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Back Pain - Case Study by Ben Cormack

Case A – a Case Study for therapeutic functional movement

Background

Having suffered with back pain for the last 10 years, X’s back would flair up every few months acutely and leave her in agony for a few days. She suffered with a fairly constant non-specific ache and sense of tightness that was worse when she first got up in the morning.

After a diagnosis of ‘non specific lower back pain’ from scans on previous occasions over 3 years apart, there showed some degeneration of the lumbar spine. Between scans it demonstated that the symptoms had not worsened and showed no neurological involvement.

Specific activities could trigger the back pain such as putting on her shoes, and doing the gardening. She was hesitant of bending too quickly and picking things up that are heavy as these moves were uncomfortable.

Temporary relief was found through manual therapy but this was short lived. She had also tried Pilates and ‘core stability’ with limited results even though this had been prescribed by previous health care providers.

Assessment

In assessing movement, it was obvious at how stiff the client was through the hips and lumbar area. This was apparent in her walking gait and also when we looked at relevant movements such as bending forward. This is often the case with back pain patients with a direction specific impairment.

Even before she moved the very idea of bending was problematic for her.  Trying to reduce the fear present with movements that are problematic was the first point of call. Reassuring her that her actual structure of her back was not damaged and moving it was the best thing to do for the muscles, was an important step. Disconnecting the idea in her mind that hurt is always correlated with the level of tissue damage, was significant. Using the examples of a paper cut for this resonated with her. 

We then moved on to movement. Bending is a movement from a collection of joints including the ankle, knee, hips and lumbar spine. We assessed the ability to flex through the ankles and hips and found both the left hip and ankle to be limited into flexion. When we asked her to bend over specifically using the left leg, all the movement came from the upper lumbar spine.

X also had very limited movement control or variation when asked to balance on the left leg or perform movement drills such as a simple circle from the left hip.

Treamtent aims

The treatment plan was to start to increase the actual movement and movement confidence in the left hip and then integrate that into the relevant movement of bending over.

We did this through simple non-threatening movement tasks for the left hip. This instantly decreased the protective muscular tension in the hip and we then proceeded to do the same for the left ankle. Although this was not a permanent change it showed X that positive change could be made. These movements formed her home exercise program.

We then took the new movement capacity at the hip and ankle and integrated it into the threatening movement/motor pattern of bending. By moving more from the ankle and hip the movement from the sensitive and stiff lower back was reduced. The movement was more integrated spreading the load across more joints.

We then progressed this into a ‘picking up a box’ task from various positions to make it more relevant for the client. It is important to create more ‘robustness’ for decreasing future incidences. Using a graded exposure of steadily increasing loads, speeds and ranges we could build capacity and further increase confidence.

This was aimed at being a longer term solution driven by the client rather than a quick fix. Over the next few months X’s back tightness and ache steadily decreased and the number of acute incidences also markedly decreased.