A Case Study
This week I am going to do a case study, a step by step guide of how to get someone out of pain. I obviously can't use my client's real name so Kathryn my front of house, is posing for the photographs but this is how my client evolved over the last three months.
So Sally is a 37 year old woman with three kids, ages from one year to five year old. She works as a primary school teacher and has lower back pain for the last ten years. Sally’s pain has got worse since having her first child and now she is unable to get out of bed without severe stiffness, she can't put on her shoes, it’s sore brushing her teeth and she is unable to do any activity without seizing up. The pain is all in her right hip and sometimes down her right leg.
She has tried pilates, yoga, physio, chiro, osteo, acupuncture and as well a lot of regular painkillers. All these things haven't helped her get any better and year in year out, she is getting slowly worse.
So the first time I see Sally she is at a low ebb, very down and fearful of what she will be like at 50 years old. She feels this is her last hope before surgery. She has had two MRI scans over a four year period which shows a disc bulge at L4-L5. She was referred to a surgeon who gave her a 50% chance of getting better through surgery. She feels she is becoming over reliant on painkillers and needs to change.
So for me this is my ideal client, someone who has got all the medical stuff done but has no solution but still wants to change. A lot of us want to change but are we really willing to dedicate 30 minutes each week to learning how to and then go home and implementing every step? So Sally can only bend down as far as her knees she needs to use her hands to get out of the chair and it takes her two minutes to straighten after sitting for more than two minutes.
In standing I can see she has a large arch in her lower back (I can literally fit my fist in it) and then a very flat back to the base of her neck. So we have the opposite of what the human spine should be. No part of the human spine should be flat it is rounded to displace load. In standing Sally is putting all her weight on her right leg, see right shoulder lower. She is so right sided she doesn't even know that she has a left leg.
On the bed she is unable to drop her left leg to the bed which means she is unable to stand on her left leg, her right side is perfect. So with all people in pain I ask this question, is this person sore because: 1. They are underusing this area and it’s weak = pain or are they overusing this area = pain. Sally needs to train her left leg to be stronger so she can stand on it in a queue or use it when she walks and in turn off load that right side.
I start her with two simple exercises. One is a hamstring exercise to get to drop her left knee to the bed (stand on her left leg) and the other is trying to get rid of that large arch in her back.
Knee cant drop to the bed
Left hamstring and balloon
All fours belly lift
Sally had three days of no pain but then wore high heels and was very sore that night. She feels it will never get better. In my mind I have no doubt I will get her better but if she can't see it, she will never stick the course of treatment.
I ask her to touch her toes, to her amazement she could get down to her socks. This is so important with people with chronic pain. Don't forget pain is negative, it makes you think negative thoughts and it's hard to see the light at the end of the tunnel but to be shown some improvement is always a good way to show people how things can change.
She now can drop her left knee to the bed but when asked to this on her own she is unable. This is someone I would now class as a pelvic floor client. The ability to bring the knee back and drop it to the bed is controlled by your pelvic floor muscles.
Knee can drop to the bed
TIP: - If you have a pelvic floor problem you won't pass this test -
So this allows me to change her exercise to a pelvic orientated exercise, also her right shoulder is slightly dropped so I want to add in some right rib lengthening.
Sally explains her worst pain is after standing at a GAA match or having to walk for more than half an hour. So I know I need to fix the way she stands so I give her this exercise.
Left glute max with arm reach
She has had five days pain free and delighted with the progress. She can now stand for long periods but walking is still catching her. WHY? It’s very simple. Anything that requires you to breathe more is going to fire up certain muscles and it's obvious that when Sally gets fatigued her back muscles have to come on to get her through the activity.
Sally is able to touch her toes can drop her knee to the bed on her own but why is she still in pain? Her flat upper back hasn't changed - this is important because your upper back is where all your air should go when you breathe and if it doesn't you have two options: 1: shrug your shoulders = neck pain 2: arch your back and let your ribs go up = back pain. In Sally's case she is the latter - so we need a exercise that will open her upper back and get her ribs down.
Can drop the knee on her own.
1: Wall push
2: Andrew’s exercise
Sally has had a pain free week, but can still feel an odd twinge but is very happy with progress. She now wants to be able to run again. This happens so much in the clinic, you get someone out of pain and then they want it all…. now.
To run you need a lot of control. You need very strong hamstrings and abdominals to keep you upright and to stop you from overusing your hip flexors. I gave her these three exercises and made an appointment for two weeks time.
Exercise 1: ab ball
Exercise 2 : HAMSTRING AND REACH ALTERNATE
Pain free mostly….. two days that she didn't do her exercises and felt it coming back. Her favourite exercise is the wall reach. She noted that she now more active, feels she can help her kids more, she can play with them more and her mood has improved.
She still wants to run so I allow to do a run later that week but she has to email me after to see how it goes.
The email later in the week says she was in no pain after the run. I still work with Sally today just when she needs to see me. She has improved greatly and is in a far better place now.
So why does this work?
It’s a simple and a complete approach. Most people get a massage, some needles or a crack of their back and never think why it's happening. With this approach I get to know the clients every move, I can fix the main stumbling block , re teach her how to sit, sleep and stand. I then concrete these new good positions with my tailored exercise programme. She had to email me everyday telling me how her day was which allowed me to find out each person's triggers of pain. I would put structures in place to get over these triggers. I am proud to say it's a very personal approach but knowing back pain it's a complex and personal thing, people have similarities but everyone is different. It requires a huge amount of trust as most people are afraid to change not because they don't want to get better but because they fear change will make them worse. I understand that and am I’m happy to help these people.
Will I get better if I do these exercises?
Would Sally have got to this point with just exercise? The answer is definitely NO. We did postural restorations techniques, dry needling, massage and breathing restoration techniques to achieve our goals. So everyone is very different and everyone has different stumbling blocks. Get a good assessment and work with someone you trust to achieve your goals.
Will it last?
Yes it will. Remember…. be positive and active. Don't stop searching for your answers. Find someone that will work with you and for you and stick with them. Be like Sally.