Mireille Hamway, SPTCleveland State University
CASE REPORTExamination of a high-level weight lifter with chronic low back pain:
Consideration of complex patient history and comorbidities in diagnosis and treatment efficacy
Abstract:
Background and Purpose
The cause of low back pain can be difficult to determine due to the multifactorial components that contribute to increased pain. Barriers to a successful therapy treatment can often undermine the expected outcome, and psychosocial aspects of the patient’s life can affect the perception of pain. The purpose of this article is to demonstrate the effect of psychosocial barriers on the outcome of a young female body builder with chronic low back pain. Case Description
Presented in this report is a 21-year-old female with chronic low back pain who participated in high-level weight training and has a significant complicated past medical history. The back pain began a year and a half prior to this episode of care, and the mechanism of injury was believed to be improper form during a dead lift. Psychosocial aspects of her life were affecting her ability to cope with stress and manage pain.
Outcomes
The Oswestry Disability Index (ODI) and the Numeric Pain Rating Scale (NPRS) scores did not show improvement at discharge. The patient’s ODI decreased from 29 to 21 indicating a decrease in function. The patient was asked to give a pain rating at the beginning of each session for how she felt at that time and how she felt at her worst since the previous visit. Pain intensity increased as the patient became overwhelmed with managing her physical, mental and social health.
Discussion
The patient did not demonstrate decreased pain and increased function by discharge. Psychosocial barriers, comorbidities and multiple contributing factors interfered with treatment, and the expected outcome was not achieved.
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Background and Purpose:
The identification of the cause of low back pain (LBP) is a subject of much deliberation in many physical
therapy clinics. Physical therapists follow different methods of examination based on their training and
preference. The research shows that the three main systems used, McKenzie, movement impairment,
and treatment-based classification, have good levels of inter-rater reliability and validity, but none is
proven to be superior to the others.1 When looking at a more complicated case, it may be in the best
interest of the patient to look at the information from the viewpoint of each one of these approaches.
Chronic LBP is developed in 62% of people who are experiencing back pain for the first time, and they
will continue to have symptoms that last longer than a year.2 Often, the diagnosis can be difficult to
decipher when there are many comorbidities and an extensive patient history. Many factors can
contribute to LBP, and if all sources are not addressed, treatment directed at only some sources may be
rendered useless. Some common factors include poor coordination and muscle performance of core
musculature, referred pelvic pain, mechanical derangement, and myofascial trigger point referral. 3-8
Performance of core musculature can be especially difficult to ascertain due to the efficiency
of muscle compensation during testing. When there is poor coordination and timing during
athletic activities, this can lead to fatigue in some muscles, which will result in a spine
vulnerable to injury.5 A core stability exercise program is a common treatment and is
designed to retrain muscles to activate appropriately.2 Also, the definition of core muscles
varies in the literature. The pelvic floor is often omitted, and myofascial trigger points found
in musculature can refer to the low back and posterior thigh which mimics radicular
symptoms (pain from a spinal nerve root that refers into the extremities).3,7,9 Radicular
symptoms are a key indicator of a derangement classification in the McKenzie mechanical
diagnosis and therapy method of examination. (This method is discussed in further detail in
the exam portion of this article.) The centralization or peripheralization of these symptoms
(pain coming towards the source at the spine or pain spreading further into the extremities)
2
determines the treatment direction for a patient classified with this diagnosis. If the patient
is misdiagnosed, the chronic pain will continue and limitations will hinder participation in
activities for a longer period.
In addition to body, structure and function impairments, the psychosocial background of the
patient will affect treatment efficacy. In a study done by Groeneweg et al, psychosocial
variables were examined as predictors of a positive treatment outcome for people with neck
pain. The researchers concluded that treatment was affected by outcome expectancy,
treatment credibility, fear avoidance and locus of control.10 Also, in particular with veterans,
a comorbidity often accompanying chronic pain is PTSD. Patients who are experiencing both
diagnoses have a greater degree of perceived pain intensity, distress, life interference, and
disability than those who only experience one.11
With all the possible contributions to chronic low back pain, it is easy to see the difficulty in
treating such a multi-faceted condition. The purpose of this case report is to demonstrate
the effect of psychosocial barriers on the outcome of a young female body builder with
chronic low back pain. The secondary purpose is to highlight the importance of a holistic
approach during an episode of care.
.Case Description: Patient History and Systems Review
This case report describes a patient who was referred to physical therapy for low back pain. The patient
is a 21-year-old female who served four years in the military and participated in high-level weight
training. She has a significant past medical history involving post-traumatic stress disorder (PTSD), major
depressive disorder, severe headaches, pelvic floor and uterine dysfunction and generalized anxiety.
The patient presented to the clinic with a chief complaint of pain in the lumbar spine and posterior right
lower extremity to the level of the knee. Pain began a year and a half prior to the evaluation and was
believed to be caused by dead lifting, a technique in which a person will bend at the waist and knees to
lift a weight bar from ground level using bilateral upper extremities (see figure 1). She stated that she
3
heard a “pop” while performing the lift and
has had difficulty with movement,
prolonged positioning, and pain since this
incident. She was diagnosed by a physician
at the time of injury with a herniated disc
and referred to physical therapy (PT). She
felt that she responded well to mechanical
lumbar traction; however, the effects were
short-lived, lasting only a day or two. Other treatments by multiple providers included epidural steroid
injection, radiofrequency ablation, transcutaneous electrical nerve stimulation (TENS), trigger point
injections, muscle relaxants, NSAIDS, and therapeutic exercise. The patient expressed concern that she
would not be able to return to weight-lifting activity and felt frustrated with many different treatment
options failing to relieve her pain. Her pain was reported as the most limiting factor to her participation
in lifting. She reported a 4-8/10 pain range which she experienced daily. Prior to injury, she was training
as a professional body builder and competed in local events. Since then, she had lost 65lbs and ceased
all weight-lifting activity. Focusing on weight-lifting was therapeutic for the patient and helped to
alleviate symptoms from mental health disorders. The mental health factors contributing to these
symptoms included PTSD that resulted from a sexual assault she experienced while in the military,
suicidal thoughts, unsupportive family and social complications. She had sought out treatment for
mental health symptoms as well, and the patient was being treated by psychiatry during the same
period as this episode of care. In addition to PT and psychiatry, the patient was receiving services from a
neurologist for headaches, a chiropractor for low back pain, a women’s health physician for pelvic floor
and uterine dysfunction, and pain management. The patient was overwhelmed with multiple conditions,
several healthcare providers and constant appointments, and a myriad of symptoms affecting her day to
4
Figure 1: Image A demonstrates poor technique when performing deadlift and Image B displays proper form. With incorrect form, the forces distributed through the lumbar spine have potential to cause injury. Image obtained from http://www.precisionnutrition.com/all-about-spinal-health
BA
day life. She felt that the key to get everything under control was to return to her weight-lifting training.
This was the main patient goal: to reduce pain in order to return to training.
Clinical Impression #1
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Physical therapists are specialists when assessing musculoskeletal and movement dysfunction.
According to the APTA Guide to Physical therapist practice, the physical therapy examination involves
tests and measures that determine muscle performance and joint mobility which influences the ability
of the person to perform functional activities.12 The tests and measures used allow for differential
diagnosis of the physical therapy problem and direct treatment. The primary patient identified problem
is back pain caused by a specific mechanism of injury (MOI) which led to decreased activity and
participation. This patient is a good candidate to demonstrate the importance of differential diagnosis as
her medical history and comorbidities are extensive. She has multiple factors that could potentially
contribute to her LBP, and all factors may not have been addressed during her episode of care. She also
presents with typical LBP symptoms which are addressed with conventional exam techniques and
methods. The presentation of back pain with radicular symptoms into the right lower extremity guides
6
the exam towards a McKenzie method of testing.6,13 Due to the MOI, instability in the lumbar spine or a
fracture of the pars interarticularis were considered as well. There were no significant findings in any
imaging reports indicating there may also be involvement of muscle weakness. Muscle activation, timing
and coordination to stabilize the spine during dynamic activity is crucial, and when dysfunction is
present in muscle performance, this may lead to injury. Figure 2 demonstrates the decision-making
process and displays the identification of problems that guided the examination and treatment. Using
the HOAC II model, the patient identified problems lead to inclusion of specific tests and measures in the
objective exam: repeated movement testing to establish directional preference, stork-standing lumbar
extension test to screen for fracture, Prone Knee bend, slump and straight leg raise tests to assess nerve
involvement, prone segmental instability test to test for instability, abdominal and paraspinal stability
testing to establish proper activation of core muscles, and segmental mobility testing to check joint play
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at each segment. In taking a holistic approach to patient care to more accurately provide a prognosis,
additional information was gathered prior to beginning objective measures. This included sleep and
nutrition habits, substance abuse, social support, and stress management. The most significant findings
from additional questioning involved the patient not sleeping, eating or managing stress well. The
patient had difficulty sleeping and positioning to sleep, poor nutritional intake, and no healthy stress
management plan to replace her previous tactic. Her social relationships were also complicated, and
family members were major contributors to stress. There was no admission to substance abuse,
particularly to steroid use which would affect the integrity of soft tissues. Although the patient appeared
motivated at her first visit, these habits affect compliance with a home exercise program (HEP) and may
interfere with the effectiveness of care. Social support is also a good predictor of positive outcomes,
and the lack of support the patient receives may also contribute to a poorer prognosis. The objective
exam will provide additional detail to facilitate the differential diagnosis using all the techniques
considered during the first impression as well as help determine an accurate prognosis.
Examination
The patient received a physical therapy exam which typically includes manual muscle testing (MMT),
range of motion measurements (ROM), and special tests/screening tests. ROM measurements were
completed at bilateral hip, knee and ankle joints using a standard goniometer as described by Reese.14
Muscle testing was completed on major muscle groups of bilateral lower extremities using techniques
outlined and described in McGee.15 Significant findings from these portions of the exam are summarized
in Table 1. Deficits were shown in small stabilizing muscles, such as gluteus medius (GM), transverse
abdominus (TA), and multifidus which indicates a lack of support for the spine during dynamic activities.
The patient presents with normal gross muscle strength due to extensive resistance training; however,
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when body building, smaller stabilizing muscles are typically not the focus of training. This becomes
apparent when these muscles are tested. Screening tests for reflexes, vitals, red flags and sensation
were all normal. The special test portion of the exam will be the focus of discussion in this section and
findings are also summarized in Table 1. The patient’s complaint of pain with prolonged positioning and
pain into the posterior right lower extremity were the symptoms that primarily guided the exam.
Radicular symptoms are key to assessing for derangement using the McKenzie Mechanical Diagnosis and
Therapy theory (MDT). There are three basic diagnoses of the spine that McKenzie describes: postural,
dysfunction and derangement. Derangement is described as a disruption in the
Table 1: Summary of Exam Findings
Muscle Strength Testing • Gross testing of hip adduction, external rotation, internal rotation, abduction, flexion, and extension: 5 bilaterally
• Gross testing of knee flexion and extension: 5 bilaterally
• Gross testing of ankle in all planes of motion: 5 bilaterally
• Specific muscles tested where deficits were demonstrated:
• Right Gluteus Medius: 4• Left Gluteus Medius: 3• Abdominals: moderately
decreased strength in transverse, sagittal and frontal planes; compensatory muscle activation with double straight-leg lowering test and side plank test.
• Multifidus: decreased activation and evident compensatory techniques
Range of Motion • Bilateral lower extremity measurements were all within normal limits
• Gross assessment of lumbar ROM• Flexion: Moderate loss with
increased pain• Extension: Moderate loss with
increased pain
9
• Lateral Flexion R/L: no losses• Rotation R/L: minimal losses
Special Tests • Repeated flexion/extension: no change in radicular symptoms after 10 repetitions.
• Stork-Standing Lumbar Extension Test: negative
• Prone knee bend: positive• Slump: positive• Straight leg raise: negative• Prone segmental instability: negative• Segmental mobility testing: Hypermobile
through L2-5, hypomobile in lower thoracic region
mechanical alignment of the vertebral segment, possibly caused by disc abnormalities, that can present
as symptoms in myotomal or dermatomal patterns due to irritation of the nerve root.13 This method of
assessment is widely accepted and practiced, but validity and reliability varies between studies.16 MDT
was utilized by asking the patient to flex and extend the lumbar spine repeatedly in standing and in lying
(prone for extension and supine for flexion). The response expected if derangement is present is
peripheralization or centralization of radicular symptoms of the lower extremity. There was no change in
posterior right leg pain when performing the repeated movement test after 10 repetitions.
Due to the mechanism of injury and the age of the patient, ruling out pars interarticularis fracture (PIF)
is necessary. The stork-standing lumbar extension test is used to rule out PIF. The patient stands on one
leg and extends the trunk. A positive sign for fracture is provocation of pain while standing on the leg
ipsilateral to pain. The research available discusses the inability of this test to properly rule out PIF;
however, the gold standard measurements are expensive and not easily accessible during a PT
examination.17 The patient did not have a positive sign with this test and the examining PT ruled out this
diagnosis. The neurological exam findings were more significant. Prone knee bend, slump and straight-
leg raise are all common tests used to provoke pain caused by nerve tension. The patient had positive
slump and prone knee bend results. The prone knee bend test is used to stress the femoral nerve and is
10
performed by having the patient lie prone while the PT stabilizes at the pelvis and passively flexes the
knee. A positive sign is reproduction of the patient’s symptoms and indicates L2-4 involvement. The
slump test is indicative of dural tension and is performed by having the patient, in a seated position,
round the back and flex the neck. The therapist will then passively extend the knee and dorsiflex the
foot. Provocation of familiar symptoms is considered a positive test. Research support for these tests is
limited and sensitivity and specificity is poor.18,19 These tests are often used in the clinic due to ease of
administration and lack of alternative screening techniques. The prone segmental instability test is more
statistically supported than the nerve tension test. There are studies that find this test to be more
reliable than other tests used to diagnose instability, but validity is not known. 20 To conduct this test,
the patient lays prone with both lower extremities over the edge, feet resting on the floor. Pressure is
applied in an anterior direction to the segment being tested. The same pressure is applied again while
the patient lifts both legs from the floor. If familiar pain is reproduced when the patient is in resting
position, but not active position, then the test is considered positive. The results in this case were
negative. Lastly, segmental mobility was also examined. The reliability of these judgements made by
clinicians is shown to be fair, but between clinicians there is typically agreement and is shown to be
useful clinically.20 The assessment of the patient, completed by applying a posterior to anterior
compression force through each segment, made evident a hypermobility of L2-L5 vertebrae and a
hypomobility of lower thoracic segments. After evaluation of these findings, a second clinical impression
was formed.
Clinical Impression 2
After careful consideration of the objective exam and patient history, core instability was determined as
the main cause of the patient’s back pain. This instability lead to the hypermobility of the lumbar spine
and eventual nerve compression. With nerve tension tests being poorly supported in the literature, it
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becomes difficult to attribute back pain to a derangement diagnosis when the repeated movement
testing did not reproduce symptoms.18,19 The lifting activity in which the patient participated repeatedly
would put the patient at risk for injury when core muscles are not activating sufficiently.4,5 The plan for
the patient treatment was focused on retraining core muscle timing and coordination through dynamic
activities, such as planks with alternating extremity extension. A full description of therapeutic exercises
will be provided in the treatment section. Reassessment continued throughout the plan of care to gauge
the patient’s response to treatment. The patient’s symptoms appear to be consistent with the typical
presentation of LBP.1,6,13 Prognosis for goal achievement was considered excellent at this stage of the
patient’s evaluation. Her age and fitness level added to the positive prognosis. Later, the poor response
to treatment will be discussed and the difficulty of diagnosing a patient with a complex history will be
displayed.
Intervention
Education was provided to the patient immediately following the evaluation regarding sitting and
standing posture, proper form while performing lifts, and the importance of strengthening core muscles.
The plan of care for this patient was designed to address core strength deficits and neural tension. The
exercises taught and performed included: hip abduction in side-lying, clamshells, planks, prone
multifidus activation and supine neural mobilization. The exercise descriptions are provided in appendix
A. Research shows that core stabilization is found to be beneficial in decreasing pain and disability in
patients with low back pain.2,21 Dry needling was also performed at the start of the session to address
trigger points in the paraspinals that may be causing pain or preventing muscle balance. The piston
method was used and needles were applied bilaterally to lumbar multifidus from L3 through L5. Dry
needling is gaining in popularity and shown to decrease pain in less time than traditional therapies
12
alone.22 A moist-heat pack was applied at the end of the treatment session to the lumbar area to
promote relaxation and decrease pain.
Visits 2-3: The patient stated that she did not feel pain was decreasing. Muscle strengthening occurs
over time, so treatment was provided to give immediate relief from pain and support the spine. TENS is
shown to be an effective analgesic by using peripheral and central mechanisms to reduce pain; however,
there are tolerance effects that may impact use with chronic pain.23 This is still unclear in the research.
The patient was issued a TENS unit and posture pal tape was applied to the lumbar spine. The patient
reported compliance at this point in the episode of care. This initial plan and progression is expected to
have good results with a young female who is physically fit.
Visits 4-5: As the treatment sessions continued, additional contributing factors to her back pain became
evident and psychosocial health began to affect treatment and compliance. The patient attempted to
return to her lifting routine as she felt symptoms were starting to decrease. She was asked to take a
video of her dead-lift technique and bring it in for analysis. After reviewing the video with the patient,
she understood that there was a hinging motion occurring at the L3-L4 level of the spine where she
currently was experiencing pain. The patient was educated further on the importance of maintaining
core stability during this activity to protect her back.
Visits 6-8: The patient began to see a chiropractor and a women’s health specialist. A procedure
performed in the women’s health office now added to lumbar pain and created excessive menstrual
symptoms. This affected the patient’s compliance with her home exercise program, and she began to
report exacerbations of her symptoms. Upon reviewing her history, and with the recent procedure
completed, the pelvic floor was considered for trigger point referral. Studies show that obturator
internus can refer pain to the posterior thigh, and pelvic floor pain can result from sexual trauma.7,9 The
obturator internus provocation test and the obturator sign were performed to confirm this was
13
occurring with the patient. A stretch for the hip external rotators was added to her home exercise
program; however, compliance was decreasing as the episode of care continued. The stretch was
performed by beginning in supine with both legs bent and both feet on the ground. Then the patient will
cross the foot of the affected side over the thigh of the unaffected side. The patient will rotate the pelvis
toward the unaffected side while making sure both shoulders stay in contact with the supporting
surface. The patient was also referred to a physical therapy pelvic floor specialist.
Visits 9-10: The patient stated that she was having a serious family argument and having difficulty
sleeping. She also reported a return to previous pain levels and expressed being unable to work without
frequent breaks. The patient also had new complaints of migraine headaches for which she sought
treatment from a neurologist. She appeared increasingly emotionally distraught. She was currently
being treated by a psychiatrist for PTSD and family counseling. She was not adhering to the program
designed during the therapy sessions and displayed signs of regression. Progressing therapeutic
exercises was difficult as she was not displaying readiness for the next level of difficulty. The patient was
discharged from care at visit 11 as she stated that she may need to discontinue therapy in order to focus
on her mental and emotional health.
Table 2 Oswestry Disability Index Domains and Example Statements
Information obtained directly from the Oswestry Disability index and Rehabmeasures.org
Domains
Pain IntensityPersonal CareLiftingWalkingSittingStandingSleepingSexSocialTravel
Example Statements for Pain Intensity
0-I have no pain at the moment 1-The pain is very mild at the moment 2-The pain is moderate at the moment 3-The pain is fairly severe at the moment
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4-The pain is very severe at the moment 5-The pain is the worst imaginable at the moment
Outcomes
The primary measures of evaluating the patient’s progress were the Oswestry Disability Index (ODI) and
the Numeric Pain Rating Scale (NPRS). The ODI is used to determine the impact low back pain has on
functional abilities. It is a 10-item questionnaire where each item has six statements from which the
patient must choose the one that best applies. Each statement is assigned a numeric value from 0-5, 0
indicating the least disability and 5 indicating the greatest disability. See table 2 for a list of the domains
and example statements. The maximum score is 50 and the results are analyzed using a percentage. (A
score of 45 out of 50 is a 90%.) The minimal detectable change is 12.72 for patients with chronic low
back pain and the minimally clinically important difference is 9.5. Test-retest reliability is excellent,
criterion validity is unclear in the research, and there is an excellent correlation between the ODI and
the visual analog scale as well as with patients’ subjective assessment of improvement pre- and post-
operatively.24
The NPRS is an 11-point scale that allows the patient to choose a rating which best describes the
intensity of pain experienced. The patient verbalizes the score by stating a number between 0 and 10, 0
being no pain at all, and 10 being the most intense pain imaginable. This pain rating scale has been
tested on populations who experience chronic pain and the minimal detectable change is 2 points (95%
confidence interval) with patients who have low back pain. Test-retest reliability is adequate, and
interrater reliability is excellent. Cut-off scores are established as follows: a rating of 1-3 indicates mild
pain, 4-7 is moderate pain, and 8-10 is severe. There is an excellent correlation between NPRS and the
visual analog scale as well as the 21-point Numeric Rating Scale.24 During the episode of care, the patient
was asked to rate her pain using the NPRS at the beginning of every visit. She completed the ODI during
the evaluation and at discharge. Her scores are summarized in Figures 3.
15
1 2-3 4-6 7-8 9-10 110
5
10
15
20
25
30
35
Figure 3: Summary of Outcome Measures
Pain Rating Upon Arrival Pain rating at worst since previous visitODI Scores ODI
Visit #
Scor
e
In the graph, there is a fluctuation of symptoms and recovery shown. This demonstrates how other
domains in the patient’s life and concurrent treatment affect the episode of care. At baseline, the
patient was reporting 4/10 pain at best and 7-8/10 pain at worst. At discharge, the patient’s pain score
increased to 6 and 9 respectively. Her ODI scores reflect an increased effect on function as well. It was
expected, given the patient’s age and fitness level, to have a positive outcome. This case displays that
positive outcomes may not occur as expected when the patient has multiple components impacting her
life.
Discussion
Chronic low back pain is a common diagnosis seen in physical therapy clinics with over half of the people
who experience back pain transitioning to a chronic classification.2 Symptoms vary but typically include
an inability to tolerate prolonged positioning, pain that radiates into the lower extremities, and an
inability to participate in activities that were once regularly enjoyed.2,8,21 Core instability is often a cause
16
The graph above demonstrates the increase in pain and the decrease in function throughout the episode of care.
of low back pain as the core muscles work to protect the spine during dynamic activities such as
reaching, lifting, playing sports or performing activities of daily living.21,25 Core strengthening programs
are proven to decrease back pain and increase function.2,21 Many factors, however, can contribute to
low back pain. Psychosocial complexities and various providers administering treatment concurrently, as
well as mechanical issues that are more difficult to identify, can be a hindrance to progress as is seen in
this case. PTSD is shown to influence the patient’s perception of pain intensity and ability to cope with
stress or injury.7,11 Emotions are also closely related to activation of pain from myofascial trigger
points.9,22
A 21-year-old fit female presented to the clinic with typical low back symptoms. Upon examination, she
displayed core weakness, segmental hypermobility, and muscle imbalance with presence of myofascial
trigger points. A core strengthening program was designed to address her specific deficits, and various
treatment techniques were performed to reduce pain. Positive outcomes and typical progression were
expected; however, minimal improvements, if any, were seen. When looking at the whole person,
psychosocial factors were present and additional mechanical issues were discovered. This patient had
experienced sexual trauma, social support complexities, and multiple medical issues which were being
addressed simultaneously by several health care providers. The patient expressed feelings of being
overwhelmed and became increasingly non-compliant. Also, PTSD most likely affected how she
perceived the intensity of pain. It is more difficult for these types of patients to recover and they
experience pain longer.11
Anecdotally in this clinic, where female patients have often experienced sexual trauma, there appears to
be a connection to pelvic floor dysfunction and referral of pain into the low back and lower extremities.
There is limited research that shows a connection between pelvic floor pain and rape, but a link to
chronic back pain has not been explored.7 Some studies show that emotional stress can initiate
17
excessive muscle activation leading to myofascial trigger points which can increase pain.3,9,22 Further
consideration of the patient’s history lead to testing of the obturator internus where myofascial trigger
points were apparent, and a referral to a pelvic floor specialist was discussed with the patient. The
various sources of stress and health-related problems made it difficult for the patient to address her low
back pain.
A holistic approach is important when looking at all patients regardless of presentation. All domains
should be analyzed for potential barriers to care and strategies should be implemented to address these
barriers and increase quality of life for the patient. Physical therapists should be able to teach stress
coping strategies to patients. Often, the pain or limitation is a source of stress, or, for some, exercise is
the coping strategy they have used up to the point of injury or disability. When this is taken away, the
patient may need additional tactics to address stress and cope with the emotional strain that comes
with chronic pain. Further research is needed to explore how each domain affects the plan of care and
to display how the treatment outcome may differ if these factors are addressed. Also, it would be
beneficial to develop outcome measures that will help clinicians better understand the strength of the
patient’s coping mechanism and social support system to identify a need to provide alternate coping
strategies. There is a lack of research connecting sexual trauma to low back pain and further exploration
into this topic is needed as well.
18
References
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Appendix AHome Exercise Program
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Stabilization Plank
Start End
Clamshell
Start End
22
Lie on stomach propped up on your hands and toes with your chin tucked-in and your feet together.
Lift up your pelvis creating a straight line with your body.
Hold the position without arching your back.
Hold for 15 seconds, 2 times a day and build time as tolerated
Lie on your side with both legs slightly bent.
Lift your top leg (injured leg), keeping your pelvis stable, your leg slightly bent and your heels together. Rotate your hip so that your foot and your kneecap are pointing upward during the movement.
Return to the initial position and repeat.
10 times per set, 2-3 sets, 1-2 times a day
Stabilization Superman
Start
End
Hip AbductionStart End
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Lie on your stomach with your chin tucked in, your arms by your side and the thumbs in and toward the ceiling.
Activate your lower abdominals (transversus abdomini) by bringing your belly button inward and by activating your pelvic floor muscles 20 to 30% of a maximal contraction.
Maintain a steady abdominal breathing while you pull your shoulder blades down towards your bum and lift one arm, keeping it close to your body as you lift the opposite leg, keeping both hips on the floor.
Return to the initial position and repeat with the other arm and opposite leg.
10 reps per set, 2-3 sets, 1-2 times per day
[Grab your reader’s attention with a great quote from the document or use this space to emphasize a key point. To place this text box anywhere on the page, just drag it.]
Supine Neural MobilizationStart End
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Lie on your back with your leg straight and your back in a neutral position (slightly arched).
Activate your lower abdominals (transversus abdomini) by bringing your belly button inward and by activating your pelvic floor muscles (inner thigh) 20 to 30% of maximal contraction.
Lift one knee towards your chest as far as possible and hold it there with your hands.
Maintain a steady abdominal breathing while you straighten your knee and slowly lower your leg toward the floor, keeping your back and pelvis completely still.
Return slowly to the initial position and repeat beginning with the other leg.
10 reps per set, 1 set, 1 time a day
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