Chronic lower back pain: A case study

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A Case Study by Achieve Physiotherapy

In this post, we outline a case study of a patient who visited our Physiotherapy clinic in Birmingham in relation to lower back pain…

 

Low back pain, 16 month history

Patient X visited the Achieve Physiotherapy Birmingham clinic in Edgbaston complaining of low back pain referring down the left buttock and hamstring into the calf region. This had been going on for about 16 months and the patient was unaware of any cause.

The patient had been to see GP on 3 different occasions, on the 1st visit he was given pain relief (paracetamol), on 2nd visit was then given co-codamol and Amitriptyline and sent for Lumbar spine X-rays, and on the 3rd visit was sent a referral for NHS physiotherapy assessment, for which he had to wait 8 weeks for. After initial assessment by the physio, he was seen 3 times and was given lumbar extension exercises, mechanical traction and advised to use heat as much as possible.

This course of treatment had little impact on his symptoms and the patient was referred to the chronic back pain classes after being discharged from one-to-one physiotherapy. He was given a maximum of 6 sessions consisting of core stability exercises and cardiovascular activity on a cross-trainer and bike. The patient reported a minor improvement since the onset of pain 16 months previously but was still complaining of 7/10 pain. The patient found out about Achieve Physiotherapy Birmingham through a friend who had also had treatment with us and was very happy with the outcome.

 

SUBJECTIVE EXAMINATION (information from patient)

“Patient x reports a pain level of 7/10 and stiffness in the morning when he first gets out of bed, this “eases off” after around 1 hour once he is up and moving around. The patient reports awareness of a dull ache at all times which is worse in cold weather, sitting for long periods and lying in bed at night.

The patient enjoys playing 5 a side football once a week with friends and also likes walking his dog but is unable to do this as frequently as he would like due to pain. He would like to get back to playing 5 a side but is quite fearful it may cause more damage.”

OBJECTIVE EXAMINATION

(information from physical examination)

On examination, the patient had restricted lumbar (lower back) movements, especially in flexion, which caused the referring left leg pain to return.  He also presented with pain through the range of back extension. There was a noticeable stiffness and a reduction in movement of the vertebral joints and on palpation, there was significantly increased muscle tension, tightness and pain throughout the left side lower back and gluteal regions with major trigger points in Left sided lower back muscles and in the piriformis muscle (in the glutes).

Patient X presented with an asymmetrical gait (altered walking pattern) with reduced heel strike on left side. Leg length was measured and a discrepancy was found, left being longer compared to right, the patient also demonstrated a bi-lateral equinus condition at the ankle joint which caused his feet to over-pronate (roll in excessively) when walking.

 

Clinical reasoning & diagnosis

Due to the back pain being present for such a long time, joint and soft tissue stiffness, irritation and hyper-tonicity (spasm and knots in the muscle) in the left-sided muscles (lumbar & gluteal) had led to altered mechanical function over an extended period of time and resulted in a chronic cycle of inflammation and pain, consequently leading to repeated formation of scar tissue and adhesions at the site(s) of trauma.

The underlying factors causing the clients symptoms at the time of assessment were a combination of hypomobility (lack of movement) of the lumbar joints that had been inflamed at the onset of injury, and hypermobility (excessive movement) of the surrounding joints in an attempt to compensate for the aforementioned stiff motion segments, which in turn had led to spasm and tightness in the surrounding muscles.

Treatment protocol

Time was taken to fully explain to Mr X  the treatment and rehabilitation protocols required to tick the relevant boxes and the time scales required to achieve these outcomes. A basic overview of the physio treatment plan provided was:

  • Sufficient rest from aggravating activities, needed to determine a baseline level of irritation, advised for 10-14 days.
  • Deep soft tissue massage/myo fascial release/trigger point therapy to the areas of irritation and surrounding tissues in the lower back and gluteal region.
  • Joint articulations and manipulation to the lumbar region and sacroiliac joint to facilitate normal movement mechanics and relieve stiffness and tightness in the joints
  • Biomechanical correction – bilateral orthotic devices fitted to negate leg length discrepancy and correct over-pronation – reinstating correct walking pattern and mechanical loading from up from the feet
  • Gentle stretching and mobility exercises
  • Once symptoms were under control, commenced low impact exercise to improve CV fitness and boost circulation to the affected area.
  • Tailored Strength & conditioning programme to reinstate normal muscular function and tone.
  • Introduced activity specific speed exercises and drills before returning to play 5 a side.

Outcome of treatment

The patient reported all aggravating factors were resolved. Sleeping was much improved and the ability to sit comfortably for extended periods of time was regained, though now understands the importance of not being too sedentary for long periods and maintaining good posture.

The patient returned to playing 5-a-side football 8 weeks (and 8 sessions) after first receiving treatment from Achieve Physiotherapy and is enjoying being able to return to previous activities without the back pain which had been hampering them for over a year.

If you would like to find out more about how Achieve Physiotherapy can help you with any injury or pain problems you have please get in touch!