Back pain treatment

Scott Smith struggled to find the starting point for a young trampolinist’s rehab from a nasty fall

No therapist likes to see a patient in severe pain. It is even worse when that patient is really young and is accompanied by a very concerned parent. In this instance, a 15-year-old trampolinist, Rachel, had injured her back four months previously, while training for the national titles. She was practising backward somersaults when she failed to fully rotate and landed on her stomach in an extended position. The impact was intensified by falling on to a poorly cushioned support surface.

Rachel had immediate local pain and sought medical treatment. She was started on a course of anti-inflammatory medication and advised to visit the physiotherapist assigned to the trampolining team. The symptoms in Rachel’s back had now turned quite nasty and she was experiencing bilateral leg pain down to the knees. She could only bend as far as her knees and was able to sit for just 10 minutes before the pain became too intense.

She attended physiotherapy, where, I am told, she was given local joint mobilisation, massage and some stability exercises for the transversus abdominis muscle. After two months of treatment, Rachel’s back pain levels had reduced only 10% and she had no improvement in centralising the pain to her back, so she was then sent to a neurosurgeon. He promptly sent her for plain X-rays and an MRI scan.

Ahead of the scan results, the surgeon and the referring physio told Rachel that she probably had a bulging disc in her lower back, which would require surgery followed by a lengthy period of rehabilitation before she could resume her trampoline training. But all the investigations came back normal. The surgeon would not operate without the scans revealing any disc bulging/ herniation or nerve root impingement. The neurosurgeon diagnosed Rachel’s pain as being of a muscular origin and sent her back to the physio.

Rachel and her parents were concerned about this diagnosis, believing that if the pain was only muscular in origin, previous physiotherapy should have alleviated it. They consulted their GP, who referred the young trampolinist to me.

Whenever I see a patient who has seen another therapist, I try to assess the type of treatment they have received and reason out why it has not worked. The patient’s compliance with their exercise prescription is always potentially a very significant factor. In this case the treatment seemed reasonably appropriate for most low back pain syndromes, involving a great deal of local manual treatment on lumbar spine and sacroiliac joint complexes. The manual therapy actually had the effect of increasing Rachel’s pain after the treatment sessions, for the next two to three days.

I found the following significant signs:

Rachel found it very difficult to initiate her deep lumbar stabilisers (pelvic floor and transversus abdominis). She had a very positive shear test at the second-last lumbar segment (L4/5). This is a test to demonstrate the stiffness or passive stability of the joint. The structures that contribute to this joint stability are the disc, the ligaments and the joint capsules. It is an easy and fast test for the physiotherapist to do when they suspect that there might be an unstable or loose joint. And indeed, in Rachel’s case there was an excessive range of motion. Feeling that I had a good grasp on why Rachel had not improved, I started treating her by attempting to regain more muscle control around the injured joints (L4/5 and L5/S1). The reasoning was that if she did not have sufficient passive stability provided by the disc and ligamentous structures, she needed really good muscle control. I also included some manual techniques to help relieve the local pain.

After four or five sessions I was left scratching my head because Rachel’s symptoms had not changed at all. She still had bilateral posterior thigh pain; she was still unable to sit for longer than 10 minutes and there was no improvement in her pain-free range of movement. She could not even contemplate performing the highly complex manoeuvres she was accustomed to in trampolining.

The only part of the treatment that Rachel had been unable to grasp was the lower abdominal exercises. She said she did a lot of them but was unable to feel anything and was not sure if they were helping her. This is very common with low back pain: patients lose awareness of this muscle contraction and cannot tell the difference between a slow, easy contraction and one that is stronger and more phasic.

When you encounter tricky patients it is very good to work with experienced therapists. You can use them as a sounding board and sometimes things become a bit more logical. My work colleague confirmed my thought processes with Rachel’s problem but like me could not explain why her symptoms had not improved.

We then really thought about what was causing the pain. We believed it was because the ligamentous structures in her lower back had been injured in the fall, and these damaged structures were no longer providing passive support. Coupled with this, she was unable to contract her local stabilising muscles to assist with stabilisation. As a gymnast, it is likely that Rachel already possessed unusual flexibility and her need for greater muscle control was simply exacerbated by any damage sustained in her fall. It is common to encounter former gymnasts in whom painful joint problems occur once they cease their high-level training. Rachel’s deep stabilising muscles, which would have helped to control the strain on the joints that occurs with everyday activity, were not firing appropriately. The only remaining strategy we could think of was to fit Rachel with a low back brace to help make her aware of her spinal position and control the movement of those lower joints. So that’s what we did.

What happened next truly amazed me. When I next saw Rachel five days later, she said the leg pains had disappeared, she was able to sit for up to an hour, and could bend to her ankles without any serious pain in her back. A $60 back brace had brought about the improvements in Rachel’s pain that all the manual therapies and exercise prescriptions had failed to achieve, despite our best intentions.

Once the level of pain had reduced it was a lot easier to activate transversus abdominis. The retraining was aided by the use of real-time ultrasound. The exercise programme was quickly progressed. It is always nice to see patients become physically stronger and participate in drills that mimic their sporting environment. It gives them added motivation.

Rachel’s sport requires her to land on her back and front with a lot of force. She had to have very strong obliques and rectus abdominis muscles before she was allowed to perform any such manoeuvres. I am certainly not a physio who believes that the rehabilitation process should be biased towards transversus abdominis activation only, but the level of muscular strength and control obtained by the patient must meet the demands of their particular sport.

Rachel therefore progressed into a lot of planks or hovers off a Swiss ball and side planks on a bed. She was also doing a lot of higher-level gluteal exercises.

Conclusion

I think the moral of the story is to really work out what is driving the whole process with your patient’s pain. Maybe when we see patients who have restrictions in their movement we will consider that they are not just stiff but might have joints that have lost part of their ligamentous integrity. They do not move through their full range because of protective muscle spasm. This can even occur in patients who have had their injury some months before. In Rachel’s case you would suspect this, especially in view of the quite severe trauma to her back.

Rachel’s condition should have been easy to diagnose based on her history, but also because of the strong steer provided by the outcome of the previous manual treatment: it had exacerbated her pain for up to three days. This was probably making those unstable segments in her back more inflamed.

As therapists, we always want to see progress. Sometimes we push the programmes on too soon, before the under-lying deep muscle stability control has been regained. This probably occurred in Rachel’s case. So if you have progressed your patient’s programme and their pain has reignited, maybe they do not yet have the deep control you had reckoned on.