Time flies when you’re having fun, but for a cyclist with back pain it can stretch out for what seems like forever. It’s now a year since Phil came to me for a bike fit to try to resolve his back and leg pain, and seven months since we started consistently working on corrective conditioning to get to the bottom of the problem. I know this sounds like a long time, but with chronic musculo-skeletal problems, it can be a long road to recovery, which is why I’m inviting you to follow Phil’s story in real time here. If you haven’t read the first installment, have a quick catch up: http://jomcrae.co.uk/just-an-ordinary-bloke-who-wants-to-ride-his-bike/

Being forced off the bike because of injury is every keen cyclists’ worst nightmare. Weeks can seem like months, and lack of progress can be depressing and feel terminal. Chronic and persistent back pain (as opposed to pain due to an isolated ‘incident’ of onset) has usually taken years to develop, and consequently may take months to fully resolve. For some, a serious back problem may seem to appear quite suddenly like the titanic iceberg on the horizon. But in truth, most cyclists who end up in trouble have ignored and normalized minor symptoms like stiffness and back ache, whilst progressive changes move their body towards a potentially bigger disaster. Let’s face it, for many cyclists as long as they can swing their leg over their bike, they will happily ignore everything else for as long as possible.

I’m used to working with and around chronic problems and often am called upon when therapists and bike fitters have no more to offer. While I enjoy the challenge of tackling long term issues, to be perfectly honest, at the outset even I do not relish the first six months of us working together.

People in pain can be difficult, and I understand why. They panic easily, are often depressed, and want to see progress as soon as possible, so I empathize with their frustration whilst brainstorming, reviewing and reworking to try to find our first steps forward. I have learnt from experience that the first 6-9 months is a process that requires close monitoring, dove-tailing with therapists who can help with acute pain, and adjusting the clients understanding and mind set to the issues they are tackling.

Using a pain diary with a simple score out of 10 is a good way to monitor trends in pain and problems

A pain diary is an essential tool in my arsenal of assessment with this type of client. Just as a training diary provides valuable feedback for any athlete, a pain diary can help to track and trace provocative and alleviating pain factors, raising our awareness about what the key lifestyle elements are in each person’s situation. My exercise programs in these cases are a prescription for movements that will help, but also guidelines as to what should be avoided. Even when a client is following an almost daily program from me, it’s hardly surprising that the stuff of life that happens for the other 15 hours a day needs to be managed and adjusted too.

Although I’m often quite explicit about what not to do, most clients accidentally provoke pain several times doing something habitual in their normal day before they realize how important it is that they avoid it. For me, the pain diary is what allows me to point out the pattern of provocation, as well as ensure there’s not something in my exercise program that is causing problems.

Unexpected things can crop up in daily life that provoke the problem. These need to be identified and avoided for overall progress to continue

For Phil in the first few months there were several such incidents that set him back in the short term. The first came around Christmas when he bent over to lift a heavy reptile tank (for pet lizards). The second significant trauma came when he had to manually force a train door shut as part of his job as a train driver. Both movements required levels of strength and core control well above Phil’s current conditioning status which worsened his lower back and increased the nerve pain into his buttock and down his leg.

Unsurprisingly for a disc pathology the most provocative thing for Phil is sitting down for prolonged periods. Cars are often the worst because of their slumpy seats, but the theatre, the cinema, and the various seats on various trains all caused problems. From his diary Phil could even identify which of the trains he drives offers the kindest driving position for his back.

The most drastic news that Phil’s diary delivered was that even the small amount of cycling he was doing (commuting to and from work occasionally) made his back pain worse. It helps me a lot if a client can come to this realization themselves because of their diary, rather than by my suggestion. Proof if ever proof was needed that Velominati Rule #5 is not always the answer.

And so, for a period of about 6 weeks Phil didn’t turn a pedal, and for three months between February and April he didn’t get out on the road at all. At around this same time, I had my first chance to properly review the impact or otherwise of the exercises that were on my programs, and slightly change tack. One or two had been provocative and so we had made an adjustment, but there had also been some complications from medical interventions – including a steroid injection and several weeks taking the prescription anti-inflammatory Naproxen.

Since our change of program at the beginning of April, Phil’s back pain has stabilized to a daily 3/10 (with no pain killers) and normal life has become easier and more manageable. He continues to stretch every morning and complete two strengthening programs of about an hour each week. Pleasingly bike riding is back on the program, with some controlled 30 minute turbo sessions, and some 60-90 minute light road riding. Phil also enjoyed a few days of riding trouble free in sunny Spain during the half term holidays, which was a real landmark.

So for now, we are both happy with progress and proceeding with caution. Some stability is welcome, even if Phil is not yet completely pain free. Integration of more cycling will depend on the next few months, but at least during the summer Phil will be able get out for a bit of fresh air in the warmer weather. And the work away at exercise, the further away Phil moves from the surgeon’s knife.