A Case Study on Low Back Pain: Fast Resolution

Danny Dinh

Physiotherapist

March 22, 2022

Case study

Last year, an elderly man, Mr. P., came to my clinic complaining of right-sided lower back pain. As soon as he came in, I knew that he was in dire straits: just taking off his boots was a challenge, and he had to be helped to open the door into my office. His pain had started six months ago after helping his daughter set up her tempo shelter for the winter. Since then, he’s had pain every day in the following activities: reaching for a high shelf, lying flat in his bed, even walking for 5 minutes, and washing his hair in the shower.

He spent a month trying lower back mobility drills that he found on the Internet but noticed no improvement. Instead, he felt like his problem was getting worse, which is what brought him to seek help.

Together, we saw that while most of his lumbar movements were fine, he had pain whenever he tried to extend his back backward. After attempting a few exercises together that only seemed to make his pain worse, we saw that repeatedly bending forward would not only bring him immediate relief but improve his lumbar mobility. And thus, he was sent home with that specific exercise.

One visit later, however, Mr. P. felt that while the exercise was very valuable in decreasing his pain so that he could continue his activities, he only felt that he was marginally better: his pain would always come back, which forced him to do another set of the lumbar flexion exercise. “I want a more long-term solution”, he said. 

I couldn't agree more. 

We perfected the angle of his lumbar flexion exercise and saw that just by shifting the angle of the flexion, by placing a foot on a stool, he was getting even more improvements than the initial exercise. 

Two visits later focusing on strengthening and perfecting our plan, Mr. P. declared that he was 100% better, and so we concluded our treatments. A phone call 3 months down the line served to answer any questions and to ensure that he also remained better.

But isn’t bending forward bad for my back?

Not at all! The act of bending forward, aka flexing the spine, is perfectly natural and is actually integral to our lifestyle. Can you imagine trying to avoid flexing the spine at all times? How would you get around petting your dog, picking up your phone under the car seat, or fixing the kitchen sink? 

The reason why people often injure themselves in flexion-related activities, such as shoveling snow or lifting something heavy, is the same as why some get injured while running after being inactive for a long time: they do too much too soon!

Does this mean that shoveling snow, lifting objects, or running are inherently dangerous activities?

Of course not! It’s a matter of progressing and warming up appropriately for the activity, as well as taking breaks. Instead of shoveling 20cm of snow in your driveway in one go after sitting at your desk for 8 hours, break this activity up into chunks and take a small break every 15 minutes. And instead of lifting something heavy, injuring yourself, and then blaming the fact that you “bent forward too much”, ask a friend for help. 

This concept and advice also apply to posture: contrary to popular belief, sitting in a slouched position does not directly lead to back pain. This is supported by a systematic review of systematic reviews published in 2019 (NCBI: 31451200), which concluded that “there is no consensus regarding causality of physical exposure to LBP”. 

Our lower backs love movements in all directions, including sitting with a slight flexion/curve. However, if you find that sitting with a “bad” posture increases your back pain, try balancing it out with sitting more upright. Using a lumbar roll could help with that.

Okay, I get that lumbar flexion is not inherently bad for my back, but that still doesn’t explain how it helped Mr. P.

Mr. P.’s history and pain patterns indicated that he could have a rapidly reversible condition, a.k.a. a lumbar derangement. These conditions can typically be resolved quite fast, within weeks of starting proper treatment.

The working theory regarding the nature of a lumbar derangement is that a space occupier disrupts the movement between two articular joint surfaces. Joint derangements can typically be resolved rapidly by performing an exercise in a specific direction repeatedly.

After experimenting with other exercises and listening to Mr. P’s story, we found out that repeated lumbar flexions would help relieve his pain and increase his mobility in the clinic. After performing that exercise at home for a week, it was clear that this improvement could be replicated at home as well!

This story is far from unique. From personal experience, more than half of the patients who enter my clinic with back pain, whether traumatic or insidious, acute or chronic, end up being part of the “rapidly reversible derangement” subgroup.

But I’ve been doing so many low back exercises, and yet I still have pain.

While stretching and exercising the lower back in all movements is good for general health, the key part of resolving a lumbar derangement is to move in a specific direction and temporarily pause exercises in other directions. It’s like removing a piece of food stuck between your teeth with a toothpick: sometimes, coming at it from any direction is sufficient to remove it. However, most of the time you need to find the exact right angle to remove it!

Some derangements need not only to move in a specific direction but also with a specific load. It is the physiotherapist’s role to methodically rule out possible directions and find the perfect exercise for your condition. My ultimate goal is to help you treat yourself by guiding you towards the right exercise.

We keep talking about exercise and movement, but what about manual therapy?

Manual therapy can play a key role in my practice of treating back pain. It helps me better zone in on the exact “point” where the patient feels their pain, creates a therapeutic alliance, and sometimes reduces the pain faster than just doing exercises. 

    That being said, we would seldom start an evaluation or a treatment with just manual therapy: just like how exercises to treat a rapidly reversible condition need to be in the right direction before being repeated, manual therapy also needs to be in the right direction. My process is as follows: once a directional preference has been established through a response-based assessment, my patients and I work together to perform the exercise while I do manual therapy and we both observe how their symptoms and mechanics change. If we find they improve better with manual therapy, we’ll keep repeating that treatment. If not, then we’ll just go back to exercises.

    It’s like putting the right amount of hot sauce in your meal: some people like more, some people like less (others prefer no hot sauce at all, but we don’t talk to them). You don’t want to start off by dumping a lot of hot sauce, especially if you haven’t tried the sauce yet and don’t know how spicy it is. This is akin to doing a few movements in a specific direction (ie: putting a bit of hot sauce) before determining if pushing further with manual therapy (ie: dumping the bottle in) would be necessary.

    Was this analogy good or did I just want to talk about hot sauce? Good question.

But how will I know if this will work for me?

A rapidly reversible low back condition, or a derangement, is often characterized by a variability in pain site. For example, if your pain often moves from the left side of your lower back to the right side of the center low back, or even in your leg, we would consider it variable. Another key characteristic of a lumbar derangement is an obstruction to movement when aggravated: stiffness when getting up from a chair and difficulty straightening completely when standing are examples.

These characteristics are considered “green flags” and increase the chance of us dealing with a rapidly reversible condition. However, their presence or absence does not completely include or exclude a derangement.

Even if your back pain is not rapidly reversible, rest assured, it very likely still has a positive prognosis. That being said, identifying a condition as rapidly reversible or not is always the main goal of our first session together. This is logical: why take longer to get rid of pain when we can quickly rule out whether the condition can be rapidly reduced? Through a response-based assessment where we monitor your symptomatic and mechanical movements to specifically-chosen lumbar movements, we will determine if a reductive exercise can be found.

Moving forward

If any of the information or stories in this article speaks to you, feel free to check out my profile to read more of my articles or to book a 1-hour private room evaluation with me.

If you’d like to discuss any of the points raised in this article in more detail, I would love to speak to you. You can contact me by email at dannydinh.physio@gmail.com or by phone at 438-801-0417. I currently offer free no-strings-attached 15-minute phone call sessions to discuss how I can best assist you.

Further reading

Here are some suggestions of articles I have written recently, organized by topics.

An in-depth explanation of my physiotherapy philosophy: Part 1, Part 2

Neck pain: a case study, answering common questions from patients

Low back pain & sciatica: case study 1, case study 2

Knee pain: case study 1

Shoulder pain: case study 1

An explanation of referred pain

Why choose telerehabilitation

7 reasons why I love my profession

Images courtesy of: Abris Tempo, Ortho Library, Physio Advisor, Fireworks BBQ