The art of screwing up

About making mistakes, taking calculated risks, and having less and less to lose

The feet of a tightrope walker. 27 October 2007. Wiros from Barcelona, Spain.

Versão em português: A arte de fazer cagada

Whoever read my post about uncertainty and making choices under unpredictability and uncertainty might be inclined to ask, “So, what happened?” In the context of uncertainty, what did I decide, and then what was the consequence?

The ongoing story about which you might have wanted to know the unfolding of is that of my latest conundrum: how do I do rehabilitation, or plan a training program for an older person with chronic pain of infectious origin? And then add: “who happens to have been a competitive athlete, retained specific musculoskeletal injuries with life-long sequelae, and have exercise adaptations specific to the sport”. Not the other way round, as I always thought of myself as an athlete who happened to be old, and then ill, and then chronically impaired. Framing it this other (realistic) way highlights the uncertainty inherent to this particular biological system. Such systems are highly unpredictable, and planning anything, including a treatment or management protocol, is hard. Last week’s story ended with decisions to be made, and this is what happened. What happened highlighted another central issue to life in general, but magnified by age, or by living with a chronic illness (which are almost synonymous now): risk taking. Considering the previous week’s pain flare up, which could or not have been triggered by the exercise protocol I used, what should I have done? If you are not into exercise, read the sentence as “considering the previous week’s possible adverse effects to treatment, what should I have done?”. Whatever options I had carried a risk. The lowest risk would be associated with completely changing the exercise/treatment protocol: routine, volume, intensity, everything. That would stray me even farther than I am from understanding the behavior of the injury and its associated pain. I need to understand it as best as I can to manage it, regain and maintain function and autonomy.

I decided the obvious: repeat as accurately as possible the conditions of the sessions done on April 5, 6, and 7, which were followed by the pain disaster. If I observed the same delayed expression of general crapyness and specific pain, I would favor the hypothesis that suggests these were and are bouts of Post Exertional Malaise (PEM). If not, we are back to “could be anything”, including the effect of prolonged sitting, as I considered before.

I did exactly the same protocol, from Saturday to Monday. I felt great Tuesday, so I decided to address the prolonged sitting hypothesis with a high rep bodyweight squat protocol throughout the day, taking micro-breaks every 45 minutes and doing 15 bodyweight squats.

The day went very well, and I barely noticed a sore spot on the top of my knee, over the patella. Wednesday, the following day, the spot was really sore. There is no doubt that I caused an acute inflammation on the left patellar tendon. That is a sensitive part of my body, having been used for grafting in an ACL reconstruction surgery. Of course, I only considered that this was a response to this particular practice - the high rep bodyweight squat protocol - and that it was both too voluminous and too intense for me, after having done all the sets, for two consecutive days.

At night, I considered the damage and how to proceed: a deep squat is intense on the knee joint, and 120 reps is a high volume. Repeating it with pain, a third time is out of the question. Still, within the intermittent bodyweight movement protocol, by which I interrupt sitting periods with short bouts of these movements and avoid aggravating postural aggressions, I looked for something that does not involve knee flexion and can be done in high volume. What about 8 sets X 10 reps of bodyweight good mornings? It sounded reasonable to me. I didn’t consider it would be that much more of a stress to the lower back than the protocol I have been doing fine with, of 6 X 6 deadlifts at 40kg bar weight.

Simplistic and just outright wrong reasoning and the result was catastrophic: I am again nursing a major pain flare-up, this time with a very well-known cause. It almost feels good, just for knowing.

There are many lessons to learn from this week’s mistakes, and some interesting technical training ideas, but I think the most important one was my learning about risk-taking now. How cautious and how bold should I be? Isn’t it risky to try these crazy protocols?

Yes and no. It is a bit reckless to try high-volume bodyweight squats on a typical myalgic encephalomyelitis patient. I may be anything, but I’m not a “typical” ME/CFS patient: I am just another one of the thousands of people who live with chronic pain and chronic fatigue, at varying levels, after they had COVID-19. Whether one and the other - long COVID and ME/CFS - are the same entity or very related ones is an ongoing controversy. We are all patients with, let’s say, a “post-viral chronic pain and fatigue syndrome”. PEM is highly prevalent in these syndromes and I have been cautious both with cardiorespiratory training and with higher intensity protocols, but I have been slowly pushing the boundaries of my exercise tolerance. I don’t think my mistake was volume, though. On the squat days, there was no negative response other than the patellar tendon inflammation. This can be handled with rest for the knee joint and reintroduction of knee flexion, weighted or not, as gradually as possible. My mistake was underestimating the vulnerability of my hips in a straight-legged hinge movement.

“Woman Doing Good Morning Bodyweight Fitness Exercise” at Freepik

The hinge movement is a challenge to the chronic back injury that underlies my chronic back pain. There is a lot of damage around what used to be my L3 and L4 before they fused under bacterial action, when I had spondylodiscitis, in 2013. Good mornings are a great strengthening and postural awareness exercise, but not with this protocol, nor at this stage. I had never done bodyweight good mornings and assumed they couldn’t be any more stressful than empty bar good mornings. To me, they were: not having a bar made it at least more uncomfortable (and slightly more painful). I confess I noticed that in the first set, yet I went through with the plan to do all 8 sets, in a total of 80 BW good mornings.

After the first sets, the movement didn’t seem to bother me so much. By the last sets, it was bothering me a lot again, and again I ignored the sign and completed my planned protocol.

I made two consecutive big and accurate mistakes, well planned for, well executed, and well documented. There is no way to not learn with such a meticulous experience. Maybe the first takeaway is that, wrong or not, I’m glad I made them. I told Andre about them after I screwed up. Could I have prevented the pain I am in today if I had talked to Andre about the plan before executing it instead of after having done it? Possibly. Probably, even. But this is not a universe where I can delay every decision for one day of careful pondering: chronic illness and aging form a dynamic and quickly changing, unpredictable landscape. There are many decisions around unknowns, everyday.

Could I have prevented it any other way, for example by making sure I had the best information to make the decisions? Yes and no: I just asked the following question to Gemini, Google's LLM AI: “Please compare the exercise "good morning" with the traditional deadlift and the RDL concerning spinal erectors’ engagement, as well as the other muscles in the posterior chain.

I am interested in: compared relative strain on hip extension / back hyperextension muscles; compared strain on the sacro lumbar region; compared injury potential / aggravating potential for injuries in the sacro-lumbar area; compared benefits in rehabilitation of back injury; compared benefits in strength increase”. Gemini gave me a detailed analysis and concluded that “GM: Potentially the highest direct strain and shear force on the sacro-lumbar region per pound lifted due to the extreme leverage. Any breakdown in form (lumbar rounding) under load is exceptionally risky here. Requires lighter weights relative to DL/RDL. The Good Morning places the most direct, leveraged stress on the spinal erectors, making it excellent for building back endurance but also the riskiest if form falters.” According to my request, it added the most relevant research publications related to the topic in the past decade. It would have taken five minutes, if that much, to elaborate the prompt, get the response, read it (at least the summaries), and decide.

I could have asked this question and made the right choice. That, however, was only one of the questions I had in my mind, and I didn’t think it was the most relevant. It was. I made a mistake. Had I talked to Andre, he might either have known the answer, or known the question: either one would lead me to safety.

There is no institutional body of knowledge or raw experience in helping people navigate the reality of chronic pain and fatigue. There is some information, not well organized yet, and it is still submerged in controversy. There hasn’t been enough time to allow a critical mass of practitioners and practices around these new disorders. That colleague from graduate school who specialized in the recovery of long COVID among former athletes? He doesn’t exist. Nor does the other buddy with grants from the NIH to study exercise tolerance and readjustment among middle-aged patients in the ME/CFS spectrum. The research doesn’t exist, the colleagues don’t exist. There is nobody to ask.

What the available resources offer to patients is not even effective for bare maintenance, let alone any glimpse at improvement. If Andre starts to train an ME/CFS patient tomorrow, he and the client will face the same sets of hard choices and a limited set of methodological options. Whatever approach is chosen, there is a lot (if not most) of decision-making in real-time, as the training session happens. A trainer cannot risk the client’s health, which limits their choice even further. But I can take risks with myself.

It doesn’t mean I should, but one of the luxuries I have is making informed decisions. They are not necessarily the best by being informed - sometimes it’s better to be based on practical experience -, but they are the best for me. What I have to decide is something there is nobody I can consult about. I know I have to train and I know my body doesn’t respond even remotely as it used to even three or four years ago, and as it had for decades. It’s a new body about which I still don’t know very much, but the little I know is still a lot more than anybody else, and that includes how much I technically, medically, and subjectively know about it. I’m a good coach, but I’m definitely the best coach for myself today.

I acknowledge the environment of uncertainty and new and unstable ideas on all these disorders and “new” entities, and how risky it is to decide anything. Unfortunately for the majority of patients, this uncertain scenario means that most professionals will not be inclined to take risks, and there is nothing in the current toolbox that can significantly help us.

I take my risks with treatments, and, in my case, treatment includes training. Like with physicians, there is nobody “out there” who knows how to train someone “like me”. What’s a client “like me”? A client with symptoms of chronic, persistent, and intense lower back and sacrolumbar pain, and associated fatigue. This client happened to have had COVID-19 for three to six months before exhibiting that pain. The client also happens to be a former competitive and still practicing powerlifter, to have had a serious spinal pathology in 2013 that left sequelae, and to be improving certain aspects of daily functioning while still living with high levels of daily pain… What else? Is there anything here “typical” of any class of people except for the single member set that includes me? How much do we know about long COVID and ME/CFS? You would be surprised by how frustratingly little. Former athletes and chronic illness? Older former athletes in general? Forget it: there is only one person who can make the best-informed decision here, and that person is me. I can’t expect anyone to take the risks involved, or keep tags on so many moving targets in medical research.

The proactive patient - the only one with a chance of improvement in non-transmissible conditions - is an informed and permanently self-educating one. He or she moves and acts in a landscape of uncertainty and unpredictability.

I made mistakes this week. I also got things right, I feel closer to understanding this whole response-to-exercise-thing in the way it is working now: I don’t think I’m dealing with an inexorably vulnerable system like PEM, intolerant to any exercise stimulus. I think it is a highly unstable and fluctuating system with unpredictable responses, but capable of positive exercise adaptation, such as strength gain, as I have measured in this past year. In other words, good news! I am still capable of managing a little stress, which makes me still (re) trainable, and that is a good thing. It means rehabilitation, it means functional gains, it means more autonomy, and it means, above all, the promise of less pain.

The bad news is that it is still quite a vulnerable system, that tolerance to exercise stimulus fluctuates wildly (and I should always assume to be low), and it seems whatever the stimulus is if it is new, the response isn’t great.

I took risks. I made mistakes. I paid a high price in terms of my well-being, with high levels of pain and disability. I will take more risks and make more mistakes, and I’m sure there will be countless more pain flare-ups ahead. But without risks, I have no chance to improve or even maintain my physical health.

I took very well-documented risks, and I have learned a lot. I am preparing myself to make “good” mistakes, mistakes I can extract the most information from.

Intense pain simplifies some decisions. Risks become more acceptable. Am I ok with many other episodes of excruciating pain like this one? Yes, I am. I am very consciously walking into a future when it will happen. It is the price I have to pay for even a chance at improving my condition.

I will recover and I will try again, and I’ll keep lifting.

My next reinvention adventure is psilocybin and the chance of resetting pain by taking advantage of the window of neuroplasticity. I have nothing to lose.

Old age: the last adventure left to Man. Or not.