Purpose of this case study

1. To help someone live powerfully, without pain or injury.

2. To examine the effectiveness of the ONI system in approaching mechanical back pain.

3. To provide a learning experience for the ONI team. Lead by myself, this was designed to be a chance for everyone to use what they've been learning all year in real time. A chance to work with a real person with real issues. In a group environment, the team had opportunities to contribute to assessment and analysis, treatment planning, and execution (manual therapy and exercise prescription).

What is Mechanical Back Pain

The most common cause of back pain is mechanical back pain. Which means that the structures of the spine have been affected such as bone, ligaments, muscles, discs, joints, and nerves.

Typically mechanical back pain arises from adopting poor posture for extended periods of time, poorly designed seating, or incorrect bending and lifting technique. It has been shown that “a balanced approach, which takes into account patient psychosocial factors and incorporates multidisciplinary care, increases the likelihood of success from back pain interventions.” - What is mechanical back pain and how best to treat it?

Who is the case study

Toyah W., aged 25 is a mother who wants to work on her health and fitness goals, but is held back by her back pain. She presented with intermittent back pain that would result in spasms of the lower back muscles and has also reported that 8 months ago, she had symptoms of sciatica.

Red Flags

Before assessing for biomechanical dysfunction, we checked red flags for back pain such as asking if the pain was constant or intermittent and if she had bowel and bladder incontinence (lack of voluntary control over urination or defacation). These checks are always done and are necessary to screen out for medical emergencies.

Assessment & Analysis

Our assessments consisted of standing posture analysis, a slump test, and broad movement testing.

Initial posture analysis in standing showed:

• Rounding in the thoracic spine (kyphosis)

• Dowager’s Hump

• Protracted shoulders

• Anterior pelvic tilt

Slump test:

A slump test is a neural tension test. In this case we used it to see if symptoms of sciatica were aggravated or present. This was performed in a seated position with Toyah in neutral, sitting tall to begin with. She was then asked to ‘slump’ forward at the thoracic and lumbar spine, then to place her chin on the chest, then asked to extend one knee at a time and finally to dorsiflex at the ankle.

None of these movements produced pain or related symptoms of sciatica.

Broad movement testing:

Often when we’re looking at back pain, we want to see the bigger picture before we zoom in. If the hips aren’t stable then the back can compensate. We used the below screens to try and catch any of those compensations to then look in more detail from.

• Single Leg Standing Test:
  The glutes play a major role in stabilising and if they aren’t engaged then the lumbar is often used to compensate. In Toyah’s case, we saw a lack of gluteal muscle engagement, confirmed by palpation and feedback from Toyah. This affects hip position, thus lumbar position.

• Hinge Test:
  A hip hinge is a pattern that is used in daily life and involves the posterior chain. If length is an issue from the hamstrings, the back can compensate. For Toyah, her posterior chain length was more than adequate, but when asked to pick a weight up off the floor, the hip hinge pattern was not observed. Instead, the bending motion came from the lumbar spine, indicating a potential for overuse.

• Basic Spinal Movements:
  If parts of the spine are immobile or can’t flex and extend efficiently then other parts of the spine will compensate for them and become over-used. Basic spinal flexion and extension was tested in a ‘Cat/Camel’ position and once cued, Toyah could demonstrate adequate movement actively through flexion and extension globally through the spine.
  
  However, local lumbar flexion was limited in both range and proprioception. The muscles surrounding the lumbar were reported to feel ‘tight’ or ‘taut’. Thoracic extension was also difficult for Toyah, as she normally demonstrates extension through mostly her lumbar spine.

In summary, the movement analysis indicates that the lower back pain and spasms are likely linked to instability in the pelvis and glutes, with overuse from compensations happening in general movement, for example not hinging from the hips when picking things up. This causes more stress on the lower back, causing more spasms to occur.

The Treatment Plan

The plan was to get Toyah out of pain first, and then to reinforce more efficient motor behaviour with stability and strengthening exercises. Over 6 weeks (6 x 45– 60 minute sessions), we used a combination of massage and exercise for Toyah to gain awareness of her muscles and then challenged the activation of those muscles through a range of functional needs: stability, strength, speed, and coordination. This progression of incrementally increasing stress causes the cells involved to adapt to higher demand in theory, as well as training Toyah’s movement patterns to adjust so that the use of these stabilisers becomes instinctual.

Sessional Notes:

Week 1

Initial assessments and safety checks as described above. Toyah’s lower back pain and spasms are linked to instability in the glutes, lack of mobility and control in the lumbar spine, and a hip hinge pattern. These are the progressions we will be working on. Exercises coached during session is described as below and used as homework:

Homework: Three times a day

• Single Leg Stability 30s/side

• Core Breathing 30s/side

Single Leg Stability: Maintain neutral spine and pelvic positioning as you balance on one leg, raising the other. It’s important that the body is well stacked, with the hips level and glutes activated. Common compensations are a hip hike or drop (Trendelenburg sign), feet flattening, or knee bending.

Core Breathing: Lying supine, cue in diaphragmatic breathing by placing a hand on the abdominal area. As in you inhale, the hand should rise as the belly expands. Maintain this breathing as you raise your knees toward the chest, so that they are perpendicular to the ground. Hold this position while maintaining breathing in a neutral spine position. This exercise can be made harder by reaching the legs away from the core.

Week 2

Single Leg stability: Right looks more stabile and stays more stacked, left side shows slight imbalance and rotation (left side anteriorly tilts).

Core Breathing: Showing greater control as ribs stay down with diaphragmatic breathing, although it is still shallow.

This session, we introduced a thoracic extension exercise, designed to mitigate against the compensation of the lumbar. A bench was used a cue for Toyah to maintain contact with in a flexed lumbar position. She was asked to maintain contact with the bench using her ribs as she “reached tall” without the pressure on the bench changing. Reaching the arms out adds load to this position.

Homework: Twice a day

• Single Leg Stability: 30s/side

• Core Breathing: 30s/side

• Thoracic Extension + Reach: x10

Next session: revise and advance single leg + core exercises

Week 3

Thoracic extension has improved as well as general spinal proprioception. Toyah can now get into slight lumbar flexion during the segmental roll with more coordination and ease. Single leg stability has shown major progress. Toyah’s knees stay locked and even the right side goes to a stacked position naturally. Left side does so once cued.

This session we used manual therapy to reduce tension and improve proprioception. A combination of broad and specific techniques were used such as:

• Padding

• Myofascial release

We also introduced the hip hinge as an exercise progression. Both in a symmetrical bipedal stance and in a single leg stance. The hip hinge was looking stable and controlled so we began to load it with a 10kg dumbbell. The single leg hip hinge was losing proprioception in the glute on the right side.

Homework:

• Hip Hinge (10kg): 2x10

• Single Leg Hip Hinge (Supported): x10/side

Week 4

Toyah has reported that she feels like she has more control of her muscles and that she is feeling muscle ache in the muscles we targeted last week. The single leg deadlift still hikes more on the right side, but once cued into position with touch, Toyah can feel glute activation. The hip hinge/deadlift is looking very comfortable at 10kg, so we have progressed to heavier weight (40kg) with room in the tank for more.

Homework:

• Single Leg Deadlift: 2x10

Week 5

As the approach is very 'training oriented’ and Toyah’s main strength movements are very tidy now, we can move into challenging those patterns with endurance. In a circuit format including deadlifts and planks.

Week 6

This week, Toyah was feeling unwell so we used this as a chance to test for proprioception rather than push the strength exercises like the hip hinge/deadlift.

• Spinal awareness and control: Improved in a seated position so Toyah has now advanced into segmentally rolling in a Cat/Camel position (hands and knees).

• Core breathing: Showed improvement as position is maintained with fuller diaphragmatic breathing vs week 1.

The Results

At the beginning of this case study, we set out to help Toyah live powerfully, without injury or pain. I believe we’ve made notable headway in this direction as Toyah has reported that her pain levels have reduced significantly and her confidence and motivation for an active lifestyle has returned. Her movement patterns have also improved, to a point where Toyah can comfortably do compound strength exercises in a circuit format on her own. Overall, the case study was successful as Toyah was out of pain early on in the treatment plan, which meant that we could focus on setting up better patterns for the future.

“Before i started this case study with Laurent and his very talented group of trainers, I was living with level 7 pain every day, thanks to my back muscles. I've lived with this pain for about 10 years, starting from when I did rowing at school, with no advice on how to care for my back.

From the second session on wards, after only 3 simple, singular muscle control style exercises, I felt huge changes in my daily level of pain, going to a 3, then shrinking to non existence for the better part of my weeks. I found the way everything was explained so easy to under stand and follow.

By week 3 we had made so much progress in changing the way I use my back, that we were ready to start training.
We continued with a simple balance and extension exercise on one leg, which was hugely effective at strengthening the muscles causing hip muscle pain.

I would of never thought that dead lifting would be suitable for me with a recently recovered back, but Laurent knows exactly what he’s doing, and it was the perfect exercise - using all the muscles I needed to strengthen my posture and emphasising the correct way I should be bending my back, it was so effective and the coaching all staff gave was top notch.

It's a long, slow and steady type of task, but the level of strength in my back is already significant better, and my pain levels + amount of days that I’m in pain, are less than half than what they were.

I honestly would of been happy with one level of pain less so I'm absolutely over the moon with my results. For now I'm just following Laurent’s advice at home and continuing to strengthen my core and back muscles.”

- Toyah

Case Study Lead: Laurent Pang

Team Involved: Abby McCarthy, Sam High, Michael Lahood

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