Archives for April 2018

I’m in the process of recovering from a nasty injury. Why am I telling you this? Because shit happens to everyone, and I thought it might be useful to you to see how I deal with it. This is not my first training injury, and I’d be very surprised if it was my last. My basic approach is the same as for training when sick: fuck it, but don't poke the bear. It boils down to a few key mental principles applicable to most difficult situations, and a couple of guidelines for treating the actual injury, which are applicable to most injuries.

Before we take a step further, while I am technically a doctor now, I’m not a medical doctor. And even if I were, I’m not your doctor. So this is what I do, what works for me, in case you might find it useful or interesting. Do not under any circumstances mistake it for qualified medical advice.

In the course of writing this article, I formulated the principles that I'm following to get through the problem. They are:

• Keep gently moving (I’ll expand on specific treatment too)
• Keep a sense of humour (even when you can’t pull up your trousers)
• Fear is the enemy (much worse than pain)
• Use professional help (it’s often worth it)
• Get back on the horse (because fear is still the enemy)
• Perspective (viewed from the right angle, even severe injuries aren’t that important)

So, what happened?

On Monday January 29th I was in the gym, and managed to sprain my back doing a hex-bar deadlift. (A hex-bar is a weights bar in the shape of a hexagon, which you can step inside of, and lift like picking up two suitcases. You can see the lift discussed and done here.) It was one of those situations where there were no obvious mistakes: my form was correct, I'd prepared properly, I was paying attention, it was a weight I'd lifted before, but for some reason my right thigh declined to take its share of the load half way up, and so the whole lot came onto my lower back. Ow.

I hobbled home, took some ibuprofen, and not to my surprise could barely get out of bed the following day. Major ow.

The injury is on the right hand side of my lower back, between my hip and my spine. When I very carefully levered myself out of bed on January 30th, I ran through some range of motion tests, and found that I could do just about everything except bend forwards. Normally, I can lay my palms flat on the floor with locked-straight legs. Now, I could reach approximately one inch down my thighs.

Keep gently moving

This is a musculoskeletal sprain, in which there is some damage to the muscles, but also to the soft tissues (ligaments and/or tendons). This sets my expectations, and my approach. Using agony as a useful guide to whether a motion was a good idea or not (if it causes shooting pain, don't do it), I gently kept moving for the next few days, and the spasms eased off, and by the Friday (2nd Feb) I was able to go up to London as planned to see a friend. At the weekend I ran some errands, and even managed to drive (though driving was unpleasant). I was taking about 400mgs of ibuprofen three times a day, to limit the inflammation, and doing very gentle range of motion exercises to maintain flexibility as much as possible without aggravating the injury. Pain can be a learned response, a habit. ‘Doing this movement hurts this way'; the pain becomes associated with the movement, and it can persist long after the initial cause for it has gone. So it's really important to learn to move without the pain, and to break the connection as quickly as possible, which is done by doing the movement right up to the point just before the pain starts, and gradually pushing that range of motion further and further without triggering the pain response.

The specifics:

1. Keep moving as much as possible, but be gentle and attentive about it.
2. Rest often. Many short sessions, punctuated by many rests, is better than long sessions that induce fatigue.
3. Regain range of motion before adding weight. It’s critically important that the injury site is returned to a reasonable range of motion before you add weight to the movement. When you have an injured spot, your body will tend to immobilise it, so your range of motion comes from other areas. I think of regaining mobility like making a bow. The idea is to avoid stiff spots or hinges, so the stress of the draw is evenly distributed along the limbs. If the bow hinges at any spot, that’s where it will break. I really don’t want to acquire a compensating over-flexibility next to the stiff area in my back. So I have to be very careful about locating the motion in the correct place.
4. The timeline for soft tissue injury is at least 9-12 months for full recovery of tendons and ligaments (because they have a very poor blood supply, as they are not very metabolically active). So I will be taking this injury into account in my training for at least a year. Once the worst is over (which it already is) that just means paying attention to the area, doing exercises to build strength there, and retain mobility, and watch for signs of strain. Muscles heal in 3-6 weeks, usually, depending on how badly they are damaged. Muscle damage doesn’t worry me, I only have to make sure that I don’t trigger protective spasms which will slow the process while I stimulate the ligaments to repair themselves.
5. Breathing and meditation. What, you didn’t think I’d forget about breathing, did you? The best ally you have in healing is your brain. By focussing attention on the problem area, you can persuade your body to send resources to it. I do this by breathing into the area itself (in this case, as if my breath is inflating my arse. Great image, huh?), and by simply sitting (or for the first few weeks lying down, because sitting aggravated the problem) and paying gentle attention to the injury. Not interfering, just noticing.
6. Medication: no more than two weeks of continuous painkiller use (for me); I can go back to them if needed after a week off. Anti-inflammatories work best if they build up a bit in your system; they usually take a few hours to work their magic. So taking them on rising, on going to bed, and maybe once more during the day, is much better than taking them when the pain happens to peak. I am also using my magic medicine (lotion from a kung-fu instructor) which is great for bruises and sprains, and for pain control, ibuprofen cream on the sore spot. I also found this “Advance 7” cream to be really effective (thanks Sam!).

Keep a sense of humour

Monday morning, Feb 5th, I woke up, moved an inch, and regretted it deeply. Somehow during the night the injury had gotten ten times worse. I lay there with a full bladder, and seriously considered not getting out of bed to get to the bathroom. My wife was away and the kids were in bed, so there was nothing for it but to keep everything as still as possible, while nonetheless getting out of bed onto the floor, from the floor to upright, and making full use of the walls and doors, get to the loo. That done, I woke the kids, and told them they'd be walking themselves to school. Bless their little hearts, they had no problem dressing, getting their own breakfast, and getting on their way. I called the doctor just to check that I didn’t need to go into A+E, and he confirmed that this was common for a back sprain, and told me what symptoms to watch out for (e.g. nerve pain radiating out, or numbness) in case it was something worse.

I was faced with a problem of needing to keep moving, a bit, to prevent everything seizing up completely, and yet every movement creating blinding pain. My solution was to dose up on a bit more ibuprofen, and watch Altered Carbon on Netflix; 45 minutes or so of lying down, then get up at the end of each episode and move a bit. Work of any kind was out of the question, as I couldn’t be in an ergonomically acceptable position to use the laptop (standing or even sitting) for more than a few minutes. And the last thing I needed was to bugger my wrists by typing lying down. Also, the pain was too bad for the kind of work reading I need to do (the kind where you have to pay close attention to something that is not particularly gripping). So no work for me! I did manage to shepherd The Theory and Practice of Historical Martial Arts through layout and into print, but that was it.

The next day was about the same, only worse. Sat on the loo, ready to get back up, I tried to reach down to snag the hem of my trousers between the extended tips of my fingers to pull them up, but it caused a spasm of pain so bad I nearly passed out. I managed to lever myself up, and shuffle to the bedroom and lie down on my side on the bed, and bring my ankles back towards my arse; once there, I could snag the trousers, and pull them up. Picture the scene. I did, and it was bloody funny. Dignity can go fuck itself.

Really. If you'd been there, and had your empathy circuits temporarily removed, you'd have been laughing your arse off. Creating a little distance between the agonised carcass you live in, and the you that's there to notice it, makes handling the injury easier. It's a bit less personal. Most comedy revolves around pain of one sort or another- why not your own?

Fear is the enemy

It would be easy to imagine all sorts of horrible futures in which the injury is permanent, I'll never swing a sword again, all that terrifying shit. But it's also possible to imagine a future in which the back injury is a funny story about events long passed. Focussing on the worst case scenario is borrowing trouble that hasn't happened yet. How mobile I used to be, and how mobile I may become, are both irrelevant. The only thing that matters is how mobile I am now, and what I can do to make that better. Banish ‘if only' statements. “If only I'd stopped one weight earlier”. “If only my back didn't hurt”. And so on. They are useless bullshit to be eradicated. It's perfectly possible to make yourself miserable by grieving for an imagined future *that might never have come to pass*. For all I know, by staying home for a few weeks I may have avoided a fatal car accident that would have killed me had I not been too injured to drive. There's no way to know, so speculation is futile and counter-productive. If you must project into the future, make it positive. “I will get better” or, “even if I don't get better, I'll be fine; I can cope.” But it's much better to just deal with the current situation without judging it relative to past or future.

For me at least, Pain ≠ Suffering. Pain + Fear = Suffering. I can’t avoid the pain, but by eliminating the fear, there’s no suffering. I'm fine, it just hurts.

Gradually, being careful to limit my painkiller intake, and keeping moving, and doing as much of my usual training routines as the injury allowed, it got better over the course of the week— and Altered Carbon was awesome. I probably wouldn't have got to watch it otherwise, as my wife isn't into that sort of show and we usually watch stuff together.

After being on painkillers for two straight weeks, I decided to come off them and just live with the pain. I really don't need a painkiller addiction, nor the kidney or stomach issues they can cause. Two weeks to the day after starting to take them, I stopped.

Get professional help

The following week I was still stuck in the house, unable to walk more than a few steps, or drive at all, pretty much until the weekend, when I had a seminar to teach on the Sunday. Doctor Theatre took over, and the seminar was fine, but it was a stretch and I was very careful not to demonstrate more than absolutely necessary. Progress continued slowly but surely for the next week… Then on Monday 26th February when I woke up my lower back was sore but still getting better, but my neck had seized up. This was not surprising, as I have such a long history of neck issues, and the back injury had prevented me from doing the full preventive routines.  By being super-careful, I didn't make either problem worse, and on the Wednesday I was well enough from the chest down to walk, and so could get out of the house and to go see an osteopath to fix my neck. It took three sessions over the course of the next couple of weeks, but by the second week of March, I was pretty much back to normal.
There are professional services that can sometimes help. Use them.

Also, I bought a pair of those nordic walking sticks, that make you look like you forgot your skis. I was a tad dismissive of them in my previous post, but damn, they make a difference. After having them for a day, I was already able to walk further without hurting my back, and then had a chance encounter with a friend who happened to know how to use them properly and taught me the trick of it. Hot damn, it’s like you can push yourself forwards even when your legs are knackered. Now I use them everywhere I go (despite the constant ski references). I exchange knowing nods with fellow un-embarrassable stick users, and indeed with stick-wielding pensioners. The only really odd thing about them is that I've never caught myself using them in a sword-like fashion. Normally, any long object in my hand gets automatically converted into a sword, but for some reason, these haven't. Maybe it's the hand grips.

Get back on the horse

By gradually increasing the amount of exercise I was getting each day, and being strict as hell about my spine maintenance routines, I was fit to go back to the deadlift on March 16th.

“WHAT???” I hear you cry. “Are you mad?”

No. When I say back to the deadlift, I mean *just the bar*, a very careful single rep to check out the system, a couple more because it was ok, then a few more pulling from the rack (so the bar is held up off the ground). Other than that I did some bench presses, pull-ups, the usual, but all still quite light, and well “in the pocket”. The critical point was getting back on the metaphorical horse; interacting with the bar again to re-learn that it's a tool for creating strength not injury. Since then, I’ve built it back up to nearly half of the weight that I was lifting when the injury occurred. I’m in no rush. I think it's vital for long-term psychological health to get back on the horse.

I had a similar injury some years ago doing kettlebell swings with my 24kg bell. It turns out, after careful examination of the evidence and my experience, that kettlebell swings and my spine are just not made for each other, so I don’t do them any more. But I do do clean and presses with the bell, Turkish get-ups, and similar. I’ve rehabilitated the equipment, but learned to avoid that specific exercise with it.

Perspective

My final thought on this is perspective. I don't view my training goals in increments of weeks or months; I usually think in terms of two to five years. In any five year period there will almost certainly be periods of at least a few weeks where training is impossible for one reason or another. Flu. Injury. Family crisis. Something will come up. But even a major setback is unlikely to take me far away from my long-term goals.
This graph shows the US stock market over the last century:

My back injury is like one of the dips. Shitty to live through, but even the monster crash of 2008 bottomed out at a higher point than the best of the 1960s, and recovery was pretty damn fast. An injury like this, handled right, is just a blip.
This analogy only holds good up to a point: the human body is much less resilient overall than the stock market; its 100 year old self will never outperform its 20 year old self. A body is easy to permanently damage or destroy. I have a friend who has had to quit historical swordsmanship after 20 years because of damage to his knee- he's right to put his health over the Art, and my heart breaks for him. But my point about perspective stands; by viewing my progress over a long enough time span, I don't have to worry about short-term dips like the one I'm just pulling out of. This perspective is also very useful for maintaining a sense of humour.

In the grand scheme of things, my back is the very tiniest of tiny problems. Yes, when the spasm hits it seems to take over the entire world, but that’s an illusion caused by faulty perspective. To put it another way; I’d trade my kids being healthy for my back being fucked any day of the week. On the same day that my back took a turn for the worse (February 5th) two people I care about died. My mother in law Bridget, age 79, after years of ill health, and my friend Hugh Hancock, age 40, with a heart attack out of the blue. Compared to this, a sore back is a minor temporary inconvenience at worst.

You may recall I'm doing a 106km walk on the first weekend of May; the Isle of Wight Action Challenge. This injury has royally fucked my training program, of course. But it has given me at least one very useful practice: keeping moving despite severe pain. I wouldn't be surprised if, around kilometre 90, that's a more useful ability than simple fitness. I’m doing the walk in aid of Room to Read, a charity promoting education in the developing world. If you’d like to support it, please go here and be generous!

To sum up, those points again:

• Keep gently moving
• Keep a sense of humour
• Fear is the enemy
• Get some help
• Get back on the horse
• Perspective

They serve me well: I hope you never need them, but in case you do, I hope they serve you even better!