“Avoid axial loading activities”

[Soule]

Hey Will,
Thought you might get a kick out of this MRI review from one of my clients. The conclusion seems to be that he has no major issues with his spine and yet the Doc’s orders are to “avoid any high impact/axial loading activities”


<redacted name> has been experiencing intermittent low back. I reviewed his lumbar MRI which showed a spondylolysis at L4-5 which can contribute to his low back pain. I do not see any significant nerve compression that would warrant surgery at this time. He is to monitor his symptoms and continue doing a strong HEP focusing on core strengthening. I am also referring him to a pain management doctor to establish care in the event he has another debilitating episode.

As for his neck, he had been experiencing neck pain with left sided radiculopathy. I reviewed his MRI which showed stenosis, however it is not as severe at this time and there is plenty of room in his spinal canal. He is to monitor his symptoms and if he develops motor deficits, he is to return to the office. Otherwise, he is to avoid any high impact/axial loading activities and let pain be his guide.
1. Spondylolysis
M43.00: Spondylolysis, site unspecified
2. Low back pain
M54.5: Low back pain
3. Neck pain
M54.2: Cervicalgia
4. Cervical radiculopathy
M54.12: Radiculopathy, cervical region
5. Spinal stenosis in cervical region
M48.02: Spinal stenosis, cervical region

[Will Morris]

If you wanted to preserve your medical license and eliminate the possibility of being the subject of litigation, this is sound advice. Perhaps it is not the best advice for the patient, but in the court room, this is likely the safest thing for this physician to say. If he says it is safe to train, and this individual has another episode, he could very well blame the doctor for his episode and bring suit against him. If that were the case, whatever expert witness they brought in would likely say that under no circumstances should someone with common MRI findings in adult humans subject themselves to the horrors of high impact activities or axial loading.

[Soule]

In your opinion, is it within this Doctor’s scope of practice to comment on axial loading?

[Will Morris]

Soule, it actually isn't up to me or my opinion on this. Physical activity, to include exercise recommendations has been definitely and conclusively, judged to be within the scope of all medical doctor's knowledge and scope of practice.

[Soule]

Good to know! Thanks Doc

[jfsully]

If you had cervical stenosis, and maybe a cervical disc herniation to boot (not the case here), about the only really bad thing you could do is let someone hammer you on the top of the head repeatedly with a 2x10. This would be considered high-impact axial loading, and should definitely be avoided. Any doctor who tells you this is OK to do should lose their license.

The advice to avoid the high impact axial loading of the cervical spine likely is related to the pain symptoms your client has already had, not due to results of the MRI. This would be common advice given with or without the MRI. The MRI was probably to check whether there is something awful happening that would require surgery. There is not. Just like a crap MRI doesn't mean you have problems, a "clean" MRI doesn't mean you have no symptoms. Sounds like your guy has has some radiculopathy symptoms already.

You are correct that the doctor is not on the cutting edge of using barbell training to rehab and build strength. That's not surprising. The doctor's role here is to tell you what kind of things to do to avoid further injury, and you can then make your choices and take your chances. But, like Will said, you don't get to sue the doctor if something bad happens if you don't follow their extremely conservative advice. (well, you probably do get to sue anyway, but your chances of collecting anything go way down)

[Gbraddock]

Hammer by 2x10 to the head will def do it! LOL.

I was gonna ask...

I don’t see how ANY of the SS movements load the cervical spine? Like at all! I would think the closest thing to axial loading of the thoracolumbar spine would be maybe high bar squats (more vertical spine angle) which are not part of the recommended lifts anyway. Wasn’t mentioned anyway in the post.

[Will Morris]

Hammer by 2x10 to the head will def do it! LOL.

I was gonna ask...

I don’t see how ANY of the SS movements load the cervical spine? Like at all! I would think the closest thing to axial loading of the thoracolumbar spine would be maybe high bar squats (more vertical spine angle) which are not part of the recommended lifts anyway. Wasn’t mentioned anyway in the post.

Maybe if someone really cranks their neck into cervical flexion while low bar squatting in an attempt to "look down", but with central canal stenosis, flexion isn't the issue. It is classically described as being extension sensitive. There are a couple factors that have been described as to why this is the case. The exceptionally few central canal stenosis patients I have had, that were actually assessed to by symptomatic from the stenosis, all responded to repeated flexion and we modified the program to have them take up a position of less extension but brace in a tiny amount of flexion. Seemed to work well, but those patients were not the original poster and they didn't come to me with a recommendation to never axially load their spine again.

[Gbraddock]

Maybe if someone really cranks their neck into cervical flexion while low bar squatting in an attempt to "look down", but with central canal stenosis, flexion isn't the issue. It is classically described as being extension sensitive. There are a couple factors that have been described as to why this is the case. The exceptionally few central canal stenosis patients I have had, that were actually assessed to by symptomatic from the stenosis, all responded to repeated flexion and we modified the program to have them take up a position of less extension but brace in a tiny amount of flexion. Seemed to work well, but those patients were not the original poster and they didn't come to me with a recommendation to never axially load their spine again.

Yeah def not a myelopathic patient

[Soule]

If you had cervical stenosis, and maybe a cervical disc herniation to boot (not the case here), about the only really bad thing you could do is let someone hammer you on the top of the head repeatedly with a 2x10. This would be considered high-impact axial loading, and should definitely be avoided. Any doctor who tells you this is OK to do should lose their license.

I interpreted his notes as high-impact OR axial loading activities. If what he meant was high-impact axial loading then thats another story. I’m certainly not having my clients do any janky shit like barbell jump squats!