Persistent low back pain

A 48-year-old gentleman presented to our clinic with a long history of low back pain. The pain started after lifting incident at work three years previously. Initially, he had very severe pain in his back and some pain into his right leg and he had to take time off work.

He underwent a course of chiropractic and physiotherapy care, local to him, which made some small improvements however his pain remained and persisted. He was gradually able to return to work on restricted duties.

He stopped going to the gym and playing golf. He came to see me with a view to having another opinion. He explained to me that he was very fearful of movement and guarded and had been told he should ‘not bend his back as this will cause his disc to be more damaged’ and ‘potentially cause more nerve pain into his leg’.  He was otherwise well and had to work on a shift rotation system with his job which involved some manual lifting.

On examination, it was clearly evident that he moved in a very guarded fashion when he tried to bend his back he was very rigid when he sat down and when he stood back up again. He was very nervous about trying to any movements involving bending at all.  A previous MRI scan did show some disc bulging on the right side near the L5 nerve root.  This is sometimes relevant but not always as many people with no history of back pain show disc bulging on MRI. (See reference below – 1) Sometimes the scan is very relevant but was not so much in this gentleman’s case.

Neurological testing revealed there was no significant compromise to the signal along the sciatic nerve from the back. His muscles were very tight and guarded and he had weak hip muscles.

This gentleman had a very guarded posture because of previous pain experience and also messages given by previous healthcare professionals (Spinal consultant and previous therapist) about protecting his back. This, however, had led to an ongoing maladaptive guarding of his lower back and fear of movement which we know is associated with increased pain. Also as a shift worker he sleeping pattern was not good this is also a factor in sensitising the nervous and leave it prone to causing persisting pain.

I started to try different movements with this gentleman in different ways to help and try and relax his back and to learn to bend pain-free. We started this in a hands and knees position which later progress to a supported sitting position there are supported standing position eventually to leading to bending upright without fear of movement.

This is a graded exposure way of treating low back pain and trying to break the overprotective guarding mechanisms that are actually causing a compressive load on his back and actually contributing to his ongoing pain. This along with education about how pain does not mean harm and that his problem now was more of an issue with his thoughts and protecting his back was more the problem rather than an injury that had not healed.

Over the course of five months, we worked on gradually exposing the back to bending and strengthening his hips to take some pressure off of his back. This combined with educating him about what pain actually is and how the body responds to certain injuries in both good ways and bad ways, helped reduce his pain, improve his strength and confidence in his back.

We also discussed the relevance of his scan and that this did not dictate his long term outcome. He eventually returned to the gym and the golf.

The treatment involved some hands-on treatment initially to help relax off tight muscles and help guide movement and then progressed to a graded exposure and exercise programme. He was seen by me a total of 8 times over 5 months.  This can be variable from person to person.  Often there are no quick fixes to bring about long term real change.

Mark Brennan MCSP MMACP

  1. The relevance of MRI Scans