Patient A, is a 58 year old amateur golfer who attended the clinic with a 2 year old right lower back and gluteal pain with sciatic radiation down the back of the right leg. The Patient has a continual area of pain and irritation in the right lower back which is worse on a morning after getting out of bed and than gradually eases off to a little pain on general activities during the day. The pain and stiffness increases during prolonged driving and sitting. There is a major increase in pain and irritation when doing more strenuous activities such as playing golf and is now becoming difficult to complete 5 holes before the pain and irritation gets to level which causes the golfer to stop playing.
On examination the patient has restriction on all lower back movements with a mixture of pain, stiffness and sciatic radiation on bending forwards and side bending to the right. On palpation the patient presents with increased tissue tension in all the lower spinal muscles with major trigger points in Right L4/L5 and L5/S1 as well as the right gluteal area, which on palpating this trigger produces the sciatic leg pain. Numerous MRI scans and X-Rays over the years show degenerative changes commensurate with the age of the patient, but no major abnormalities were detected.
TREATMENT AND REHABILITATION PROTOCOLS
It was then explained to the patient that the treatment and rehabilitation protocols with regard to the “boxes that needed ticking” and the time scales required to achieve these outcomes.
The goals of the management strategy are to :
1. Improve the quality of the soft tissues by reducing the tissue tension and removing the triggers.
2. Restore normal, or near to normal spinal mechanics.
3. Implement a strength and conditioning programme for the area.
4. Introduce cardiovascular programme.
5. Rehabilitation back to all activities.
The management strategy can be divided into time elements, from the initial consultation onwards so that the patient knows what to expect at each stage and how long each stage will last. Outlined below is a typical scenario.
PROTOCOL FOR 0-4 WEEKS
It must be understood by the patient, Mr A ,that he must rest from irritating activities at the commencement of the protocol.
To improve the quality of tissues, this is achieved by various types of deep soft tissue massage, specifically working on the tight and stiff areas, as well as the various triggers (areas of muscular pain) in the soft tissues. The patient has around 4 to 6 sessions of this.
To restore normal spinal mechanics, this is achieved by manipulating and mobilizing the lower back joints that are “stuck” and not “moving correctly”. These manipulations are carried out at the end of the soft tissue massage sessions above.
Throughout the 0-4 weeks protocol Mr A must be icing his injured area four times per day for 10 mins to help reduce tissue bruising and reduce chronic inflammation.
At the end of the 4 weeks we should have reduced the painful symptoms to a level at which we can commence strength and conditioning protocols.
PROTOCOL FOR 4-8 WEEKS
To maintain the improvement in the quality of tissues and spinal movement the patient , Mr A, must have one treatment session per week, that is, another 4 sessions during this time.
The implementation of Mr A’s strength and conditioning programme begins at this stage because after years of pain and irritation the spinal muscles at all levels will be deconditioned and if Mr A resumed his normal sporting activities he would “break down” again. The strength and conditioning protocols are aimed at two types of muscle groups and therefore there are two programmes.
The FIRST protocol is designed to work on the deep postural muscle groups, you are given specific exercise drills, these must be carried out daily for the first 3 weeks of the 4 -8 week protocol.
The SECOND protocol is designed to work on the large outer spinal muscle groups, such as, abdominals, back extensors, etc. These exercise drills are added at week 3 of the second protocol.
Throughout the 4-8 weeks protocol the Castleford patient must be icing his injured area four times per day for 10 mins to help reduce tissue bruising and reduce chronic inflammation.
PROTOCOL FOR 8 – 12 WEEKS
At the commencement of week 8 in the 8 -12 weeks protocol a cardio-vascular exercise protocol is introduced. This type of protocol would be low impact and carried out alternate days for 30 mins each session.This is designed to increase Mr A’s general fitness prior to doing specific rehabilitation drills.
At week 10 in the 8-12 weeks protocol specific rehabilitation drills commence before Mr x’s golfing can begin, such as:
1. Introduce walking drills, increasing distance, speed and terrain contours to simulate 18 holes of golf.
2. Introduce flexability drills to increase range of movement allowing the swinging of a club
3. Introduce squatting and lunging drills to simulate crouching on the course
4. Introduce specific time on the driving range, i.e. 30 minutes working sub maximally.
5. Introduce gradual increase in golf time on course starting at nine holes and progressing depending on the reaction.
Throughout the 8-12 weeks protocol the patient must be icing his injured area four times per day for 20 mins to help prevent any reaction to the increase in activity.