My treatment philosophy is guided by 2 core principles: 1. I optimize my patients' recovery time frame as much as possible. 2. I empower my patients to be as independent in their rehab as much as pos...
This article offers an in-depth look at the treatment of a patient of mine, Mrs. O. Unlike my previous 2 case studies on the neck and lower back which summarized the treatments I provided, this one will go in-depth into the patient’s history, our evaluation, as well as each of our subsequent visits. Any identifying details about the patient’s history and profile were altered to protect anonymity.
We will highlight the power of a proper mechanical evaluation and exercises, which fully resolved Mrs. O.’s pain despite us having all our sessions virtually. This article is also a follow-up to my physical therapy philosophy articles (part 1 and part 2), as it showcases my two core principles as a physical therapist.
Like many of my patients, Mrs. O. had low back pain. Even though her pain was greatest in her back, it was not localized there: it irradiated to her coccyx and then both her thighs along a sciatic distribution and she also felt some numbness in her left foot that she attributed to her back condition.
Unlike many of my patients, however, Mrs. O. was initially reticent in letting me treat her sciatica. It was not that her low back pain was not bothering her, but that she had little hope that it could be treated. The only reason why I knew of her pain is that I was initially treating her for a wrist sprain. On her last visit for that problem, her back pain came up in our final conversation and I dug deeper to find out more.
Mrs. O. was now 55 and had been living with this pain since her early twenties. “Hopefully it’ll retire at the same time as me,” she joked. There was a time when Mrs. O. was very proactive in trying to find a solution for her condition. Over many years, she saw different physical therapists, chiropractors, and even a neurosurgeon. Psoas and piriformis releases, hot and cold contrast baths, spinal manipulations, and anti-inflammatory medicine, all were tried with no significant results. The only thing that gave her any real results was a cortisone injection, but that was short-lived: the pain, unfortunately, came back after around 5 months.
What was as infuriating as the pain’s persistence was the reason it came in the first place. On a lazy Sunday morning, Mrs. O. got out of her bed and reached to her side to grab a shirt. But instead of finding her shirt, she felt a tremendous strain in her coccyx and low back.
After some explanation of my philosophy of treatment, Mrs. O. agreed to try an evaluation and a few exercises. She had been satisfied with our treatment of her wrist sprain and was willing to take another shot at her lower back. An additional challenge of our treatment of her condition was that our sessions were done entirely by video calls; we were in the middle of the COVID-19 pandemic and Mrs. O. preferred limiting her displacements due to other health conditions.
If you have questions about physiotherapy done via telerehabilitation, check out this new article I wrote on this new and innovative way of delivering care.
On our 1st visit, we started with an interview to obtain more details about Mrs. O's condition: her pain was generally aggravated whenever she stood for more than 30 minutes, when she crossed her legs and when she walked upstairs. Like Ms. V., her pain was highly variable: some days she would have no pain with her activities, and some days she would have such excruciating pain that she couldn't even stand up and perform her daily tasks.
In terms of the range of motion, Mrs. O had some limitations in both bending forward and backward as well as whenever she would turn to her right side. She also felt some pinching in her back when she would raise her right knee up and when she sat cross-legged. Going up and downstairs was also painful.
Mrs. O. had an abundance of baselines - movements and positions that reproduce her pain and help us monitor improvements and regressions. When testing repeated movements, I noticed that after completing a set of standing extensions (as depicted in the picture), Mrs. O's baselines moderately improved, and thus this was the exercise that I sent her to do at home 10 times every 2 hours.
Why was Mrs. O only given one exercise to perform at home after our first session? The reason for that is that we were screening for a directional preference, which is a single movement that when performed at the right force and frequency, can rapidly resolve a patient's condition. For a deeper explanation of different classifications of patients' conditions, feel free to check out my philosophy physical therapy article.
"I am pleasantly surprised. "
That’s what Mrs. O. declared when she joined our second session’s Zoom meeting. Her pain was not gone but she was seeing a good improvement. When I asked her to quantify it, she said "Well, maybe my pain was about a 7 out of 10 at its peak on usual days. After I've been doing the exercise for a few days, I'd say it's more of a 4 out of 10."
I could sense that Mrs. O was starting to have a little bit more hope but she was still not entirely convinced. After all, her pain was extremely variable: there was a chance that her pain would have decreased even without the exercise. She could go weeks at a time without feeling any severe pain.
I agreed with her and was eager to see if we could reproduce the improvements in our session. As in our first session, we checked her baselines: painful movements such as bending backward, forward, rotating to the side, and crossing her right leg over. Then, we performed the extension standing exercise and rechecked baselines.
As in our first session, her baselines all improved.
“What do you think?” I asked her.
“I think this is either one heck of a coincidence or the exercise is actually helping,” she answered.
“What do you think we should do?” I asked her.
“I think I should be doing as many of these extensions as possible.”
And so at the end of our 2nd visit, we kept the extension standing exercise and added other strengthening exercises to work on her general upper and lower body strength.
As soon as our third session started, I knew I was in for a challenge. When asked how she was doing, Mrs. O. answered that she felt much regressed.
The first few days after our second session, she had been feeling great and optimistic; her pain was more of a 1 or 2/10 then. Three days ago, however, her pain shot back up to its usual 6-7/10. From our first session, I knew that this was a common occurrence for her highly variable pain. Still, I wanted to dig deeper.
We did a quick re-evaluation. Mrs. O. was indeed worse: not only were the usual baselines hurting her more, but she had also lost a moderate amount of mobility.
I wanted to test a theory. I made Mrs. O. perform a set of lumbar extensions. Her baselines improved. Then we performed a set of lumbar flexions, which were quite painful. Her baseline movements were back to being painful and limited. (Refer to the image below to see what lumbar extensions and flexions are)
I had a suspicion that the reason why Mrs. O.’s condition deteriorated wasn’t that her lumbar extension exercise was no longer working, but that she had stayed in a sustained flexed (bent forward) position. I shared my thoughts with Mrs. O. and she found it possible. She noted that the night before her pain flared back up, she had spent hours bent forward, trying to fix her sink.
We decided to conduct an experiment: for the next 72 hours, Mrs. O. was going to try to bend forward as little as possible while still continuing her lumbar extension exercise.
3 days later, I called Mrs. O. for our planned phone appointment: my theory was proven right. After avoiding flexion for only three days, her pain was back to being a 3-4/10 instead of a 7. I then told her it was alright to restart bending her back forward as usual and to restart doing her strengthening exercises, with the caveat that whenever she would spend much time bent forward, to take frequent breaks and perform more lumbar extensions than usual.
Something that I emphasize to any of my patients who need to temporarily decrease their time spent in lumbar flexion, is that it is temporary and unique to their condition. Not everyone who has back pain should avoid this movement. It is essential for our daily functioning and is not inherently harmful at all. Some low back pain can even improve with repeated lumbar flexions.
It’s all about load management: Mrs. O. was fine when she was doing a few flexions per day, but the pendulum went too far when she spent multiple hours in that position to fix her sink. To remedy that, we overcompensated by avoiding that movement while we waited for her pain to calm down. Once she was back on track, it was alright to restart flexing her back as usual, provided that she takes a few breaks and performed more of the lumbar extension exercise than usual if she spent more time flexed.
All lower back pain is different. Your directional preference (if present) and ideal treatment plan will likely differ greatly from Mrs. O. and Mr. P. It will be my duty to help guide us toward the optimal individual plan for you.
We concluded our physical therapy visits after 7. Here is what we did for the last 4 visits.
Session #4: After doing her exercises for two weeks, Mrs. O.’s pain was even more improved now: a 1 or 2/10 and only provoked when she bent forward deeply and when she would go upstairs. Mrs. O. was now very hopeful that she could get rid of the pain that she had been carrying for decades. As we discussed Mrs. O.’s other goals other than decreasing her pain, she got emotional. It was completely normal: as she was listing all the sports and activities she had stopped or avoided doing because of her back pain, she was overwhelmed. We focused on progressing her strengthening exercises to better prepare her for an eventual return to playing tennis.
Session #5: In our fourth session, Mrs. O. was still improving steadily. She now no longer had pain when she would raise her knees or take the stairs. One problem still remained, however: she still had pain whenever she bent forward. That was the only thing that was still causing her issues. She was highly happy about her improvements, but I knew that we were not exactly done yet: as a fellow tennis player, I knew that bending forward was needed in many shots. We started the sandwich protocol: which is an exercise program combining flexions and extensions to help a patient be able to flex forward pain-free.
Session #6: Mrs. O. could now flex fully pain-free. She still did not consider herself fully recovered, as she still had random bouts of pain once or twice a week, but she had restarted playing some light tennis with her husband with no issue.
Session #7: Our seventh and final session was conducted two months after the sixth. Mrs. O’s pain was now a clear zero, and she declared herself fully recovered. She did not have any random bouts of pain anymore and had stopped needing to perform the lumbar extension exercise. In this session, as in all my final sessions with my patients, I made her a plan to autonomously maintain her improvements and what to do if the pain ever comes back.
“Everything we did in our sessions, you did in the comfort of your home without any special tools or physical therapy maneuvers,” I told her. To summarize the management of recurrences plan, Mrs. O. was taught how to check her own baselines and to perform the lumbar extension exercise if her pain ever came back.
Here is what I would consider being the main takeaways from this article:
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 email@example.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.
Here are some suggestions of articles I have written recently, organized by topics.
Knee pain: case study 1
Shoulder pain: case study 1
Images courtesy of: The Epoch Times, HEP2Go, Exhale Pilates London, GQ, PainHEALTH