Lena (41 years -old) was referred to me with an extensive, 18-year history of lower back pain that had become progressively worse, both in the frequency of acute episodes and intensity of her symptoms over the preceding 2 years. This was severely affecting her quality of life; she was unable to sit for more than 30 minutes which meant she was unable to enjoy eating out with friends, she had stopped travelling due to the fear of sitting for prolonged periods, and she was unable do the thing she loved the most which was strength training. She had tried spinal injections and extensive physical therapy with little change in her symptoms.

The main aggravating factors to her symptoms were activities that involved flexing her spine such as picking up objects from the floor, emptying the dishwasher, sitting, driving, squatting and standing from a seated position.

Having had multiple MRIs, X-rays and blood tests she came to me with the following diagnosis:

• Mechanical lower back pain
• Lower lumbar spondylosis at L4/L5, L5/S1
• Disc related pathology at L4/5, L5/S1
• Bilateral sacroiliac joint degeneration

She had surgery booked for 11 weeks time (lumbar spinal fusion) and our sessions were her last attempt at avoiding surgery.

During her thorough assessment we discovered the following:

LIFESTYLE

Her daily movement habits:

1. Every morning she would stretch her spine into flexion doing forward folds, the child’s pose and seated forward folds.
2. Every time she stood up she initiated the movement by flexing forwards, this frequently caused spasms and increased her symptoms. This is a natural movement pattern that we all do when we stand, however, due to the sensitivity of her tissues this was enough to cause her pain.
3. She drove with a very low car seat with the front higher than the back which created further lumbar flexion.

We determined that her back was very sensitive to her current levels of spinal flexion. The flexion dosage from her daily movements was exceeding the capacity of her tissues to recover, creating a cycle of chronic inflammation and sensitivity. The first step was to temporarily reduce some of the flexion activities of her spine, this included removing the forward folds, seated forward folds and child’s pose stretches from her daily routine. The second was to teach her how to stand from seated without increasing her lumbar flexion, she was able to stand without pain immediately. We also changed some of her sitting ergonomics. We raised the height of her car seat and provided a seat wedge to reduce lumbar flexion.

NOTE: Lumbar flexion is not an inherently a bad movement, it’s a fundamental motion of the spine.

EXERCISE
Her current existing program: 

She had been performing various core exercises such as bird dogs and dead bugs together with her stretch routine. My biggest criticism of the exercises was that they were not progressive enough, they did not specifically target and progress components of fitness such as spinal extension endurance. To see change in any component of fitness, we require adequate overload, it has to be challenging.

Exercises we prescribed: 

The biggest change we made to her exercise was the addition of back extension isometrics (static holds) e.g. 2 minute holds, 30 seconds rest x 3 sets. She had been performing a similar exercise but only for 40 seconds per set, for 3 sets and she admitted that she found this very easy. This was not enough stress to create increased endurance, to achieve this we needed to challenge the endurance muscle fibres of her lower back by making the exercise longer in duration and it had to be fatiguing. As she adapted, we kept making it harder. The purpose of this was to give her lower back more endurance and more capacity.

MANUAL THERAPY
Her existing manual therapy had focused more on massage, instead we used Osteopathic Therapy techniques to help increase the mobility of her spine and hips.

This was the initial stage of our treatment plan and after 2 weeks she experienced significant improvement in her symptoms.

We then moved on to slowly improve her capacity to tolerate lumbar flexion. We had limited this movement during the first 4 weeks of her program, but as we need to be able to flex the spine for daily living it was vital to introduce this back into her training as soon as possible. If we didn’t, we knew the risk of her experiencing an acute episode of pain performing a simply activity such bending down to tie her shoes was high.

CONCLUSION
We managed to control her symptoms, improve her quality of life and she avoided surgery! She is now back to her favourite pastime of squatting and deadlifting, pain-free!

I asked her what made our approach work, where other methods hadn’t. She felt the biggest difference was the combination of daily movement advice, Osteopathic Therapy techniques and the intensity and progression of the exercises we prescribed. She also felt fully supported and encouraged throughout the program and knew she could call on me immediately if she had any set backs.