Ursula was sent to me by a colleague.
They were old friends and he had been trying to help her with her back pain for a few months.
It can be very challenging treating friends and family. They know your quirks and foibles.
The time you fell over with a glass of wine in hand can help pierce the veil of ‘guru’ and take away from your perceived expertise.
So even though this colleague is one of the best practitioners I know he had experienced a few problems helping Ursula understand what was occurring.
Ursula had been suffering low back pain intermittently for 10 years.
When it came on it was extreme, severe and crippling. She would be laid out for a week or more, horizontal and glued to Netflix (or VHS depending on the year we are discussing).
She had been seeing a practitioner through those bursts and he would crack her back, massage a few things and then tell her to come back in a few days.
This would repeat for a while and then as Ursula started feeling better they would space their appointments out for a month at a time.
The practitioner told her her disc had slipped and because she had a weak core it kept slipping out.
Ursula would be given exercises and she would do them for those periods of time when she was sore. However like most of us, as she started to feel better the exercises would drop away.
Who Is She?
For the majority of her adult life Ursula had been working as a manager in the high end dining scenes of Melbourne and other cultural capitals.
High stress environments that encourage the work-hard play-hard attitude.
Ursula was in her early to mid 30’s and like many within these environments, especially for those with strong intellects and broad interests, she started to tire of the lifestyle and began looking for something else.
Two years before presenting to our clinic Ursula moved into managing a large and very successful health clinic. The business was owned by her friend, the very same friend and colleague who sent her to see me.
Her sleeping habits improved, her stress levels nosedived and her exercise routine was rediscovered and revitalised.
More specifically and importantly, she was doing pilates 3-4 times per week. Even with that rigorous schedule she would still have to see her rub-and-crack practitioner regularly for that “weak core.”
One other thing popped up in her history. The previous two years had seen a number of close friends and family die. Due to privacy I will not discuss this further but bear in mind that this plays a large role in the amount of stress that Ursula was under.
What She Thought Was Going On
Ursula knew a few things: her back was in a really bad way, it had been for years and was likely to get worse. The discs were bulged and in dire straits. Due to the weak core she was unable to stabilise them.
Several months before seeing me, my friend and colleague vetoed the maintenance rub-and-crack treatments. They weren’t working to prevent or alleviate the nature of her pain.
He spent time working on her strength and fitness as well as her perception of pain, what it is, how it works, why it is useful but why it can also be a bit skewed.
Delivering pain science is hard at the best of times. It runs contrary to how many of us would intuitively think it to work.
Pain equals damage is what we are taught from a very young age.
But it’s not.
Pain is equal to the brain’s worry about an area.
How Did She Interpret It?
No matter how many great resources Ursula was shown – videos, books, youtube clips – she interpreted the info to mean that the pain she felt in her back was all in her head.
So is everyone’s.
Pain is a projection of the brain’s worry about an area.
The level of the worry is equal to the level of pain you feel.
The influencing factors include information from the area concerned, in this case, Ursula’s back.
However they also include the information she had been told in the past.
“Disc injury.” “Slipped Disc.” “Weak Core.” “Instability.”
The same disc injury that she had determined to be happening over the last 10 years. The same injury that was never going to get better.
Stress. Work stress, family stress, close friends’ deaths. Stress doesn’t cause pain but it does act as an amplifier of worry.
Worry equals pain. So an amplification of worry amplifies pain.
And just to quickly clarify for you the reader, discs cannot slip, where would they slip to? The shops to buy some milk? No they can become irritated like any other part of the body and similar to any other part of the body they recover with the right treatment regime.
The Movement Problems
After establishing the history and working through a few misconceptions it was time to watch how Ursula moved.
She absolutely refused to bend forward. She could rotate, she could lean sideways, but bend forward? No way.
Why? She was afraid she wouldn’t get back up afterwards.
Adding to this fear, previous practitioners had told Ursula that bending forward would aggravate her disc injuries and to be fair on them bending forward had been the movement that had irritated her in the past.
Taking all of this into account, Ursula was still able to squat with no pain.
Which if you think about it is pretty similar to bending forward.
What Was Going On?
She had had the injury for so long that her brain was super sensitive to any load placed on that part of the back.
The brain is constantly receiving information from all parts of the body and most of the time those bits of information are ignored.
Because of the issues she has had over the years with her low back Ursula’s brain is primed and ready to protect her. It is worried about that part of her body.
So whenever she does something that moves her low back too much the brain gets overexcitedly protective and stops her movement by the only way it can. Pain. And lots of it.
So What Did We Do?
We did some hands on treatment, massaged some hip/glute muscles, manipulated her mid-back and sent her on her way with some homework.
The homework was to change the way she thought about her back, especially during the pilates-type exercises that was doing.
She had to recognise that when in the pilates machines she was doing movements that her brain would over react to when she was standing upright.
Moving beyond physical symptoms, Ursula was also fighting an inner voice that constantly warned her about her back, worrying her and preventing her from going about her daily life.
In an attempt to use a metaphor or an analogy to combat her inner voice I said “Imagine there is a little gremlin in the back pocket of your brain.
Every time you have a worry or a fear or a “I shouldn’t do that” thought, think of that vigilant yet curmudgeonly gremlin and to tell it to f*** off.”
But What About Her Core?
Let’s just remember, Ursula was doing pilates 3-4 times per week and had been for 2 years. For periods during that time she had been practicing 7 sessions a week.
This was not a woman with a weak core. It was utterly impossible that her core was too weak to control the movement of her spine.
It was just that she had to change the way she was thinking about her pilates. When doing it she had to think about the movements she was doing as preparing her for doing those movements whilst upright.
And she had to accept that it was literally impossible for someone to have done that much pilates and still have a weak core.
So How Did It Go?
Interestingly I had forgotten about my gremlin analogy when I began writing this piece. Going over the notes of our two sessions, I read in the post treatment advice portion “gremlin analogy.”
Not quite sure what it meant, I ignored it and wrote out the case above.
But as a part of this series I want to follow up with the patients that I write about and so I called Ursula to check in with how she had been going, to get her permission to write about her treatment and to see what had resonated from the sessions we had together.
Satisfyingly for me she has not had any crippling back pain in the last 2 months since seeing me.
Even better, when I asked after what she had remembered and used in the time since our consult she said she’s been telling her gremlin to F*** off regularly.
***** Ursula is not her real name but rather the name of one Bill Adamson’s favourite authors. We have chosen it to protect the identity/story of the person depicted in this case study.