On Plateaus, pain levels, success

[mmglobal]

You've seen me post on Diane's surgery blog that she had hit a plateau. This is based on my observations that she reports the same pain levels and I still see her needing to rest with her knees up because of some mild sciatic pain that is activity-induced.

The other night, we were walking Zoey to the park and I just couldn't keep up with Diane. I started asking more questions about her pain and her activities. What I discovered was that while her pain had hit a plateau, her progress had not. She was doing more and more each day. While I observed her at this plateau, she said that for the past several days, she had been out and about all day... no meds... little rest... activities increasing daily. Not much of a plateau, huh?

I've discussed with several surgeons, the theory that each patient has a pain level that they consider tolerable. The moderate their activities to keep them within this boundary. This is why some people are severely disabled with only moderate pain, while others are only moderately disabled with severe pain. Some patient limit their lifestyles because they must avoid the pain level that they can't tolerate. If the limitations are severe, they are disabled. Regardless of their pain level, they can't function well because they must avoid that threshold.

I was speaking to a client who was 5 months post-op from a very dramatic surgery. His patient story page is not ready yet, but you can see his films at the bottom of this page. This was one of the most amazing surgeries I've seen... there is much more here than meets the eye, with a wedge osteotomy to correct a deformity caused by a misshapen vertebral body. In any case, at 5 months post-op, I spoke to him and he was describing pain levels and medication levels that really gave me pause. Here is what our conversation was like:

Mark: "Ken, it sounds to me like you are describing an unsuccessful outcome. But, you were out of breath when you answered the phone... what were you doing?"

Ken: "I was out in the backyard throwing the football with my sixteen year-old!"

Mark: "Could you do that before the surgery?"

Ken: "Hell no! Mark, I was in bed 22 hours a day before the surgery."

Mark: "What is your life like now?"

Ken: "I can get out and run errands, I can drive, I can go to my sons football games, I can do things on my own, I can function so much better than before!"

My point is that clinically, he sounds the same as he was. Talking to him, we discussed severe pain that makes it sound like the surgery was not successful. But, it's a smashing success.

I'm hoping that this provokes an interesting discussion on pain vs. meds. vs. activities, vs. relative disability levels. This even goes to how the data is reported. Many surgeons have expressed frustration that they see patients who go down in the books as failures when they actually have good outcomes. What do you think?

All the best,

Mark

[dshobbies]

Interesting point Mark. It's something I really didn't even think about until I started reading and posting on forums. It never occured to me to take meds for my pain, or at least the level that would have provided me with some kind of life style. I was too afraid that activity would cause another rupture or otherwise worsen my condition. By the way, this is something else that I've also never encountered on forums. Just how much does one's activity level impact or compromise the status quo of already weakened discs? Maybe the question should be, should someone keep going if their pain is controlled by strong meds? My choice was no. I know of others who completely disagree.

[Maria]

I think I'm the opposite of what Dale is talking about as I've chosen pain management and continuing to function at the maximum that I can while on pain meds. I have my personal situation that leads me to this decision as well as just being a big old scaredy cat re failed surgery and other factors.

I plateaued (sp?) for years on pain meds until I was challenged to do more and be more than I was used to being... it was an awesome feeling to be bubbly, alive and enjoying life again.

I believe if one is more active and not in more pain, that's progress. My pain has always been what limited me. Even in terms of just pain management and plateauing I would have to say the ability to go beyond what I would normally be doing and have less or the same amount of pain is progress.

I think in terms of the musculoskeletal system and bodily organs in their response to increased activity.. even the mind is no longer at a plateau in my opinion if one is more active and actually doing *better* as evidenced by activity levels, decreased limitations and even the same amount of pain (but I would have to think it's less overall).

I'm at a mental plateau and need to move on.. the body does what it does and I go along with how I feel. Feel better, act better, move better. Feel worse, act worse, move less.

How is my body reacting to this overall...consequences of movement vs. non movement.

I'm not sure I've reached an overall plateau yet. I think that part of my body is doing much better for the wear and tear and part is not. It is very difficult for me to submit to surgery when I see myself being upright most of the day (have to avoid much sitting tho) and functional. I call this progress because of the years I spent in bed so much of the time.

My last episode that rendered me on bedrest with horrible low back spasms where I literally screamed with each movement as my low back was jolted, even with tiniest of movement was relieved with a few days rest and a shot of Toradol....

Toradol injections have become my new friend and adjunct to my drug treatment plan. Am I screwing my spine up further? Yeah, probably there's more degeneration but what about the rest of my body when I am functional??? What about my musculoskeletal system, what about my bones and the importance of being weight bearing on a fairly regular basis..

Functioning better overall with the same amount or less pain, I consider that progress.... if anything does that for me even a pain management regime I consider that progress for as long as it is. Plateau.. I reached one, I surpassed it and while I may be at one now.. I don't know which way I'll go.. backwards or forwards..

Plateauing is normal I think, sometimes I think we do not notice the progress we are making because we become mentally adjusted to a certain way of functioning or level... sometimes we're all wrapped around where we stand ...

[Firerescuefin]

In dealing with my own spine issues, I am always struggling with the amount of activity that is healthy and promotes good spinal health. I was a competitive powerlifter and firefighter challenge (competition) participant for years, then became a competitive cyclist and triathlete...before my back said enough.

I have thought a lot about this as I have been going through the experiences associated with a spine injury, and through the research I have done/ observed others doing the same. I would think that a low tolerance for pain truly works against the spine patient. See if my logic make sense:

Injury takes place - Structures are compromised

Patient guards against pain or concern of future injury - Supporting structures become increasingly weakened, putting more stress on already compromised structures, resulting in more pain/weakness/dysfunction/degeneration.

Obviously, my level/type of activity (pre-injury) was not healthy (especially the powerlifting/competitive firefighting competitions). 3 months after microdiscectomy @ l4/5 I was still in a lot of pain (both sciatic and back). This was after going into the surgery as fit as possible...and the routine core excercises that my PT had prescribed during rehab. After researching additional PT protocols, I decided to go to a PT using the MEDX machines/protocol. My initial evaluation showed spinal musculature that was 40% weaker than the average male/my age/with my bodymass. To say I was suprised was an understatement. In someone with a compromised spine, you would like to see those levels above average. Now whether that is possible would be different depending on each individual case..and obviously there is some risk that would go along with that (My PT said she had seen 1 person in the 8 years using the protocol re-herniate). I currently am testing above average, but my pain levels increased initially before they decreased due to the inactivity and atrophy. Am I pain free, not even close. Is the pain less...yes, substantially. Am I more functional...Yes. Do I feel like I have done everything in my power to give myself a positive outcome/prepare my body for something more invasive, i.e. ADR...Yes.

I guess to build on what Mark was saying....the inter-relation of the psychological (perception of pain and disability) and physical components regarding spine injury are both incredibly complex and relevant in the life and possible recovery of someone with an injury.

[mmglobal]

Interesting discussion was generated by this post at braintalk....

I just started a thread on Wolfv's supine workstation....

http://www.ispine.org/forum/showthread.php?p=3982