Mandy Knaap

+27 21 557 6066





On Saturday, 6th September 2014, I woke early to get to work by 8.30am. I decided to catch up on paperwork and sat in front of my plinth.  As I got up to fetch my first patient, I thought:  “Oh dear – my lower back doesn’t feel too good”. Maybe I had just sat badly.

As I treated my 4 patients that morning, the pain progressively increased. After I finished working I did a few mobility exercises to try and loosen up my back. I could hardly get into the car after work to drive home. It felt like an intense muscle spasm, even though I’d done nothing to cause a spasm. I only had local back pain which was very sensitive to touch and muscle spasm (or so I thought) which visibly caused a bulge across my back at waist level. I had no referred pain down my legs or pins or needles or numbness or muscle weakness. It was surely then not a bulging disc. So I went home and behaved like any obedient patient and rested in bed that Saturday afternoon and Sunday. I did everything that I tell my acute lower back patients to do:

1. Active rest – meaning – lying down on my side with a pillow between my knees alternating with nonweightbearing mobility exercises.

2. Used my microwave heat bag.

3. Took anti-inflammatories  and muscle relaxants (physios are not allowed to prescribe meds but can advise patients to see their GP / talk to their pharmacist about these medications).

4. Had hot baths.

I hardly stood up or walked – only for the essentials such as going to the bathroom or showering etc. I even ate my food lying on my side. The only thing I didn’t do, which I would recommend to patients with acute lower back pain, is have a Voltaren injection at their GP. I would normally recommend an anti-inflammatory injection if the pain is very bad or if the first physio treatment doesn’t  decrease the pain sufficiently.

By the Monday morning, the pain was still the same. But being a very loyal physio, off I went to work.  I did, however, make an appointment at my GP for an  anti-inflammatory injection (she could only see me midday) and I had a physio treatment with my colleague.  I felt great after these two interventions and thought : “Ok, my back didn’t respond to all the conservative treatments of the weekend but now it’s improved a lot, so it probably was just that the muscle spasms was very intense so conservative treatment wasn’t enough. I treated three more patients that afternoon and the pain was back.  So I went home and rested again.

On Tuesday, 9th September I had a networking breakfast. I sat very upright with a lot of support in my lumbar spine and actually felt OK.

I was supposed to do a home visit for a lower back pain patient at midday but decided to cancel that as leaning over a low bed is not great even when you have no lower back pain. I  saw two patients later that afternoon and was pretty sore afterwards.  I continued my regime as per the weekend when I got home after work. I treated patients again on Wednesday, 10th September for the whole day and had a second physiotherapy treatment.

As my back was red, swollen and inflamed, my physio colleague said she was not keen to treat me but I insisted on treatment. I thought : “ The harder and deeper the  treatments the quicker I’d get better”. I had patients depending on me that I needed to treat so I wanted to get better quickly. And of course, I thought: “I’m tough! I can cope with this pain”.

When I got up on Thursday morning I was in agony again. I went back to the GP for a second “cocktail” injection.  My Mom had to drive me there as I couldn’t sit to drive due to the pain. I was told I had to be on bed rest and if I was not better by Sunday (this was 4 days of bed rest), I had to phone her and she’d book me off for longer. I had to cancel all my patients. I was given pain medication, the equivalent of Valium as  a muscle relaxant and Voltaren. I couldn’t believe that I was having to take these days off work. I was never sick. I also thought : “I am a physiotherapist and why can’t I fix myself? “

I continued my rest/exercise regime and took all the medication the doctor prescribed. The pain did improve markedly but the swelling/lump in my back still persisted.  My mobility was better but I couldn’t reach past my knees. Driving was still incredibly sore – It felt as though my spine was pushing against a hard brick and it was a soft car seat.

I went back to work on Monday 20th September as I was feeling better and as I felt a sense of responsibility towards my staff and patients and I felt  guilty about being away from work.  I’d rested for four days and taken taken all those meds, so as far as I was concerned, I had to be better.

Treating my first 7 patients that morning was manageable but I had to stand carefully, lean against the bed, bend my knees and alter my work style to cope.  I rested after the 7 morning patients. After I treated my 3 afternoon patients I was in agony again.  I could hardly drive myself home. I went straight to bed, but even lying on my side with a pillow between my knees was agony. Voltaren suppositories helped after I had eaten.

I went back to the Doctor again the next day.  I said to the Doctor: “I don’t know why I’m here?”  Her answer: “So you can be told that you will not go to work and I’m booking you off for 9 days”.  I was given more medication. It’s amazing how we as physios get annoyed with patients that don’t listen to us, but listen when the Doctor tells them to stay off work. Then I don’t listen myself (the now patient, not physio).

I was very obedient and did all the things again that I tell patients to do. I also started treating myself with techniques that I could do on my own.  Self treatment is limited though and quite difficult to do. I organized with my Mom and secretary to lift my kids to and from school as driving was still pretty painful. I also continued physio treatment with my colleague.

On the Thursday,  25th September, I was back at work. I was slightly uncomfortable, but the pain was manageable.  I was coping. I worked that afternoon and Friday morning.

However, the swelling in my back was slightly worse and was getting harder. I had never seen anything like this in a patient in my 24 years as a physio.  So, on the insistence of mainly, my Mom, but also my physio colleagues and staff, I organized to go for an ultrasound scan to see what the soft tissue swelling was. The radiologist was not happy with the findings of the ultrasound and said I should have an MRI scan. This made me very nervous but fortunately they managed to organize the MRI immediately. I wouldn’t have to stress too long.  “Was it a cyst, a growth or a tumour?” I stressed.

After the MRI the radiologist diagnosed a subcutaneous abscess extending into my lumbar muscles at around L3 level and extending backwards between the spinous processes of L3 and L4. He insisted I see a neurosurgeon that day. He informed me that the neurosurgeon would probably want to surgically drain the abscess immediately. I thought: ” How could I, a physio, have back surgery?   How was I going to be able to work properly after an operation?” I am a very physical physio and do mostly hands-on treatment and I treat quite hard. I was not scared of the surgery or pain, but was concerned that they’d find something wrong with my spine.

So it was off to admissions. I am not a panicky person but I was obviously stressed about the whole operation idea as my BP on arrival in the ward was 150/110. When the neurosurgeon saw me, he did a clinical examination and history taking and had a good look at the X-Rays, ultrasound scan and MRI. He then explained his findings and what treatment he was going to follow. He agreed with the radiologist that it was an abscess. They thought it was possibly from a local small wound or a spider bite. Though there was no physical sign of this. No-one could say how it started, but just that it had been brewing for a long time. “Sjoe!,” Was I relieved when he told me he was going to first try intravenous antibiotics for about 5 days to see if that would clear the infection. If the intravenous antibiotics worked, I’d be in hospital for 5-7 days and would then go home on a 6 week regime of oral antibiotics. I could also start working within a few days of discharge.

After 5 days on antibiotics the swelling was still there but at least I had no pain. The neurosurgeon was worried that the infection would spread into the bones and cause an osteitis which is much more difficult to treat and takes longer.  I went for a second ultrasound which was inconclusive. The next day I had a third ultrasound during which they tried to aspirate some of the infected material so they could culture it, to see if it was a resistant bug. The infected material had become so thickened that they could only aspirate a miniscule amount and only after they had hunted around for a thicker needle. The culture showed that  it  was not a resistant bug, just a staphalococeus aureus infection.

The ultrasound showed that the infection was still present between the spinous processes so, the neurosurgeon booked me in for an operation on Thursday, 2nd October.  All that time off work at home and in hospital and I was going for a back operation anyway. The surgeon also informed me that he was going to give me an “ugly scar”. He was concerned about re-infection around internal stitches so would do old-style black stitches. I wasn’t worried about “ugly scars”, I just wanted my back to be better and to function normally.  The last time I had had major surgery was when I was 16. I had pins put into my left thigh bone which was fractured in a car accident.

The only good thing about surgery I thought, is the pre-med. What a “good feeling”. Luckily I have never tried drugs, I’m sure I could get used to “that feeling”. The nurse informed me that they don’t really do pre-med anymore. What a disappointment.

I had my operation midday on the 2nd October.  Luckily it was uneventful. He got most of the “muck” out. The infection had not spread into the bones. The supraspinous ligament between the 3rd and 4th lumbar vertebrae was, however, destroyed by the bug.   I didn’t have too much pain after the operation. They put a waterproof dressing over the cut so I could shower already that evening. I was discharged 3 days later. My stitches only came out 14 days after the operation due to the old style stitches. Due to the physical nature of my job, I was only allowed back to work once the stitches were out and I completed a 14 day intensive course of antibiotics. I returned to work about 18 days after my operation.  Over the next few weeks I improved daily though I had to be careful. 5 weeks after the operation I was working and driving and moving pain-free. The only sensation I still had was a prickle feeling over the scar when I flexed my back too much and I was still slightly stiff. But “Yah!” I felt like a human being again.

What I have learned from this whole experience:

As a patient who is a physio:  (keeping in mind that even though my condition was actually an abscess it behaved the same as a muscle spasm)

– Just because I am a physio and generally pretty healthy doesn’t mean I will respond quicker, the more aggressive and the more regular the treatment is. I demanded deep, aggressive treatment more than twice a week.  If I treat an acute lower back patient, I treat the patient lying on their side, usually with rotation type techniques first. These mobilising techniques don’t involve pushing directly on the painful spine area. I would do some local treatment on the joints and muscles, but gently, as the patient’s pain allows. But of course I insisted on deep local mobilising and deep soft tissue massage, thinking: “Oh, I’m tough and I want to get better quicker.” In hindsight though, maybe if we had been less aggressive, the pain may not have been aggravated and I may have taken longer to go for the MRI. Maybe by that time the infection may have spread to the bones.

-A lot of the things I advise patients to do didn’t work for me. E.g. sitting in the car with a lumbar roll at waist level was just too painful and uncomfortable for me. I had to support myself with one half and one full lumbar roll above and below the painful area. Normally the lumbar roll is placed at about waist level to maintain a good posture.

– Sometimes, even though you do all the right things (take meds, do active rest with gentle mobilisation exercises, apply heat, follow good lifting techniques and sitting postures) your body doesn’t always respond and you just have to rest. Even though I did rest it was not long enough so I actually ended up prolonging my own agony. Not very clever. Your body tells you how much and how long you need to rest. You have no control over how your body will respond to treatment. If you keep overdoing it, you only end up causing yourself more pain.

 As a physio:

– Not everything you have been taught works on every patient, even if they have the same/similar conditions. You have to adapt your treatment and your advice.

– It is better not to self-diagnose. Even if you have all the knowledge and specialists even have access to special tests like MRI’s etc, we  are not always able to diagnose 100% accurately 100% of the time. There are many variables.

– I do empathise with my patients and their pain when I see them in my treatment rooms for physio but I now have a new-found empathy for them from a practical side when they go home.

From a practical side:

-Having back pain is no fun. You have to adapt to so many things or just not do them at all. You can’t bend forward even to brush your teeth. Dressing your bottom half is a nightmare.  You can’t  put on underwear, pants, socks or shoes. You can’t dry your ankles and your feet. You can’t shave your legs or paint your toe nails.

Luckily I have a good balance so I could balance on one foot and pull my other foot up with my hands and dry each foot. You can also lean against the wall if your balance is poor.

-You can’t sit which also means you can’t drive.

-The heat of the water is great for relief for pain, but it is difficult to get in and out of the bath. Using a heat bag is very helpful.

-You have to stand and eat – if you are too sore to stand, you have to lay down and eat.

– You can’t carry heavy things. It is difficult to shop as you have to bend to put things into the trolley and lift your shopping bags into your boot.

-You can’t sit on the “lavatory”.  I had to rest on the back of my left thigh and rest leaning backwards.

-Then you  get other side effects like constipation (and this might happen from all the meds you take and from inactivity). Pushing increases your intra-abdominal pressure which increases your pain. So now you have to take laxatives – more pills !

– You can’t just turn over in bed. You move at a snail’s pace – the frustration! In the beginning when you are at your worst, you can’t even do things like stand and pack your kid’s lunch.

– I also can’t believe how many times you drop things. Does this seem to happen a lot more just because you can’t bend to pick things up or do we not notice how often we drop things when our backs are fine?   I developed very strong thigh muscles as I had to use my legs to squat down to pick things up. This is the correct way to do it.  I also have developed a better posture again as your back reminds you every time you flex or sit incorrectly.

-Luckily I have a good support structure but you also don’t want to impose on other people’s lives all the time.


–              Listen to your body.

–              Don’t be a martyr.

–              Ask for help and accept help.

–              Do what you are told by your GP/physio and other medical professionals.

–              If you are a medical professional don’t listen to yourself  and don’t self diagnose – listen to other professionals. From a medical point of view you are not qualified to treat yourself. You only make half of the decisions properly.

–              Sometimes it takes a while to find the correct diagnosis.

–              If there are things your physio tells you and they don’t help, inform them. There are always alternatives. Different things work for different patients and different conditions.

–              Sometimes you just have to be patient.

 Practical tips:

–          The buoyancy of a deep bath and the heat of the water relieves pain and muscle spasm, but only bath if you can get into and out of the bath on your own or if you have assistance.

–          Use heat for the pain of muscle spasms. It gives great relief.

–          Wear slip on shoes.

–          Do active rest. This means:  Lay down as much as possible in as pain free a position as you can (alternate your position between laying on your back and alternate sides).  Alternate the laying down with non-weight bearing mobility exercises as prescribed by your physio.

–          We have a good strong thigh muscles so use your legs when you pick up or lift things. Do not bend your back.

–          If you need to bend forward – either bend your legs or lean onto something to support yourself.

–          Ask your GP/pharmacist about medication if necessary (Ask for meds that won’t lead to constipation).

–          Listen to your body. Do everything within limits of your pain.

–          Ask for assistance when needed.

–          Speak to your physio about anything and everything regarding your lower back pain. They can help.