PS

PS stands for pubic symphysis.  WebMD describes it this way: "The left and right bones of your pelvic girdle are joined at the front by a narrow section of cartilage and ligament. This is called the pubic symphysis... As the pelvic bones loosen during pregnancy, the pubic symphysis can temporarily separate. This is not a dangerous condition. But it can be painful."

Um, yeah it can.  I'm not terribly worried about it, but I do think the PS is painful this pregnancy in part because my right SI is not moving at all and it's likely compensating for that.  The PT gave me some exercises to try to strengthen the area's muscles. 

WebMD continues: "A separated pubic symphysis can take 3 to 8 months to heal on its own. For most women with this condition, pain or discomfort lingers for about 2 months after childbirth."

I do hope it ends up resolving on its own.  I know some women with SI problems who also have PS problems, because everything down there is connected.  Some have even had to have a plate surgically installed to re-join the PS.  So, this may or may not be a long term issue.  I will report on it as I go, of course.

Conert Standing

Last night our church did its Christmas concert.  I was able to stand and sing for about 45 minutes of the concert, even with a uterus the size of a soccer ball (according to babycenter.com).  I sat for the last two songs, but I was hidden on stage behind the congas.  I would never have been able to dream of standing so long before my iFuse.  I am doing very well this morning, too.  So, no negative after-effects, probably in part because I listened to my body and sat when I needed to.

21.5 weeks

It's A....

Girl!  We have two precious boys, and now a little girl to add to our family.  We are very thankful.

On the pain front, things are going pretty well.  Sometimes I even forget to take Tylenol on a regular basis.  I still take it at least once a day and once at night (along with nighttime Flexeril), but I no longer wake in the nights in pain - and nighttime pain wakings were every single night in the first trimester.  My guess is that everything is loosening up here in the second trimester with all the hormones flowing.  I am back in PT since my appendectomy, but I can tell I lost ground in the strengthening area while I was out.  I have been doing some neural flossing, but not enough.  I would probably get better results if I did it twice a day, but I haven't been.

On Thanksgiving, I did a lot of standing, cooking and cleaning, just on Tylenol, and the pain level was very manageable.  I hope this continues through the third trimester, but I'm not taking any chances.  I'm going to keep up my PT the whole time and also monitor my activity level to make sure I don't overdo it.  Driving, shopping, and sitting for extended periods are still the most painful things I do, so I have to be sure not to compound these activities too much in any 24-hour period.

Surgery

I had an appendectomy last week without knowing that I had appendicitis. It was a gut-wrenching decision because of the risk of miscarriage. Ultimately, after a couple hours discussion and a lot of tears, we decided to trust the judgment of the surgeon, because my symptoms were definitely not demonstrative, and they couldn't do any standard tests because I'm pregnant. The nurses all gathered around and prayed for me and the baby before the surgery, which was very comforting. Well, the post-op labs just came back today, and the tests on my appendix show that I did indeed have acute appendicitis. My surgeon was so funny, she said, "I was so stoked!"

However, now I'm out of PT for two more weeks, since it's so much ab work.  I will try to do some gentle stretches starting tomorrow or this weekend though, so I won't lose all my work completely.

Kicker

I felt the baby move the first time at 14 weeks.  Super exciting!  I feel him/her almost every night now, between 7 and 9 p.m.

In physical therapy, I can definitely tell I'm getting stronger, and my PT is pleased with my progress in that area.  But the pain level has not decreased yet.  I am still only good until about noon every day.  I will be discussing other pain medications with my OB, because she said I'm overdoing the Tylenol.  Tylenol doesn't last and when it wears off, I'm non-functional.  So I will be speaking with her tomorrow when I go in for lab work.

Delivery

So the question I keep getting is: will you be able to have a vaginal delivery after iFuse?  After speaking with my OB today, and then calling my ortho to verify, it looks like the answer is YES.  Of course, there is a 10-20% increased chance of needing a c-section, and my OB will make that call when the time comes.  I am nervous about causing further damage or hurting my hips or left SI, but as things progress I will simply be open with my OB about my concerns.  She seems very understanding and open to dialogue, and of course I am her first case like this.  She doesn't seem to think that my pain level will get too bad either, in the third trimester.  Well, time will tell on that one, ha!  But she did *highly* recommend a support brace "sooner rather than later."  Good call.

Sore

PT is kicking my butt.  Literally -- my butt is very sore.  Soreness, meaning the sore feeling you get after working out, has come.  I think I need to back off just a tad in order to keep up the schedule and also be able to function in my roles as wife, mom, substitute teacher, and volunteer.  And when I say "back off" I just mean in number of reps and such, until my body grows more accustomed to the pace.  I'm also wanting them to get into neural flossing with me - which the PT mentioned at eval time but hasn't done in session yet. 

So far, so good.

PT Evaluation

Went to PT today, finally.  She did lots of tests and was very knowledgeable, and clearly respected that I knew my body.  After several tests, she concluded that my sciatic nerve is being pinched/strangled, and I concur.  It makes sense, since the botox in my piriformis relieved my pain so much.  Just can't have botox right now.  And, I don't want to be on botox the rest of my life anyway!  So, she wants me to stop walking for now, especially since my gait will be changing significantly through the pregnancy, and instead get a recumbent bike.  Will be trying it out in PT first before investing, because she wasn't absolutely sure on that one yet, since I'm the first pregnant, si-fused patient she's had, lol!  And of course she will be giving me stretches and exercises for strengthening.  I feel better after today!

Just A Little Each Day

I can tell that my pain level is slowly but surely increasing with the passing days and weeks.  My hormones are relaxing my ligaments, which is surely contributing to the pain levels.  Since I am only on Tylenol, and won't be able to start PT until Wednesday of this week, I have to look at my schedule very carefully to make sure I'm not overbooked.  If I substitute teach one morning, that's likely all I will be able to do that day.  I made the mistake of going grocery shopping after a morning of subbing this week.  That night I took my kids to a birthday party.  When I came home after the party, I needed my cane and an ice pack, and was in tears from pain - I never cry from pain but I did that night.  WAY too much that day.  Note to self: keep commitments to a minimum.  It will all be worth it in the end.  I just keep reminding myself it's temporary.  Just about 6 months to go, and then I can take anti-inflammatories again.

Today I got all the laundry in the house done.  It's because I did nothing else all day, and took very frequent ice pack breaks.  It's good to know your limits.

Takin' It Easy

So I did something yesterday during my exercise - either during the walk in the cold morning, or during my floor exercises - which increased my pain level.  So, taking it easy today - just stretching.  The pain level definitely increases some when you can only take Tylenol, but I just remind myself that this is just temporary.  I am seriously beginning to wonder if I have hip involvement now as well, even though my hip MRI was clean 2.5 years ago.  I'll be asking the PT about that next week. 

I've been trying to substitute teach half days but have only found one job per week so early in the year.  I'm also doing some volunteer work for 4 hours per week, which I have also found physically challenging due to all the sitting.  So I've been home a lot the last couple weeks.  I know, I should enjoy it while I can, because everything will get crazy come April!

Tricare, Medicare, Rah Rah Rah

So I've decided to switch from Tricare Prime to Tricare Standard.  It will give me a hiccup of about a week, but I'm *hoping* that the change gets processed within a week, so I can go to a local family doc and get a written referral to PT before my appointment on the 27th.   Good thing I called this afternoon to find out though, because if I had shown up next week without a written referral and handed them my Medicare card, they would have sent me away, even with a Tricare Prime referral.  Since Medicare is primary, they have to have a written referral whether I have Prime or Standard as my secondary.

As soon as my Tricare change gets processed, I'm also choosing an OB.  I've been going on post which is required with Tricare Prime, and have seen a different provider at every visit.  That's ridiculous.  With 3 rods in my pelvis and a bicornuate uterus, I need continuity of care, and have been refused such through army medicine.  I've gotten a recommendation from a friend for a civilian OB.  I've never been fond of any of the 3 female OB's I've had before: for some reason the ones I've gotten have been femi-nazis who ridicule my choice of birth control (NFP, which, by the way, has worked perfectly for 8 years).  And I do mean ridicule.  It's kind of funny how some doctors will prescribe a grade one carcinogen for birth control and mock anyone who wants to do it naturally as backwards.  But I digress.  The recommendation I have is for a female OB, but I've heard nothing but good things about this one.  I am actually very optimistic about this change from Prime to Standard.  I will have insurance that costs a little more, but will actually give me choices, like most civilians have.

PT

My physical therapy referral was finally approved.  It's a new PT office, so not exactly continuity of care, but at least I don't have to go on-post.  It's two weeks before I can get an appointment, but they put me on the cancellation list should an appointment open up.

I got out in my garden today to till up the overgrown grass with my new tiller.  But alas, I hit a rock and it got stuck in the tines.  I will have to wait until hubs gets home because I can't figure out how to get it loose.  I've also been walking the last two mornings.  The increase in sleep has dramatically improved my morning sickness so that I can exercise again!  It's the little things...  :)

[I did finally get approval to go to my previous PT office, who's been with me for 3 years]

Pain Management

I went to my regular pain management appointment today, knowing I could not get an injection since I'm pregnant.  I was hoping to talk about other medication options, but she said there's really nothing else they can give me.  She was glad to hear I was headed back to PT, and also told me that they *CAN* give me a botox injection in my piriformis, if the pain gets bad, and do it without the xray.  Basically a blind injection.  Of course, if they miss the piriformis and hit the sciatic nerve, then I'll be paralyzed in my right leg for 3 months, but hey...  I said I would keep that as an option in my mind, should the pain get severe.

Oh, and the zofran won't fly.  Gives me killer headaches.  I'd forgotten that...

Sitting Ain't Easy

My kids are recovered from surgery and are back in school, which allowed me to do some volunteer work I've been wanting to do for a while.  I went in for a 4-hour shift, but after sitting 3.5 hours, was in so much pain I had to leave.  I am still waiting for final confirmation on my PT referral, and I do have a pain management appointment tomorrow as well.  Hopefully between these two, we can strengthen my sore areas, and also manage my pain during pregnancy.  All I know is the Tylenol extended release did very little for me, at least when it comes to sitting for long periods.  And standing in a static position for any length of time is completely off the table.  It's all muscle pain, no SI nerve pain, and for that at least, I am grateful.

I did get to finally pick up my zofran today, so with the nausea treated, hopefully I can exercise more.  That has been my biggest barrier to exercise, as you can imagine.

Survival Mode

Both my two boys (ages 4 and 5) had their tonsils out 5 days ago.  Due to the nighttime medication wakings, I have been exhausted and in survival mode.  I have done zero exercise, just trying to do some stretching to keep the pain at bay.  When I don't sleep, my morning sickness increases exponentially, ergo the lack of exercise.  However, this too shall pass.  I can do anything for 2 weeks.

Heartbeat

We saw the heartbeat Monday.  Now I can exhale...

I am off the Flexeril entirely.  I don't think it was helping much with either the muscle spasms or the sleeping problems.  I am sleeping better at night and feeling less pain now that I've found those gluteus medius stretches.  So I'm just on Tylenol now, and I also have a referral in to physical therapy.

On the emotional side, I have been dealing with people who question my choices and capabilities in caring for my kids and the new baby as well. So I have to grit my teeth as they tell me how hard my choices will be on me, as if I hadn't considered the challenges or consequences, or as if I am incompetent.  Perhaps their comments aren't meant that way, perhaps they are just trying to empathize, I don't know.  But it comes across critically. 

It is so vitally important to surround ourselves with people who will be supportive.  People will question your choice to have surgery.  People will question your choice to have another child.  But ultimately, if people can't trust me to make an informed decision based on facts, then those people don't know me and don't need to be speaking into my life.

Exercise

Last Friday, in my zeal to "get on the floor," I overdid my lower back exercises.  Any other area, if you overdo, you're a bit sore for a while.  But when you overdo and throw out your lower back, you are incapacitated for two days. YIKES.  It was lots of ice and rest and Flexeril.  I also used my thera roll after the first 24 hours.

When I was finally feeling strong enough and healed enough, I got back on the floor and did about half as much lower back work.  I did find a couple stretching exercises for the gluteus medius, which is a bugger of a muscle involved in all this, and the stretches help more than anything else I've done for them.  I will link them here for you: ONE and TWO.  The links will open in a new window.

Tylenol Arthritis

The extended release tabs are really doing the trick for me at night.  Before the pregnancy, I'd pop two aleve before bed.  But NSAIDS are a no-no, so Tylenol Arthritis it is.

My morning sickness and exhaustion (partly from the Texas August heat) has been trumping my need to walk.  I've been doing some floor exercises in the air conditioning, but not enough.  It's hard to motivate yourself to exercise when you are nauseous.  But then I remind myself of the last pregnancy and how my lack of core strength contributed to SIJD, and I get on the floor.  But not often enough.

17,000

My hcg levels have doubled perfectly and are now 17,000.  Still have two more weeks until the ultrasound where I will hear a heartbeat, Lord willing.

My last Botox injection has definitely worn off.  I am waking in the night needing Tylenol.  I will buy some of the Tylenol arthritis version today which is extended release, so hopefully it will hold me longer at night.

Walking

So I went for my first walk since being home from Scotland and Ireland.  I walked a great deal while overseas for two weeks.  I used a lot of icy hot patches for my back, and tylenol, and occasional Flexeril while we were there.  But when we got home, I found out I was pregnant and I took a week off from walking to kind of recover from the trip.

So yesterday the walk went pretty well, I tend to have piriformis spasms while I walk of course, but I just adjust my stride and don't push myself.  When I got home, I did sit-ups, the plank, and stretching.  And I did fine all day on just tylenol!  The worst part was simply the pregnancy nausea while I was walking.

2200

Last week when I first tested, my hcg levels were at 40.  Today, 8 days later, they are at 2200 (I'm 5 weeks pregnant).  That is good news that we are heading in the right direction.  They even did a vaginal ultrasound on me today since I have a history of miscarriage (only one, thank God), and I have a bicornuate uterus.  I got to see the gestational sac, and see that it's not ectopic.  So, all around received good news today.  I have been surviving on tylenol just fine for the last couple of weeks, for my piriformis syndrome.  However, since I've been waking at 3 a.m. every day this week, I asked if I could take 5 mg of flexeril as well, just at night.  There's no problem with that -- it's as safe as tylenol apparently.

I have also been using a thera roll and it helps a great deal.  So far, so good, but I'll rest a lot easier when I can hear a heartbeat.

Treatment Timeline

I will begin this journey by sharing my SIJD story. 

May 5, 2008: pain begins in late pregnancy – visit PCM (Primary Care Manager)

July 1, 2008: physical therapy

August 2008-early 2009:  PCMs try oral medications, no effect

January 2009:  PCM orders chiropractic consult, only for active duty military, so continue oral med experimentation

June 2009: x-rays at army hospital, and MRI at civilian hospital.  L4-L5, L5-S1 osteoarthritis and degenerative disc disease.  PCM wants to keep trying oral meds.  No effect.

August-September 2009: chiropractic (out of pocket) for lumbar.  No effect.

November 2009 – January 2010: two separate injections (one in Nov, one in January) at pain management, both times at L4-L5 & L5-S1.  No effect.

February 2010: physical therapy begins for lumbar, no effect.  PT switches to treatment for SI Joint – first relief ever experienced.  However, relief is minor and short-lived.

February 2010:  PCM orders MRI of hips – normal.

March-April 2010: chiropractic (out of pocket) for SI Joint –provides minor, short-lived relief.

Late April 2010: third injection, in SI Joint as well as L4-L5.  No effect.

May 2010: buy inversion table per pain management instructions, no relief – increased pain in right buttock when inverted.

May 25, 2010: bone scan at Army Hospital - normal

June 1, 2010: fourth injection,on right side of L4-L5.  Minor relief of aching pain allowing sitting for a little longer (still no standing or walking for any length of time), relief lasted 2 weeks.  No relief of sharp pain in buttock.

June 29, 2010: orthopedic appointment.  Opinion is also that it is SI Joint causing the problem, with poor prognosis.

July 6, 2010: fifth injection, at S&W pain mgmt, in SI Joint – numbing agent gave relief for 1.5 hours.  Medication changed from Gabapentin to Lyrica.  Started sleeping on ice. 

August 4, 2010: neurology appt.  His physical exam indicated no nerve root damage, but he wasn’t familiar with the treatments I asked about for SI Joint Dysfunction.  Did not offer any solutions or treatments to try.

August 9, 2010: sixth injection, at S&W, this time a caudal catheter in low back and another injection at SI Joint.  50% relief for the next two weeks.  Ice sleeping reduced. 

November 23, 2010: seventh injection series @ S&W: injections on the right side of spine from L4 down to S2.  Diagnostic for RFA (Radiofrequency Ablation).  75% relief first day.  Minor relief in the week following.  Schedule RFA for Feb 2, but insurance denies authorization.  Resubmit RFA request, RFA denied second time.  Medication changed back to Gabapentin from Lyrica, which had no effect.

February 22, 2011: same injections as Nov 2010, in addition to an SI Joint injection.  No significant relief.  Pain continues to increase.  Continue sleeping on ice or heat, depending on how the pain responds.

March 15, 2011: Found a doctor familiar with SI Joint Fusion Surgery in Tyler, TX – Joseph Conflitti.  Dr. Conflitti performs examination and reviews case history and medical records.  Confirms Sacroiliac Joint Dysfunction.  Performs pre-op evaluation for SI Joint Fusion surgery.  RFA request resubmitted again and denied again, appealed and denied a fourth time.

May 24, 2011: ninth injection series – 5 injections on the side (branches) of L4 down to S2.  Additional injection in SI Joint.  Minor, short-term relief.  Surgery request denied.

July 13, 2011:  Received fifth and final denial letter for RFA procedure.  Proceed with surgery which was appealed and approved in June.  www.si-bone.com for the procedure details.  Could not bear weight for 6 weeks post-op.

August 19, 2011: Post-op exam in Tyler with Dr. Conflitti.  Pain still continues but it is too early to call the surgery success or failure.  Conflitti confirms that if my pain has not improved by 6 months post-op, it very likely will never improve.

September 13, 2011: Tenth injection, @ S&W, this time in the piriformis muscle for Piriformis Syndrome, a common problem alongside SI Joint Dysfunction.  Piriformis Syndrome causes sciatic pain.

September 22, 2011: Post-op physical therapy evaluation.  PT states recovery will be 2 – 3 years.  Physical therapy begins on September 27.

September 27, 2011: PCM visit for walking cane prescription

November 10, 2011: Eleventh injection series @ S&W – branch block right side of L4/L5 and S1.  Relief of pain for several hours (not of sciatic pain however).  PT is continuing twice a week.

January 2012: Finally feel better post-op than pre-op.  PT discontinued due to significant progress.  No nerve pain, just muscle spasms.

March 6, 2012: Botox injection in piriformis at pain mgmt.  80% relief for 8 weeks.  Discontinue all meds except Motrin and occasional Flexeril.

June 2012:  Begin walking 1 mile several times weekly.

June 11, 2012: Botox injection in piriformis at pain mgmt.  80% relief.

July 2012:  Pregnant.  On Tylenol only at this point.