Slow going

Whilst at my musculoskeletal outpatients clinic I treated a man in his early 40s for lchronic low back pain. I was the eighth student he was seeing at the clinic and his progress had plateaued for approximately six weeks when I first saw him. He was still unable to work due to the pain and was very compliant with the advice and exercises he was given, even when he wasn't seeing progress. I became frustrated as his asterisk signs and pain were very inconsistent from session to session, and for example mobilisations one day would work quite well, whilst the next he would be in severe pain for three days, despite the same mobilisation parameters.

Whilst I did not expect a miracle recovery, nor a return to completely pain-free function due to the chronicity of his condition, I became increasingly frustrated and confused by his presentation. Each week my objective findings would indicate a different mode of treatment and management, and these would inconsistently be beneficial or detrimental to his condition.

After discussing the patient with my supervisor, he suggested trying a very general strengthening program, rather than targeting core stability muscle retraining, soft tissue work to reduce spasm and mobilisation for his hypomobility. I gave him some exercises and a gym program (he had been to the gym before but was not given a tailored program and felt it exacerbated his LBP) for general strengthening around the trunk, pelvis and lower limbs in particular.

Although he only performed these exercises for two weeks before I left, he felt that he was having less "bad days" and generally his pain was improving, as well as becoming more consistent. This was very satisfying as he was the most difficult patient I had and whenever he had an appointment I never knew what to expect or where to go with my intervention.

I learnt from this experience that, as reflected by limited and often conflicting evidence for the treatment and management of chronic LBP, there are times when your objective findings do not necessarily indicate which treatment methods will be the most effective. Patience is important for both the physio and patient (hence the term!), and a willingness/awareness to try a very general approach when specific things just aren't working. Next time I would still persist with different interventions targeting specific impairments, however I will be more patient and remember that I have the general approach to try if other methods fail.