Case Study: Acute Low Back Pain

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Clinical Experience (Home visit: 2020-2021)- A 28-Year-Old Female Police Officer

 Patient Information:

• Name: [S]

• Age: 28 years

• Gender: Female

• Occupation: Police Officer (requires long periods of walking and standing)

• Medical History: No significant past medical or orthopedic history.

• Presenting Condition: Acute low back pain following an immediate twisting movement while turning. The patient was unable to move and sought emergency care. She was advised to start physiotherapy for rehabilitation.

 

Initial Assessment:

Subjective Findings:

• Main Complaint: Acute onset of severe low back pain following a twisting motion while turning.

• Pain Characteristics:

- Pain intensity: 8/10 on the VAS (Visual Analog Scale)

- Location: Localized in the lumbar region with referral to the left gluteal region.

- Nature: Sharp pain, especially during movement or bending.

- Aggravating factors: Prolonged standing, walking, and twisting motions.

- Alleviating factors: Rest and lying down with knees supported.

- Functional Limitation: Difficulty performing daily tasks, including walking and standing for long periods (as required in her job).

Objective Findings:

• Posture: Mild forward flexed posture with a slight shift to the left.

• Range of Motion (ROM):

- Lumbar Flexion: Limited to 30° (Normal: 80-90°)

- Lumbar Extension: Limited to 10° (Normal: 20-25°)

- Side Flexion: Painful on the left side.

• Strength Testing:

- Hip flexors, extensors, and abdominal muscles were weak, 3/5 in some directions due to pain inhibition.

- Lower limb strength (hip and knee): 4/5

• Palpation Findings: Tenderness and muscle spasm in the lumbar paraspinal muscles.

• Special Tests:

- SLR (Straight Leg Raise): Negative for radicular pain.

- Trendeleburg Test: Negative

- Palpation: Tightness and muscle guarding noted in lumbar region.

 

Diagnosis:

Acute mechanical low back pain, likely due to a lumbar strain or ligament sprain triggered by an excessive twisting motion during an activity.

 

Treatment Plan:

Goals:

• Short-term Goals:

1. Reduce pain and inflammation within the first 3-5 days.

2. Restore pain-free range of motion (ROM) and improve functional mobility.

3. Educate the patient on proper posture and ergonomic modifications.

• Long-term Goals:

1. Strengthen the lumbar and core musculature to prevent recurrence.

2. Improve endurance for walking and standing, as required by her job.

3. Return to full functional activities, including work duties, without pain or restrictions.

Interventions:

Manual Therapy : Gentle joint mobilizations (Grade I-II) to improve mobility and reduce pain during the acute phase.

Exercise Prescription:

A progressive rehabilitation program starting with gentle mobility and stretching exercises, moving towards strengthening as pain decreases.

 

Exercise Program:

Days 1-7: Acute Phase

1. Pelvic Tilts (Supine Position): 

  • To improve lumbar mobility and reduce muscle tightness.
  • The patient was instructed to lie on their back with knees bent, gently flatten the lower back into the mat by tilting the pelvis upward. Hold for 5 seconds, repeat 10 times.

2. Knee-to-Chest Stretch:

  • Stretching to the lower back and hips.
  • Instruction was given to lie on the back, pull one knee to the chest, and hold for 20-30 seconds, 3-4 repetitions on each side.

3. Bridges:

  • Activating the gluteal and core muscles.
  • The patient was instructed to lie on the back with knees bent, feet flat on the floor, lift hips off the floor by tightening the glutes and core. Hold for 5 seconds, repeat 10 times.

Days 8-14: Subacute Phase

4. Cat-Cow Stretch:

  • To Increase spinal mobility and decrease stiffness.
  • The patient lie in a quadruped position, alternate between arching the back (cat) and dipping it towards the floor (cow), focusing on moving through the lumbar spine. 10-15 repetitions.

5. Side-Lying Leg Raises:

  • To strengthen the hip abductors and lateral core muscles.
  • The patient lie on one side, keeping legs straight. Lift the top leg upwards while keeping the pelvis stable. Hold for 5 seconds at the top and return. Repeat 10-12 reps each side.

6. Plank:

  • To strengthen the core muscles.
  • The patient was instructed to hold a modified plank position with knees on the ground for 10-20 seconds, gradually increasing the hold time. Repeat 3-4 times.

End of 14 Days:

By the end of 14 days, significant improvements in pain levels, ROM, and function were achieved. The patient reported pain levels decreasing to 3/10 on the VAS, with improved ability to walk and stand without discomfort. Lumbar ROM improved to approximately 80% of normal range.

Outcome:

The patient showed good progress with a reduction in pain and improved functional mobility. By the end of the 14-day treatment course, the patient was able to return to her daily activities and resume her work without significant discomfort. The patient’s lumbar ROM returned to normal, and core strength improved. The patient was advised to continue with strengthening exercises and work on postural awareness to prevent further episodes.

Recommended to return for reassessment if any new symptoms arise, with continued home exercises for strengthening and flexibility.

Reflection:

The patient adhered to the exercise regimen, and heat therapy significantly helped to reduce the acute pain in the early stages. The main challenge was managing the patient’s pain level during the first few days of treatment. Gradually increasing activity tolerance was key. Ongoing strength training and posture correction were emphasized to prevent recurrence of low back pain, especially given the patient's occupational demands.

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