Deans lower back pain started acutely during a rugby match where he landed awkwardly during a tackle. The initial episode started to settle relatively quickly and he was back playing in 5 weeks.

I met Dean (32 years-old) for the first time 2 years after his initial injury, he had been suffering frequent episodes of lower back pain, mainly related to rugby practice and matches, but it had started to affect his work as contractor.

His main symptoms where sharp catching type pain from unexpected or reactive type movements e.g. a sudden change of direction to make a tackle, or an unexpected impact, followed by muscles spasms and stiffness. For the first year he was able to find relief from his symptoms by stretching his back, doing core exercises, manual therapy and applying heat. But the frequency and severity of these episodes was increasing and he had stared to experience a sensation of his lower back ‘giving way’ when bending at work.

Deans case history provided 3 indicators that his symptoms might be due to Clinical Lumbar Instability: 

1. The description of catching type pain (‘instability catch sign’) followed by muscle spams
2. Pain with unexpected movements
3. A sensation of the back giving way (‘apprehension sign’) with bending movements at work

His thorough initial assessment revealed some key findings:

1. Positive shear instability test
2. Positive H and I Test (both improved with abdominal bracing)
3. Supine single leg traction (was painful, improved with abdominal brace)
4. Asymmetrical control and endurance on core challenges
5. No pain with seated compression testing
6. No pain with standing or seated drop tests
7. Unremarkable passive lumbar spine assessment

Lifestyle 
Dean is a fitness enthusiast who enjoyed pushing the limits in his training, in an attempt to make his back better he was performing lots of dynamic core exercises and stretching of his back. He used to feel better after these exercises, but the stretching and leg lowering exercises had started to provoke his symptoms.

Core Exercises
He was performing the following exercises 4 times per week, with high repetitions and multiple sets, often to failure:

• Abdominal Leg lowering exercises
• Medicine ball Russian twists
• Oblique crunches
• Supermans
• Standing dumbbell lateral flexion

Lower Back Stretches
He was performing the following stretches 1-2 times per day, frequently pushing into pain in an attempt to try to increase range of motion:

• Forward folds
• Cobras
• Lower body spinal twists

Deans history and clinical findings were suggesting a diagnosis of Clinical Lumbar Instability 

Typically this diagnosis responds well to exercises that create more stiffness rather than flexibility which meant Deans exercises and the frequent stretching were a contributing factor to his worsening symptoms.

Our first step in his treatment program was to remove the spine stretches, replacing them with exercises designed to increase joint control.

Our second step was to reduce the range of motion of his core exercises, choosing exercises that kept his spine relatively still e.g. planks, side planks. We manipulated the volume of the exercise to allow for recovery by reducing the number of sets and reps and reduced the intensity by stoping 2-3 reps short or 10-15 seconds short of failure.

We also prescribed movement drills to encourage the use of his hip joints during functional activities, encouraging power generation and transfer through the core, rather than generating of power from the core.

After 4 weeks we started to make Deans core exercises a little more dynamic and added some reactive drills to his program to start to replicate the unpredictable nature of Rugby.

Conclusion
We managed to control Deans symptoms by changing his exercises and training volume. Some times the exercises type and/or the volume and/or the intensity, and/or frequency exceed the tissue tolerance or the ability for tissues to recovery and positively adapt. By manipulating these variables in his program, the sensitivity of his lower back started to decrease.

He responded really well to the program and after 8 weeks was able to play rugby without back pain and get back to his manual job.