CASE STUDIES

Brennan - A Chronic Case

In Chronic cases of back or neck pain there may be an underlying level of permanent damage. Often there are x-rays or scans that show degenerative change in the spinal joints or discs. In some cases the knowledge that there is a level of permanent damage can demotivate a person from striving to get better. However from a therapy point of view we know that with the right management and rehabilitation it is possible to significantly reduce or abolish the pain in spite of the underlying damage.

Brennan

Brennan is a 29yo administrative worker. He first presented with a 2-year history of chronic low back pain. He had a pile of x-rays and scans that had been taken over the past 2 years and was wearing a back brace. He had low expectations of achieving a good result as he had been diagnosed with degeneration in some joints and a significant low back disc bulge. He had recently been referred to a spinal surgeon.

History

Brennan simply bent over to pick a tissue off the floor 2 years previously, felt a sharp pain and had not had a day without pain since. He had seen multiple therapists without any lasting results and got the most relief from wearing the brace and from a weekly massage. His pain caused him to miss quite a few days at work and he was no longer able to play sport.

The first 3 visits

The critical factor in deciding whether or not treatment is likely to be successful in chronic cases is whether it is possible to isolate specific movements that reduce the symptoms. Sometimes this is apparent in the first clinical session but more often it will take 2 or 3 sessions. In this case it was apparent that backward extension movements of the spine gave some relief whilst forward bending movements were a source of aggravation. The problem with this in Brennans case was that sitting is a forward movement of the spine, and Brennan spent up to 10 hours/day sitting at work, on transport and at home.


The solution

A serious conversation was had with Brennan. He was given two choices:

  • 1. Continue as he had been for the last 2 years and most likely go down the surgical route
  • 2. Take 7 days off work, minimise sitting for those 7 days down to less than an hour/day, and diligently follow a program of low back extension exercises.

In this case Brennan chose option 2. He took 7 days off work and was diligent with the exercise program. A week later his pain was significantly reduced and he realised that for the first time in 2 years he had control over his pain.
After 2 weeks he had experienced his first pain free day for 2 years. He stopped wearing the back brace and could see that there was light at the end of the tunnel.


The Outcome

It took a further 6 weeks weeks for Brennan to become completely pain free. During this time we had instigated a strengthening program, he was swimming twice a week and was considering a return to sport.

Does that mean that the underlying changes had all gone away? – No. The joint degeneration would always be there and he would always be at risk of another disc injury. But for the time being he had his life back. He also now had a
positive exercise habit, knew how to manage his lifestyle and posture and had really good supportive core muscle control.

He also knew that if he started to experience back symptoms at any time in the future he would come to DiY Physio before he thought about seeing the surgeon

Victoria - A complex case

Complex cases are just that – complex! They have multiple factors and have usually been present for months if not years. The reason they are so difficult to resolve is for two reasons. TIME and TRUST:

  • 1. TIME – The Therapist needs long consultation times with the patient to fully understand the complexity and how the different causative factors inter-react. If the therapist is under time pressure then something vital may be missed.
  • 2. TRUST – The patient needs to have trust in the therapist as there will almost certainly be days when things don’t go according to plan.

Victoria

Victoria is 68yo, retired, a mother of 2 adult children, a grandmother of 2, loves sewing and lives with her husband of 42 years.

History

The reason this case is so memorable is because there were so many potential causative and inter related factors that it took over an hour to take a complete history. To list a few of the medical events that had happened to Victoria in the previous 6-months:-

  • Severe neck pain
  • Pain into both arms and hands
  • Loss of sensation in both hands
  • Carpal tunnel syndrome
  • One significant stroke and several minor strokes
  • A heart attack
  • 3 broken ribs
  • Regular attacks of dizziness

Victoria had spent the last 6 months seeing one Doctor or Specialist after another and was understandably cautious about trusting yet another medical professional.

The first 3 visits

Luckily, in the very first session, we were able to isolate a very specific neck movement that gave short term relief of the neck and arm symptoms. This at least gave Victoria some sense of control over her situation which had been running wildly out of control for the previous 6 months.
Working in conjunction with Victoria’s GP and Specialist we were able to bring the dizziness under control.
A couple of cortisone injections by a specialist into the neck helped to further improve the pain.

By session number 3 we were working on Victorias posture, her stress management and her muscular control of her upper back and neck.


The solution

Both the collaborative approach between DiY Physio and Victorias medical team, and the gradual reduction in symptoms gave Victoria the all important trust that is needed for success in complex cases.

Over the next few weeks we gradually layered an exercise program that rebuilt Victoria’s posture from the ground up. Some of the postural problems went back at least 30 years to her time in childbirth.

The secret in this case was to allow 2 weeks or more between treatment sessions. Victoria didnt need a lot of hands-on treatment. What she needed was time, guidance and encouragement to work on a program every day herself.


The Outcome

Victoria has got her life back. She can sew for short periods. She can play with her grandkids. She is no longer dizzy. Her neck symptoms are very reduced and quite infrequent. Her rehab is ongoing and she will need to maintain some level of corrective exercise for the rest of her life. I am sure we will see Victoria from time to time as she feels the need

Rob - A Recurrent Case

Rob

Rob is a 35yo gym junkie. He first presented with right-sided low back pain and right leg pain some 6 months after first injuring his back doing dead lifts at the gym.

History

Rob reported having 5 or 6 episodes of pain in the 6 months since the first injury. The pattern he described is that he would see a Chiropractor for a few sessions, feel better and go back to the gym only to reinjure himself. After a few episodes he started seeing an Osteopath but the pattern was the same – he would improve, return to the gym and reaggravate.

The first 3 visits

By the time Rob came to DIY Physio, he was disillusioned and starting to feel that his gym days might be over.
Happily, it only took 2 sessions to work out why he had become a recurrent back pain sufferer.

Just looking at Rob standing in his shorts two things were very clear:

  • 1. His left leg was significantly shorter that his right and
  • 2. He had all the signs of a small disc bulge in his low back.

The McKenzie Assessment method confirmed the underlying disc bulge, and placing a small wedge in his left shoe corrected the leg length.


The solution

Rob then needed a clear explanation of what his injury was and how he needed to manage it if he was to resolve the problem long-term and eventually to be able to get back into high intensity gym work.

The thing with disc bulges is that, like any other damaged tissue, they need time to heal. And in Rob’s case they hadn’t been getting that. Small disc bulges are often overlooked and misdiagnosed as ‘muscular’ injury. The rehab process for a disc bulge is very different to the rehab process for a muscular injury – and Rob had been following the wrong path. Hence the recurrent re-injury.

Once Rob understood what was needed he was a willing and very compliant patient. He was unable to go to the gym for 6 weeks and had to follow a very specific series of exercises designed to reduce the stress on his injured disc and to allow it to heal fully. In the meantime he could get his exercise fix with swimming and some specific Pilates training.


The Outcome

After 6-weeks I introduced Rob to an Exercise Physiologist to oversee his return to the gym.

Rob is not only back at the gym he now understands how to better balance his exercise program and also exactly what to do should he start to get any niggles in the future. He also has a supply of wedges to be placed in the left shoe of every pair of shoes that he owns.