Chronic lower back pain

Achieve - Physiotherapist Birmingham: Case Study

In this post, we outline a case study of a patient who visited our clinic in
Birmingham (Physiotherapy Edgbaston)in relation to lower back pain...
Low back pain, 16 month history

Patient X visited the Achieve Physiotherapy Birmingham clinic in Edgaston

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
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
Patient reported all aggravating factors were resolved. Sleeping was much
improved, and patient was able to sit comfortably for extended periods of
time, 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 be
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!

Achieve Physiotherapy Birmingham

Achieve Physiotherapy Birmingham is

based in Edgbaston and we want to
help you conquer injuries, overcome
pain and Achieve health and wellbeing.
With a background in professional
sports and elite performance, Achieve
Physiotherapy Edgbaston are making Premier League standards of treatment and

rehabilitation available to everyone.

Our mission is to help you eliminate pain, overcome injuries and lead the life
you want to by utilising highly effective, proactive manual therapy and
rehabilitation techniques proven in the cauldron of professional sport.
Regardless of whether your injury is sports related or not, our specialised
treatment will help you conquer your injuries, overcome your pain and

Achieve health and well-being.

We'd be delighted to help you in any way we can, please feel free to get in
touch and we will answer any questions you may
have: info@achievephysiotherapy.co.uk