 pm

CKinnard wrote:
vosadrian wrote:This physio is pretty big into a piece of equipment that can isolate the deep back extensor muscles for strengthening and also strength testing.


which piece of equipment is this Adrian?

not this?
https://www.ebay.com.au/itm/Chattanooga-Stabiliser-Pressure-Biofeedback-by-Chattanooga-Shipping-Included/183300024788


MedX?
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RhapsodyX
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Re: Where to next? (Medical practitioner question)

Postby RhapsodyX » Fri Sep 21, 2018 7:00 pm

vosadrian wrote:...
So now I start in a week with a new physio and I expect this will include a back extensor strengthening program. This physio is pretty big into a piece of equipment that can isolate the deep back extensor muscles for strengthening and also strength testing. I have done lots of core strengthening in the past with little benefit, but mostly abdominal core. ...


Hi Adrian - good to hear you are also making progress. I'd be cautious about concentrating on the back extensors, some of the research found an association between excessive strength in the back extensors (when compared to the abdominals) and LBP in cyclists - muscular endurance was also lacking. I concentrate on the side planks and abdominal crunches, I still do back extensors but make sure I'm working on endurance (efforts under ten seconds) not strength. With the planks, I'm still noticeably weaker on the left - but as time goes on I can do more and more reps.

I'm still only at about 85% of where I was before, but it's still fun to be able to ride people off my wheel.

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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Fri Sep 21, 2018 7:25 pm

vosadrian wrote:
MedX?


ah, Nautilus Mark XXIII
It's big on the Gold Coast.

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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Mon Sep 24, 2018 9:33 am

CKinnard wrote:
vosadrian wrote:
MedX?


ah, Nautilus Mark XXIII
It's big on the Gold Coast.


Is it good?.... seems to isolate the pelvis so it can work extensors without using glutes etc.

I have spent a fair bit of time in the past (but not much recently) doing planks (front/side), and I was fairly strong in that area but not much benefit to my back pain. I have not really done any work on the extensors. I know I have instability in at least one level of my back (L4/5), so I would like to put some effort into the deep core around it (Multifidus?) to see if I can get some stability.
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CKinnard
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Re: Where to next? (Medical practitioner question)

Postby CKinnard » Mon Sep 24, 2018 10:47 am

I am not familiar with all their new pieces. It's worth a try for 6 weeks.
Personally, I prefer exercise a client can do anywhere, anytime.
There's not many exercises that cannot be done this way.
Some considerations for after you finish the MedX program:

- planks are highly overrated.
Alternatives I use for core (semispinalis, multifidus, rotatores):
- wheel barrow racing (seriously)
- ab wheel (form is important)
- push ups work the core better than planks, especially a dive bomber pushup.
- hanging knee raise with knees lifted to the side
- standing or sitting cable pulley (or resistance bands) emulating a tennis backhand and forehand stroke. (form is critical for this and has to emulate the stroke of a gun tennis player).
- russian crunch

stretch
- standing or sitting segmental side bends and rotations for the whole spine with 20kg bar or dumbbells (form critical).

non core
- 1 and 2 legged trunk extensions in frame
- bilateral and alternating leg extensions
both these can be loaded beyond bodyweight.
- L-seat (gymnast form)

higher level gymnastics
- flag pole
- planche
- front and back scale
- split progressions would be good for you too

1. stretching and strengthening is critical for the lumbar facet joints in regaining and more evenly redistributing mobility between facet joints. The most pathological segments are usually stiffer.
2. these also help better re-model and improve fluid turnover to discs and spinal cord meninges, and stretch any neurosensitive adhesions.

Results depend on pathology. These exercises may still give mild relief for stenosis, especially if there is a spondylolisthesis or adhesions.

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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Mon Sep 24, 2018 11:15 am

Thanks CKinnard!

I am highly motivated to do exercises, but often lack the ability to assess my form when doing them so try to do them right but often wonder if I am doing them right.

I will try the physio who I assume will test me with the MedX equipment. I like the idea that it can assess you against norms for my demographic. Maybe I will find I am already very strong and with good endurance in that area and therefore further development would be a waste of time. Further to that, the machine maintains form and can measure progress giving me metrics to see if I am heading in the right direction (as an engineer, this is appealing to me).

There seems to be a bit of research out there suggesting a correlation between extensor weakness and low back pain, and further to that, training of the extensors yielding reduction in pain.... but that is for general population... not cyclist specific. I suffer pain 24/7 and have had cycling breaks of up to 6 months without getting on top of it, so I think the aggravation by cycling is incidental rather than being root cause. The suggestion in research I have read is that extensors can be strained and then lose activation so then become weak and not recover properly even when the strain has recovered.
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Re: Where to next? (Medical practitioner question)

Postby vosadrian » Fri Sep 28, 2018 9:46 am

So I went to the new physio and he seems good. He is the first physio I have gone to who has said that my issues are in my back and not my SI joints or hip muscle imbalances or something like that. I am not saying that he is right and the others were wrong... but I need to try something different since I have not had success with the other approaches. This is also what CKinnard has been saying to me, but I have had trouble getting someone locally to treat me in this way. So now we will see if there is benefit in this approach!

He did some assessment and found me tight in hamstrings (as I know) as well as lower back and left hip. Did some work on mobilisation of these areas.

Finally onto the machine which is the same as this: https://informfitness.com/gym-manhattan ... chine-nyc/

This machine locks down your lower body from the pelvis down so you cannot move (though can still push against the foot plate). It allows you to bend at the lower back and can apply varied resistance electronically and can measure the force or torque you can apply. The first step is to test you. For this you go to various angles from flexed to extended and measure how hard you can push. This seems to go against everything I have learned about protecting my back which talks about lifting with the legs rather than back, so it feels like I am about to break myself but I get through it. You basically apply as much lower back extension force as you can pushing against the support for your back and neck/head. The end result is a graph of your effort verses angle which they can then compare to graphs of average people of your demographic. It turns out I am very weak (unsurprisingly I guess). Thye had a graph for lower 15% of my age, and I managed to touch it in a few places, but was generally below it. This actually surprised me. I am a reasonably high level rider who stays fit even when not doing much riding. I do a fair bit of walking and use a standing desk at work. I have done a fair bit of swimming in the past. Yet, I was weak compared to my average age group.... not the average athletic type.... the average person including those who are obese and do no exercise. Now of course there is a possibility the data has been furnished to make a point I guess. A friend of mine who recommended this physio uses the same machine and trains (2 minutes or around 20 repeats) at a higher level than my max torque I could push at for a few seconds.

Anyway, that done a plan is made to strengthen. We want to get me to above average for my age and see if that helps my symptoms. The machine can be setup to do repeats at a specified resistance torque. For me we run at 40% of my max with the plan to increase this over the next few weeks. Hopefully we get to a point where I have significantly increased the strength there and we will be able to measure that. If I do this, the hope is that the back pain and hopefully radiating pain will improve. Time will tell!!

I am pretty sore today. I felt fine when I walked out, but the muscles have been getting sore since and seem to plateauing now around 24 hours after the session.
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