i held your larynx... i held your whispers of "i love you" to your newborn baby, your joyful singing in the shower, your screams of grief and pain when your grandpa died.
i held your liver... i held that time you drank too much at your best friends wedding, the remnants of your worn out red blood cells, the time you ate a special brownie in college.
i held your tibial nerve... i held the way you got up on your tiptoes to reach your daddy's neck for a hug, the grip of your toes as you sunk into the sand at the cottage, the feeling of a foot rub.
i held your stomach ... i held those peas your mom made you eat when you were young, the butterflies when you met the man who stole your heart and to whom you would give your hand.
i held your brain... i held your thoughts, your memories, your fears and joys, your consciousness, your wants and desires, all your life experiences.
i held your abdominal wall... i held your insecurity after your C-section, the soreness after those Pilates classes.
i held your fingers... i held the delicate movements as you played your guitar, the strength of your grip that reassured your brother that every thing would be okay, the best way to eat cake icing.
i held your lung... i held the struggle of the last quarter mile of your first marathon, the times you laughed so hard you couldn't catch your breath, your first inhale and your last exhale.... i held your cancer.
Thank you to those who, in death, support learning by gifting
Thank you to Dalhousie University for respecting and
Thank you for the opportunity to hold you my hands.
Okay, so this might not seem so fantastical. Let me give you the backstory.
In early 2013, I had my third flare up of low back pain. In the previous 5 years, I had two flare-ups that lasted between 9-10 months each. Wonder why I let it get to a third? Well, I was busy. I was building a practice, opening up a multidisciplinary clinic, developing curriculum, coordinating a massage program and teaching. Besides, a truckload of Robaxacet, Aleve and Advil kept me fairly functional. By functional I mean, I couldn't sit or stand for any length of time comfortably and I had the occasional searing pain down my leg. No biggie. This third one though, it was a different. When it started, I had been lifting heavy...way too heavy. I was always pretty strong, and this foray away from yoga and into weight training fed my ego (Thanks Courtney lol). I had a big ego. I didn't realize how big until I started training, and training heavy enough to make the boys jealous. My bench was heavy, my squat was heavy, my deadlift was heavy, my leg press was CRAZY! Sounds awesome huh? Well, not exactly. Every single one of these movements were done poorly, and were very often done while in pain.
All of this set me up very nicely for my third and final flare up. It started at the beginning of 2013. I had just started working at a new clinic, was less than 1 year into a new relationship and it all just kind of happened. It was familiar when it first started, but it often came and went so I was initially not so concerned. By April, every time I went into the gym, working out would cause an intense burning across my low back. I often had to lift my shirt up because it felt as if my skin were on fire. No biggie. Get those pull-ups done and I'll down an NSAID later. By mid-April, this burning sensation was constant. One leg day, in mid-April, I had an out of body experience. It was leg press day. This was my day! 12-14 plates a side, and the worst form you've ever seen in your life. I was in pain. So much pain, but I kept going. This is when I had this experience. I saw myself having to pull my body up using my arms, heaving myself to standing, limping to add another plate. I watched this stupid girl do this over, and over. Set after set. At that moment, I truly realized the scope of my ego problem. At this point, I still didn't realize that there would be no turning back. The decline happened quickly from here. I lost the ability to do all the things we all take for granted. I taught classes standing while leaning over my desk and watched TV standing and leaning over the back of the couch. I could no longer sit without pain. My sleep progressively got worse. It started by only being able to sleep in child’s pose, then only on my back with my knees dropped to the left, then I couldn't lie down without pain and had to stand and lean over the bed to sleep. That is how I slept from May to August. Driving became very difficult. I couldn't get into or out of the car without breaking into a fit of sweating from pain. Often while driving, I found that I couldn't stand the pain of my pant leg on my right leg or my key chain rubbing up on my thigh. I would often have to hike up my pant leg to drive, and had to take all my other keys off my key chain. I now understood allodynia. I was a terrible passenger. I went from lying on my side, to kneeling on the passenger seat to whimpering. I taught yoga and was a massage therapist. I continued to work because I had bills to pay.
So where were the doctors visits in all this? My first few visits to the doc were fruitless. I was tough so didn't let on to how much pain I was in, and despite my loss of function and excruciating pain, I was still flexible enough to pass a toe touch. According to my doc, this was just a matter of "let it heal". Within a few weeks of my first doctors visit, I began to notice a pretty prominent and annoying foot slap on the right side, and inability to completely empty my bladder. At this point, I wasn't sure if this was a more serious sign or if it was because I had progressed to not being able to sit to "go" and just couldn't relax enough to empty my bladder fully. I went in to see my doctor again. At this point, I broke down and cried in her office. I never do this. I never cry in front of people. She finally understood. She provided me a requisition for an MRI. Three days after my MRI, I got a call from my doctor to review the results. Two days after that appointment, I got called by the neurosurgeons office for a consult. This was a pretty good indication that this was no joke. I was scared but relieved. Up to this point, I was living on handfuls of Tylenol 3, and an anti-depressant for pain management. I was also seeing every therapist I could. I did massage, craniosacral, Bowen technique, acupuncture, homeopathy, meditation, and laser therapy. Thousands and thousands of dollars. When I walked into the neurosurgeons office, he led me to his exam room, did a little poking around, some orthopedic tests, handed me a package labelled "pre-op" and told me the receptionist could set a date for my surgery. I was shocked. What? Me? Surgery? What do you mean? He took me to his office to show me my MRI. He explained what we were looking at and what it all meant. I told him all the therapies I was trying. At that moment, he sat down with me, looked me in the eyes and said "By all means, try everything. Try all of those things, and if they work, cancel your surgery date." He then said, very gently and honestly "But please don't spend too much of your money doing this. Your MRI shows a very damaged disc, and it has already been several months of worsening symptoms." I felt defeated. Defeated by my own intervertebral disc! I walked out of that office with my pre-op instructions and a surgery date - August 27th. What? Three more months of this? How will I manage?
It certainly didn't get better, in fact, it got much worse. I had several more visits to my doctor to try to get some pain relief and one pretty terrible emergency room visit. I added gabapentin and lyrica to my cocktail of drugs. Within weeks, none of them could touch the pain. If I took my dose of T3's, it took about an hour for them to kick in. That would take my pain from 10/10 to 8/10 for 45min to an hour, if I was lucky. I learned to time my drugs so that I could work, drive, have a shower, do grocery shopping. I had it down to a not so exact science. I needed to take my drugs at 9am so they would kick in midway on my drive to work and would give me enough relief to get me through at least my first couple treatments until I could take more drugs. I couldn't do regular daily activities like grocery shopping. For one, I couldn't trust my pain. I never knew when a big flare up would hit and I feared myself ending up curled up on the floor of aisle 7. I couldn't carry the weight of my purse so it was definitely hard to do groceries even without the fear of public embarrassment. I sweat. A lot. I was constantly sweaty from the high level pain. I cried. A lot. From pain but also from frustration. I couldn't workout, I couldn't stand in the shower, I couldn't lie down to sleep, I couldn't sit at a coffee shop with a friend, I couldn't brush my teeth without letting my pain killer kick in. But I never let on how much pain I was in. I didn't want my family to worry. I didn't want to burden anyone with that. It wouldn't have changed anything anyway. My fiancee knew. He was witness to many breakdowns. He forced me to go to the emergency room when he picked me up after teaching a yoga class, got me home and I began screaming in pain. I could keep it together to do some downward dogs so that no one would know, but once I was home I just couldn't bear being strong any longer. He saw me in those moments, and was the target of my miserable attitude and cruelty when I was frustrated and hopeless. He took all of it on with patience and kindness. (For that, I am eternally grateful) In July, he was posted overseas and I was just waiting for August to come. As August approached, the pain and my tolerance were waning. On August 26th, the day before my surgery, I taught a yoga class and treated my last set of clients. Worked right to the last hours. My parents drove me into the hospital the morning of my surgery. I arrived, saw my surgeon again and met some of the surgical team. I was getting my micro-discectomy. They gave me some sedatives and pain killers while they were prepping me for the OR. The surgeon put an "X" on my right ankle and disappeared into the operating room. As they took me into the OR, I felt relief but also fear. I had all my eggs in this basket. If this surgery didn't work, I didn't know how I could go on with this pain. How I could continue to live with the pain I had been in for the last several months. The anesthesiologist sat to my left and began to induce my slumber. I remember leaving that room. I remember waking in recovery. I woke up to the most amazing experience I have ever had, I was in no pain. None. In fact, the morning of my surgery was the last time I took any pain meds. I took no pain medication after my surgery. Not even an Advil. Nothing. A few hours after having been admitted, I was on my way to Starbucks before going home to rest. There are no words to describe that experience except to say that it was the most wonderful miracle of science and miracle, and I felt very lucky. After two weeks, I went back to work - treating and teaching yoga - slowly. I couldn't have asked for a better outcome.
In the months and years that followed, I was so grateful to have no pain. I was still very limited in movement but I didn't have pain. NOW lets get to those socks! I couldn't put on socks or shoes properly so I found other ways. But I had no pain. I couldn't get something out of the oven because bending over and taking on the weight of my trunk and upper limbs was too much so I found other ways. But I had no pain. I got very stiff through the night and when I woke up I couldn't move well so I found other ways to get out of bed and move around in the first couple hours of my day. But I had no pain. There was this constant stiffness and immovability in my low back, but compared to before the surgery, this was a small price to pay. I decided that this would be okay, as long as I didn't have that pain. For a short time after the surgery, I continued my quest to be strong (my ego was better, but I was still not completely smartened up). I got to a whopping 205 bench, weighted pull-ups and regular, easy 225 deadlifts. Not bad. But I still couldn't put on my socks. This seemed at odds with my "gym strength", and one day I finally realized it. I realized that I was responsible for teaching my body how to move again, and that it was safe to move again. I realized that a bench press meant nothing if I couldn't cross my leg without heaving my shin up by awkwardly grabbing my pant leg.
So, I changed the way I moved. I traveled to NY to take an SFG user course to learn how to hip hinge, goblet squat and execute a Turkish get up. I started to make these movements part of my regular workouts and my every day. I started with little to no weight and earned my way to more. I took several pounds off the bar to execute my bench with control and integrity. I got on the floor so my brain would feel safe while I moved. My stiffness started to decrease, I started to feel more stable doing simple tasks. Almost 2 years after my surgery, I woke up one morning to get ready to go to work. I brushed my teeth, put some clothes on and then I did it..... I put on my socks! I put on my socks like a normal person. My hips hinged and externally rotated beautifully as I dropped my butt back and lifted one leg, my lumbar spine produced flexion, my standing leg supported the weight of my body as I lifted one foot up off the floor and put my sock on with two hands. It was amazing! I was happier about this achievement than my kick ass max bench (kinda lol). I had gained so much after the surgery, but initially conceded to lose my mobility in exchange for pain relief. That was ridiculous. I didn't need to accept the loss of my mobility in exchange for pain relief. I just needed to earn my stability to gain my mobility.
If you are in a situation where you have accepted something in exchange for another perceived benefit...STOP. You don't always have to make these compromises. You can have it all. You just may need a little help to get your socks on again. You may just need to take a step back before taking one forward.
My time is divided between being a therapist and an educator. I have been in education for over 10 years, and have always found that while there were hardships, the role of educator has given me so much joy. I have, many times, been challenged. Challenged to consider what my duties and responsibilities are, and whether or not they are supporting mt profession. Recently I have found myself reflecting on my role as educator and how that influences my profession.
As an educator, I have accepted long nights preparing lesson plans, searching for ways to make sciences interesting and applicable. I have accepted less pay in exchange for doing something that fulfills me in ways beyond dollars and cents. I have accepted that I will not always have all the answers, and that not every one of my students will like me. I have accepted the misplaced anger of a student that is frustrated by the challenge to learn sometimes tough material. I have accepted that I may not be able to teach what I know to be more effective, or valuable because I am limited by an educational institutions curriculum, created to reflect current standards. I accept these things.
As an educator, I do not accept an educational institution that does not set up students to succeed and then blames educators when they fail. I do not accept the notion that "generational" differences require educators to make exceptions to rules which results in decreased accountability for those who may become primary healthcare providers. I do not accept inappropriate conversations about colleagues in their absence, rather than face to face discussions. I do not accept responsibility for a students failure when they cannot take responsibility for themselves. I do not accept that exceptions are made for financial gain while the long term effects of these decisions create lasting damage to the profession I love. I do not accept these things.
I believe that my duty as an educator is to prepare my students for examination and for the life of a successful therapist. I believe that my duty as an educator is to ensure that those entering my profession are people that are respectful, trustworthy and solid in their skill set, regardless of whether or not we hold different approaches to treatment. I do not believe that my way is the only way. I believe that the duty of an educational institution, or regulatory body, is to maintain integrity in a profession by preventing those who do not demonstrate dedication, maturity, skill and ethics from entering.
I have worked as both therapist and educator in many settings. I believe that I have always tried to honor my roles and duties as an educator and therapist. I believe that I have been in situations where the setting I practice in has sometimes made that very difficult. As I look forward, I have made the decision to discontinue being part of those thing that dishonor me as a therapist and my profession as a whole. I am thankful for those who have shaped me, and allowed me the opportunity to see integrity in action.
Shirlee Rankin, who never trades in her ethics and integrity for money. She upholds both the integrity of her school and of the massage profession, even in times where that meant that she had to make personal sacrifices. She unquestioningly stands behind her teachers, and despite our close relationship, not once spoke poorly or gossiped about a fellow staff member.
Adam Martynuik, the most amazing chiropractor I have ever worked with, practices with a confidence and dedication that elevated my own practice. His commitment to his patients often meant that I received late night text messages about differential diagnoses after he had searched through text or did online research. He never did the "snap, crackle, pop" with a single patient. What I did see was a individualized approach using manual manipulation, movement and education. A truly skilled healthcare provider.
Jess Gjertsen, a badass trainer with skills I envied from day one. I believe one of the first things I said to her was "I want to follow you around and learn everything you know." I watched her use FMS and a skilled eye to assess and investigate. I saw her interact with her clients with a tough kindness, helping people move beyond where they believed their limitations existed. I never saw her balancing on a bosu ball while doing a bicep curl and a kettle bell swing (although she probably would have executed that flawlessly lol). No party tricks, just intelligently designed, effective and individualized care.
I have been lucky enough to have been in the presence of some of the most amazing educators and therapists, as both a peer and student. I have been shaped by the good experiences and by the not so good ones. As I come to the end of a tough week, struggling with my role right now, I am thankful for these amazing colleagues, for my partner who sent me a message to remind me of who I am, and for a picture from an 8 year old client that lifted my spirits after a rough day.
Science is wonderful. It is a world full of funny, sometimes ridiculously long and impossible to pronounce words. I have a bit of a geeky pleasure that involves a glass of red and reading my medical dictionary. One of my favorite sections of a medical dictionary is the comprehensive list of phobias usually found in an appendix in the back somewhere. While I'm not one to make fun of a persons medical condition, and the potential suffering that comes with it, geniophobia (the fear of chins - yes the body part) is just too good not to laugh at a bit. Below is a list of some of my favorite medical terms and pathological conditions. Feel free to pour yourself a drink...
Easily Fragmented Friable Vegetations - hands down my favorite sentence to say when teaching cardiovascular pathology. It is a manifestation seen in infective endocarditis, where the inner lining of the heart (including valves) becomes inflamed. This condition is characterized by little clumps (vegetations) of fibrin, platelets and microorganisms that stick to the surface of the endocardium. They can break off and crumble, hence the "easily fragmented friable" part of the whole deal. Cool as F!
Suppurative - this word relates to a substance that I have personally had a close encounter with in my massage practice. I can't help a mild dry heave whenever I see it in print, or hear it uttered. I hate it because of that, but also because it sounds quite proper and positive. Something like... "He was suppurative and confident as he delivered his speech to the board of directors," or "She exemplified a type of suppurative awareness that allowed her to command the audience." But its pus. It means forming or oozing pus.
Jumping Frenchmen of Maine - I swear this is a thing. WebMD describes it as "an extremely rare disorder characterized by an unusually extreme startle reaction.", and says that "Jumping Frenchmen of Maine was first identified during the late nineteenth century in Maine and the Canadian province of Quebec among an isolated population of lumberjacks of French Canadian descent." It also involves echolalia and echopraxia, involuntary mirroring of what another person says or is doing. Whoa!
Borborygmi - the rumbling sound that occurs due to movement of gas in the intestines. You sometimes get it when you're hungry. If you say it with constriction in the back of the throat and more guttural, it kinda sounds like the actual thing. It also kind of sounds like the name of a small village on an island somewhere in the south pacific.
Pruritis Ani - this...
Got any good ones?
I loooooove biceps brachii. You too? Well read on!
Biceps brachii is a beauty. He makes his home in the land of anterior humerus and traverses across glenohumeral, humeroulnar and humeroradial. He's a bit indecisive in the genohumeral regions so he makes a big split to cover more ground. This is where it gets interesting!
The proximal portion of biceps brachii splits into a short head and a long head. The tendons of each, attaching at different locations around the shoulder. For this article, I will be exploring the amazing anatomy of the long head.
The long head of biceps brachii has so many relationships around the shoulder. It's these relationships that allow for a balance between mobility and stability in the shoulder joint. When this delicate balance is compromised, however, the result can be pain and dysfunction that affects the shoulder girdle, neck and beyond. If you have a client or patient with symptoms of LH trauma, think beyond just the tendon. It is likely not the only player in the dysfunction. If you are a patient, and your therapist is only treating your tendon, send them to this blog post.
But wait, there's more!
As if biceps brachii isn't cool enough, it is also credited with the assignment of the word muscle to all those neatly arrange bundles all over our body containing actin and myosin, all contractile and stuff, and allowing us to move. Yes. It's true. The word muscle comes from the Latin musculus, "a muscle", which is formed by the word mus, or "mouse". Muscles were called such because the shape and movement of some muscles, most notably biceps brachii, were said to resemble mice. As wicked awesome as this is, I can't see "gun show" being replaced by "mouse frolic" at your local gym any time soon.
So, in honour of biceps brachii, this #flexfriday dedicate the flex to your #armmice
Andrews JR, Carson WG, McLeod WD. Glenoid Labrum Tears Related to the Long Head of the Biceps. Am J Sports Med 1985.
Khazzam, M, George M.S., Churchill S, Kuhn, J.E. Disorders of the long head of biceps tendon. J Shoulder Elbow Surgery 2011; doi:10.1016/j.jse.2011.07.016
Todd G.K., Bell D, Goldberg J, Wade H, Pelletier M, Yu Y, William W.R. Anatomic and Biomechanical Study of the Biceps Vinculum, a Structure Within the Biceps Sheath. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2009.
Tuoheti Y, Itoi E, Minagawa H, Yamamoto N, Saito H, Seki N, et al. Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Arthroscopy 2005; doi:10.1016/j.arthro.2005.07.006
Weishaupt D, Zanetti M, Tanner A, Gerber C, Hodler J. Lesions of the Reflection Pulley of the Long Biceps Tendon: MR Arthrographic Findings. Investigative Radiology 1999.
Werner A, Mueller T, Boehm D, Gohlke F. The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval: a histo-anatomic study. Am J Sports Med 2000.
"Don't worry about me. Do what you've gotta do"
"I know it will feel better in a few days"
"No pain, no gain right?"
I probably hear comments like this at least a few times a day in my practice. Manual therapy has a dirty little secret. It has perpetuated this idea that a therapy has to hurt to work. This is a travesty. The International Association of the Study of Pain (IASP) defines pain as being associated with actual or potential tissue damage. Why are we liberally assigning therapeutic value to causing our clients pain?
As a brand new massage therapist, I also subscribed to this terrible principle. My education and the industry put a bigger premium on therapists who could perform aggressive, deep, "painful" techniques. Some clinics even charged more for it. This was viewed as somehow more effective than what people labelled "fluffy" massage. The flip side of this is that therapists who could not exert huge amounts of force were sometimes made to feel inferior. In my youthful ignorance, I jammed elbows and thumbs into the ailing soft tissues of many many people. They spent a couple days after the treatment feeling bruised and beaten, and came back for more a few weeks later. I thought this meant I was good. I was wrong.
I'm not saying that deep techniques are bad. If you can handle it then more power to ya! It's all about tolerance. But no one should be convinced that they need to grit their teeth and bear pain beyond their tolerance in order to get better. Period.
So now lets talk truth. Truth is that pain is a manifestation of the nervous system NOT of the soft tissues (one day I will write more about this). Manual therapy has this amazing ability to moderate pain but it can't be done by damaging tissue. Seems obvious. We need to view stretching, manual therapy and the like from a bit of a different lens. If we look at it from the perspective of a type of altering of the nervous system, stretching becomes less vigorous and forced, massage manipulations become slower and less painful and our view of how we approach pain manifesting in tissues gets turned upside down.
If you are a manual therapist, it is your responsibility to do your due diligence. Read more. Questions more. Learn how to investigate and critique the current literature around manual therapy. Do not continue to accept the antiquated ideas and concepts that are still, unfortunately, taught in our schools. Drop the dogma!
Need a starting point? Investigate the most recent science behind the use of ice to improve healing. You might be surprised at what you find.
Laurie Di Giulio
Aspiring Jedi therapist, lover of the art in human anatomy, reveler in the miraculousness of life.