Lower back pain patient

Ed Thompson

Mentorship Member
Joined
Nov 7, 2020
Messages
2
Hi Dave / Shane

I'm looking for some help with a patient of mine!

He's 32 year old chap who 20 months ago had a discectomy for an acute episode of insidious onset right sided sciatica which settled his leg pain.

He had a course of physio with the NHS afterwards to settle his lower back pain and in Jan 20' was feeling much better and returned to weight training and running.

In April he was doing single leg deadlifts with 60kgs and had a recurrence of his back symptoms without the leg pain this time.

He had an MRI with his previous consultant which was normal in April.

Since then he has had sleep disturbance from 1am until he wakes and then is really stiff to get going in the morning until he does a series of stretches.

I've been working with him since October initially with more traditional approaches and then after starting the mentorship in November started to use the graded exposure programme with him.

He has had a very stressful year and is in therapy and tells me his is depressed. Partly due to work, having a new born, his back and its effect on his life, and various other things.

He has had episodes for around 2 weeks without symptoms but he regularly has episodes of acute lower back pain. He denies any particular triggers.

His training schedule at the moment is 2-3x per week of weight training, 1 day legs including deadlifts, squats, lunges and bridges and the other days upper body and core.

On his last session he had resting symptoms of 5/10 in his lower back and had a bad episode of 4 days over Christmas.

His range of motion is full. In the frontal plane he does not transfer weight well. Saggital plane there is poor transfer of weight and his doesn't bend well through his trunk.

He is hyper mobile, 6ft 7 and very lean.

His posterior knee stability is weak at his hamstrings and calf. He has reduced power in his frontal plane with all 3 variations.

He reports he is always very rigid through his back to protect it and I've spent time educating him on relaxing and slouching.

His breathing pattern is poor and he tends to hold on to his breath which I have spent some time working with him on. He denies any previous injuries.

He said on his last session he doesn't think its going to get better and is openly depressed about his back and lack of progress.

We discussed other interventions including a steroid injection. He is keen to continue working in physio to solve it.

I see him every 2 weeks because he prefers to get his teeth into the rehab programme between each session and is very diligent.

My thoughts are there are yellow flags, a lack of momentum with the gaps between appointments, his weight training programme which he is keen to continue because it helps his mind, and his mindset.

The work we have been doing on the last 3 sessions has been around lunging biasing his frontal plan and sagittal plane, using the pin and stretch for hamstrings, calf, glute med., illiocostlis and obliques (not all in one go!). He finds fairly good relief with the hands on treatment focussed around his glute med and piriformis.

I think he has worked hard at his rehab and I am wondering if more rehab is appropriate or if there are any other avenues to go down.

Any help would be greatly appreciated : )

Thanks,

Ed
 

Dave

Mentorship Coach
Staff member
Staff Member
Joined
Sep 22, 2020
Messages
86
Hi Dave / Shane

I'm looking for some help with a patient of mine!

He's 32 year old chap who 20 months ago had a discectomy for an acute episode of insidious onset right sided sciatica which settled his leg pain.

He had a course of physio with the NHS afterwards to settle his lower back pain and in Jan 20' was feeling much better and returned to weight training and running.

In April he was doing single leg deadlifts with 60kgs and had a recurrence of his back symptoms without the leg pain this time.

He had an MRI with his previous consultant which was normal in April.

Since then he has had sleep disturbance from 1am until he wakes and then is really stiff to get going in the morning until he does a series of stretches.

I've been working with him since October initially with more traditional approaches and then after starting the mentorship in November started to use the graded exposure programme with him.

He has had a very stressful year and is in therapy and tells me his is depressed. Partly due to work, having a new born, his back and its effect on his life, and various other things.

He has had episodes for around 2 weeks without symptoms but he regularly has episodes of acute lower back pain. He denies any particular triggers.

His training schedule at the moment is 2-3x per week of weight training, 1 day legs including deadlifts, squats, lunges and bridges and the other days upper body and core.

On his last session he had resting symptoms of 5/10 in his lower back and had a bad episode of 4 days over Christmas.

His range of motion is full. In the frontal plane he does not transfer weight well. Saggital plane there is poor transfer of weight and his doesn't bend well through his trunk.

He is hyper mobile, 6ft 7 and very lean.

His posterior knee stability is weak at his hamstrings and calf. He has reduced power in his frontal plane with all 3 variations.

He reports he is always very rigid through his back to protect it and I've spent time educating him on relaxing and slouching.

His breathing pattern is poor and he tends to hold on to his breath which I have spent some time working with him on. He denies any previous injuries.

He said on his last session he doesn't think its going to get better and is openly depressed about his back and lack of progress.

We discussed other interventions including a steroid injection. He is keen to continue working in physio to solve it.

I see him every 2 weeks because he prefers to get his teeth into the rehab programme between each session and is very diligent.

My thoughts are there are yellow flags, a lack of momentum with the gaps between appointments, his weight training programme which he is keen to continue because it helps his mind, and his mindset.

The work we have been doing on the last 3 sessions has been around lunging biasing his frontal plan and sagittal plane, using the pin and stretch for hamstrings, calf, glute med., illiocostlis and obliques (not all in one go!). He finds fairly good relief with the hands on treatment focussed around his glute med and piriformis.

I think he has worked hard at his rehab and I am wondering if more rehab is appropriate or if there are any other avenues to go down.

Any help would be greatly appreciated : )

Thanks,

Ed
Hey Ed

Happy new year!!

Some thoughts here on how i'd approach this one!

]

Any questions just ask!
 

Sandra

Mastery Member
Mentorship Member
Joined
Nov 20, 2020
Messages
1
Hey Ed

Happy new year!!

Some thoughts here on how i'd approach this one!

]

Any questions just ask!
Dave in this case would increasing the frequency of visits even if only temporarily help as well?
 

Nuala

New member
Joined
Jan 11, 2021
Messages
2
If I could add something, it sounds to me that it could be helpful to explore his fear related beliefs not just related to his physical activity but life in general, and how these may be contributing to persistence of his symptoms. There is a free online program by a pain psychologist called Alan Gordon that I have found helpful in increasing my patients' understanding of persistent pain in a non-threatening way. See http://www.tmswiki.org/forum/painrecovery/
 

Nuala

New member
Joined
Jan 11, 2021
Messages
2
Seeing things through a lens of safety rather than danger, which is what one is attempting to achieve with the physio also. I find that the pain science education helps move that process along more quickly.
 
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