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A Real 12-Week Back Pain Rehab Case Study (Online, No Hands-On Treatment) — Transcript

by MOVE Physiotherapy · 3,432 words · 487 segments · language en · Watch on YouTube

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0:01Hey team. So I wanted to go through a
0:05example rehab process we did with a
0:08client of ours last year. And this was
0:10an individual that was struggling with
0:12chronic back issues off the back of a
0:16discreated issue that caused a lot of
0:18severe nerve issues and impairments down
0:20a particular side of their body. and it
0:22was impacting their quality of life in
0:24terms of being able to run, to be able
0:26to train and to of course be able to
0:28move with thoughtless fearless movement.
0:30So, what we're going to go through is
0:32kind of what the first well the 12 weeks
0:35that we went through with the process
0:36and how we went from stage one all the
0:38way to returning to full level of
0:41activity. And this was done within 12
0:43weeks. And this individual was down in
0:45the bottom of the country. So, we never
0:46actually met. This was all completely
0:48managed online. And this is just very
0:49much of a a demonstration of how we can
0:52manage this online and how we can make
0:54it super specific for the individual
0:56because their case was slightly
0:57different to majority of back pain but
0:59is actually very very similar to
1:01majority of people and what they
1:02struggle with. So I'm going to just go
1:04through the process go through how we
1:06identified where the weaknesses were and
1:07then from there then go through each
1:09particular phase where there are three
1:11phases. So when we looked at phase one
1:13the main focus was obviously an element
1:14of of kind of introductory movement. So
1:16you can see that we've split into three
1:18different main sessions where you got a
1:22low back rehab phase one which is all
1:24about that rib cage and pelvis and
1:25teaching people and teaching this
1:27individual on the importance of being
1:29able to control particular motions with
1:31good breathing, good control, and at the
1:32end of the day it's all there to give
1:34your nervous system a pocket of
1:35security. If you're able to do mo
1:37motions that are new, but you can
1:39control your breathing, your nervous
1:40system is going to learn and it's going
1:41to adapt. And what we'll tend to find is
1:43really powerful for people who are
1:46constantly in pain to be able to control
1:48key motions that you know they might do
1:51dayto-day, they might do in the gym,
1:52they might see other people do, but can
1:54do it with reason and with control. And
1:56breathing is a really really good way of
1:58doing that. Something that we use all
1:59the time has a big influence on the the
2:01nervous system. It allows us to move
2:03very very quickly away from a a kind of
2:05a fight orflight situation which often
2:08not where majority of our pain can be
2:10experienced as sensitivities increased
2:11as fight or flight also increases. Then
2:14session two was very much around single
2:16leg strength stability. The reason this
2:17was brought in because this individual
2:18was a runner. So at the time this person
2:21was running they were able to train but
2:22they were weren't able to kind of build
2:24any confidence with their running. We
2:25stripped it all the way back. We looked
2:28at a few things around running specific
2:29work that also linked to their injury
2:32history. They had a big ankle a
2:36asymmetry. There was [clears throat] one
2:37ankle that had been experiencing more of
2:39the nerve issues than the other side.
2:42And then what we saw was that the
2:43weakness from that was obviously
2:45translating into their running and
2:46jumping performance. Obviously causing a
2:49potential risk of force transfer issues
2:51up the chain. We then brought in a third
2:54session which was spinal decompression
2:55work. This is an individual that didn't
2:56like flexion. And so with flexion, I'm a
2:59big fan of opening up the spine to
3:01decompress it. So when the spine can
3:02move and open up, generally the hip can
3:04open up a little bit better as well,
3:06which links towards the pelvic mobility.
3:08And again, if you've got a rib cage, a
3:10pelvis, a hip, and a spine that have
3:12freedom, symptoms aren't going to be as
3:14triggered and as quickly to trigger on a
3:16day-to-day. So that was a big thing that
3:18we focused on. So you can see on the
3:19single leg strength days, there were two
3:21days. One was very much more knee
3:22dominant with an element of ankle
3:24specificity. The other one was very hip
3:26dominant with an element of more glute
3:28and posterior chain work alongside hip
3:30stretching work. So you'll see these
3:32drills if you're someone who's worked
3:33with us for a long time with kind of the
3:35midfoot bridge, the 3D quads. Thoracic
3:38rotation based drills are really really
3:39common within the program just because
3:41they're really valuable and they work
3:42really well for us.
3:44So, as you see, this person was able to
3:47focus on this program for 3 weeks and
3:50the individual themselves was able to
3:54pretty much build a bit of confidence
3:56from this phase one. And we identified
3:58really quickly with their feedback that
3:59they were having no issues, they were
4:00enjoying it, the symptoms were very,
4:02very low and they were able to complete
4:03it with no additional stress on their
4:05chain. What I forgot to show you as well
4:06was actually how we modified their
4:08testing. So we'll usually have a battery
4:10of testing which will be upper body,
4:12lower body, capacity, strength. But of
4:15course with this individual, we didn't
4:16want to rush their testing just because
4:18we hadn't got the full awareness of what
4:20they could and couldn't do. And this was
4:22a busy individual. So what we did, we
4:24just did a little bit of lower body
4:25capacity and a movement screening where
4:26we're able to look at their standing
4:28assessment which is their toe touch,
4:29side to side rotation and extension,
4:31overhead squat patterns, the heel off
4:33bridge test which you'll see over the
4:36next couple of months in terms of some
4:37key movements that we use as a
4:38particular test and why it's important
4:40and then of course the capacity which we
4:42kept in just because from the nature of
4:44their training we knew they'd be able to
4:46tolerate. If this was a person that was
4:48having acute bout of pain, we wouldn't
4:50bring in capacity testing because this
4:52is very much the second stage of rehab.
4:54We would want to create a a kind of a
4:56platform where we can build isometric
4:58strength and rib cage and pelvis control
5:00under safe confinements. Then we move
5:02into a second phase which is very much
5:03isotonic. So under reps, capacity,
5:06building tolerance to a little bit of
5:08fatigue. And then third is that that
5:10element of kind of pio ballistic
5:12increasing the intensity with with more
5:14thoughtless feelless motions under the
5:16context of subconscious. The brain's
5:17doing the work for us. The beginning
5:19kind of isometric platform of rehab is
5:21very much conscious. It's controlled and
5:23then as the continuous kind of
5:25progressions go on, we go from
5:26controlled to to chaotic just that's the
5:29quality of of training that majority of
5:31people are going to want to build
5:32towards which is again real life
5:33scenarios. So after that kind of phase
5:36one, we kept it the same and that's
5:37really important for people to
5:38understand. your your rehab doesn't have
5:39to change a lot. Like you need to build
5:42some a little bit of confidence with
5:43with key movements and you'll see that
5:46each movement has a dedicated
5:48progression. So for example, if I'm
5:50going to progress a wall sit level two,
5:51which is just basically your foot
5:53slightly in front of your knee at nice
5:54tall position. Level three is going to
5:56be foot coming more kind of behind the
5:58knee which puts more loads through the
6:00cords and the knee. And then obviously
6:01level four, five, six is going to be
6:03maybe foot in front of the knee, foot
6:05within the knee, and then foot behind
6:06the knee but then sinking deeper. So
6:08there's elements of progression that
6:09you'll see within the program.
6:11And then you will then see as we move
6:14into phase two, the additions we brought
6:16in here. We combined the rib cage and
6:17pelvis work to make a full
6:21pelvis drill where we've got an element
6:23of A1 to A3 is very glute and hip
6:26dominant. So we're actually building
6:27some tolerance from some isometric
6:29strength within a mini banded clams
6:31which do have a bit of value. Aren't
6:33useless as most people would say. I
6:34think they have a little bit of value if
6:36they're working to a good intensity. A
6:38prone bently leg extension is basically
6:40lying on your front, bending your knee
6:41and lifting your foot all to the sky,
6:43which again is just hip extension, a
6:44really valuable motion for running. And
6:46then sideline shift is bringing in that
6:48frontal plane where you're lying on your
6:49side. You're letting your leg get really
6:50long. You create like a hip lock drill
6:52and then you're adding an element of hip
6:54abduction. You'll then see that we've
6:56combined the rib cage based drills,
6:58which is just a thoracic spine stretch
6:59where we're in for all fours, nice and
7:01rounded, breathing into our back and
7:04promoting more expansion through the rib
7:06cage, which again is valuable for
7:07settling a very sensitive nervous
7:09system, but also two, a lot of people
7:11get tightness around the neck and around
7:12the back when they don't when they're
7:14very hesitant to flex. So opening up the
7:16chest to create more flexion through the
7:18rib cage and protect the spine in a way
7:21by getting the upper part of our body to
7:23move better so the spine doesn't have to
7:25hinge necessarily for us. And then
7:27pelvic tilt harling stretch and cobras
7:29are exercises you will see in the second
7:31part of the lower back rehab series
7:33which is going to be coming in the next
7:34couple of weeks. Then we brought a
7:36little bit of progression into the
7:37running specific drill. So you'll see
7:39obviously we're building into level two
7:40or three for the wall sets which is a
7:42big element of weakness that we saw with
7:43them through their quads and through
7:45their hips. And then we brought in some
7:46specific running drills like a hip block
7:48drill which is in essence a way that we
7:50teach the hip to stabilize in landing.
7:52So as the foot hits the ground when we
7:54run we want the stance leg to stay high.
7:56We want the opposite leg to also stay
7:58high too. We don't want to see any
7:59sinking because this is going to just
8:00put more stress through the spine, more
8:02stress through the hips and then of
8:04course more stress through the upper
8:05chain of the body. Then we've got a
8:08brilliant combination of standing drills
8:10that we use to build confidence from a
8:12single leg balance pertubation
8:14challenging that base support. So we use
8:16a hip circuit which is again you're
8:18going to see within the program where we
8:19use a lunge series of forward back side
8:22to side and curtsies which is like an
8:24element of a rotational lunge which
8:25again gets the whole system working with
8:28all planes of motion which we need to
8:30complete as humans. And then one kind of
8:33combination of drills that I use that
8:35are very undervalued are single leg
8:37banded strength work around hip hip
8:38flexion and hip abduction which again
8:40super valuable for runners.
8:43Then as we go into phase three as this
8:46individual was progressing really well
8:48we ultimately started focusing on
8:50progressing more balance coordination
8:52work within their rib cage and pelvis
8:54drills making it a bit more running
8:55specific. So you'll see here that we
8:57started bringing the c the cable
8:58standard hip abductions into unassisted.
9:00So you're basically using a dowel in
9:01front of you to be your balance and then
9:03actually challenging your center of mass
9:05from a side to side perspective using
9:06your glutes to have to control both the
9:09stance position and then obviously the
9:10lift into the side position which again
9:12is a beautiful drill if you've never
9:13tried it. And then building into some
9:15more lateral plane of motions like a
9:17skater jump and and progressing into
9:18motions that most people would never try
9:20if you're a longdistance runner just
9:21because it's an element of doesn't
9:23really cross over to your type of
9:25training. But if you have a nervous
9:26system that can use all variations and
9:29has freedom to do so, then again there's
9:31less risk of our nervous system wanting
9:33to trust and use our back more, which
9:34again remember is a really common part
9:36of low back rehab. Just get the lower
9:38back to do a little bit less. Okay. So
9:41what I'm going to show here is KPI
9:43number one which we use with this
9:44individual which is a single leg balance
9:46position. So you'll see this individual
9:49really struggle to tolerate single leg
9:51positions which again as a runner is
9:52super valuable. And what we found over
9:55the course of the 12 weeks was we went
9:56from 30 seconds on each side with eyes
9:58open all the way to eyes closed for over
10:01a minute with no issues at all. And this
10:03is a really important part of training
10:04that people don't consider is a KPI that
10:06doesn't have to be strength related,
10:08doesn't have to be power related. It can
10:10just be as simple as a single leg
10:11balance because again, you know that as
10:13a strength component, if we can balance
10:14and coordinate on one leg, we're going
10:16to have less issues going up the chain.
10:18Again,
10:19an important aspect as well in terms of
10:22KPIs like we say was the capacity
10:23testing. So, if we use single leg squats
10:26in conjunction with the single leg
10:27balance, we found straight away that we
10:30were having a lot of problems with
10:32balance coordination, which you can see
10:33with a standing assessment and the
10:35single leg squat wasn't looking super
10:37controlled, which again would make sense
10:38if they were having issues when they
10:39ran. So, what we made a focus of was I
10:42identified where are we weak. So on one
10:43side they could tolerate 25 but with the
10:45control you can see there and then 16 on
10:47the right which was again slightly worse
10:49more fatiguing. This is the side where
10:51we had more neural involvements. We had
10:54less control and again this is something
10:56that you don't often know unless you
10:57test it. This individual was able to get
10:59to n I think they got to 60 by the end.
11:02Yeah 60 on each side and they were doing
11:04it with much better control. You'll see
11:05the speed and control is there. The
11:07hesitancy is incredibly low and
11:09obviously the fitness and the tolerance
11:10to get to over 60 reps is incredible.
11:12Our target is just above 30. And just to
11:15finish, as we moved on to phase three,
11:17which is again just building into that
11:18coordination, balance, and strength of
11:20stability on each leg, you can see that
11:22the capacity numbers did improve to
11:24above 16, way above our targets as a as
11:27initial KPI. I do need to add that we
11:29didn't have any access to strength
11:31testing with this individual. So, it was
11:32unable for us to get any leg extension,
11:34hamstring curl, or any leg press data
11:36just cuz the gym that they used. But
11:37again, it was something that we we often
11:39do come across. Sometimes we don't have
11:41access to maybe a valve kit that we do
11:42here to test those markers or don't have
11:45access to particular machines because of
11:46the type of gym that you go to. We just
11:48use capacity heavily within our focus.
11:50So the single leg squat and the the
11:51single leg balance hold were the two
11:53main KPIs that we used in conjunction
11:55with symptoms. So we just kept this
11:57really simple and just monitored three
11:59main targets of can we improve those two
12:01KPIs I've just mentioned. And then in
12:02terms of symptoms, can we just keep an
12:04eye on kind of where are we at in the
12:05morning? How are the symptoms presenting
12:07during during dayto-day after training?
12:09And by week seven, seven seven on on the
12:13way to kind of week 12 where we were
12:15within phase three of the program, we we
12:18generally didn't have any symptoms
12:19during training, during day-to-day and
12:21their job during any of these additional
12:23rehab motions. And you'll see again like
12:25the check-ins were extremely valuable
12:27for us to know this. There were no
12:28things that we needed to add or kind of
12:30complement their work. The feedback
12:32started to die down as the as we started
12:34getting to back normality, which is
12:35normal. But what we did find that the
12:39more we focused on drills that were
12:41specific to the type of training they
12:43wanted to to basically do run, we found
12:46the motivation was super super
12:50consistent from there. If this was an
12:52individual that just wanted to run and
12:53all I did was in try and approve say
12:57strength and
12:59slow and control type training which
13:01again is valuable for some people but
13:03not for this individual then I might
13:05have really struggled to get the
13:06motivation and the the compliance which
13:08we saw with this individual which was
13:10kind of the main reason they improved.
13:12They were consistent. This individual
13:14showed up every day. I think they barely
13:16missed a session in the first four,
13:18five, six weeks and then a work period
13:20came in and they did miss one or two
13:21sessions but they were so consistent
13:23with everything else. That's the biggest
13:25part of low back rehab that people do
13:27not recognize. The consistency is all
13:29that matters because low back problems
13:32are going to stem for a good chunk of
13:33time. They do not go really quickly. And
13:36we do need to sometimes restore
13:38particular KPIs like plank and core
13:40strength and trunk testing and then
13:42capacity. But as long as you're showing
13:44up every day, you're doing something.
13:46Your movement is often that's going to
13:48help you feel better about yourself
13:49because you're starting to feel that
13:50you're not fragile anymore. And I think
13:52that's really important to consider when
13:53it comes to low back rehab. It can be
13:55specific to you and it doesn't have to
13:57be the same as someone else, but as long
13:58as you show up and you do the work, you
14:00will get that. And that's a really,
14:02really important thing to consider
14:03because like I said in my previous
14:05presentation, the prognosis is really
14:06good for majority of back issues. It's
14:09the people that stop and it hit a bit of
14:11a hiccup that don't do well. And this is
14:14the most consistent kind of individual I
14:16worked with. And we saw that for a
14:18really really chronic back issue in
14:20conjunction with some serious nerve
14:22related issues, their back running 5ks
14:24and they're hitting some some amazing
14:26targets which again they never thought
14:27they would be able to do. So take that
14:29as the main focal point from today. Show
14:31up. Make sure you do the work. Feedback.
14:34The more feedback is always the better.
14:35film and educate yourself in terms of
14:37how you've gone from here to here, how
14:39one movement looked versus this movement
14:41from kind of week one to week 12 and
14:43you'll surprise yourself because that's
14:44really important. Not everything needs
14:46to be super objective. If we can, we
14:48will, but like I said, keep it simple
14:49sometimes. A simple balance test, a
14:51simple capacity test, and then a simple
14:53kind of pain monitor test was all I
14:55needed for this individual. And this was
14:57the simplest of programs I've to ever
14:59develop someone. So yeah, link this to
15:01the previous presentation in terms of
15:03understanding the rib cage, the pelvis,
15:05how we work on building strength through
15:07the rest of the chain. So the force
15:08transfer is is a little bit more
15:10efficient. And this is going to
15:11complement the phase two to three in
15:13terms of the exercise we use to really
15:15really improve back pain for good. And
15:17then more importantly, understanding the
15:19phases from phase one to phase three.
15:21Thanks for watching. I hope you enjoyed.

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