Decoding Back Pain: A Case Study Revealed

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Episode Introduction

Back pain is a common challenge that plagues many individuals, affecting their daily lives and hindering their ability to engage in activities they enjoy. In our latest podcast episode, we delve into a fascinating case study that sheds light on the complexities of back pain and the importance of personalised treatment approaches. Join us as we unravel the mystery behind chronic back pain and explore the journey of a client seeking long term relief.

In our podcast episode, we follow the story of a 50-year-old individual who has been grappling with persistent back pain for over a decade. Despite his active lifestyle, which includes cycling, weight training, and various physical activities, he found himself constantly hindered by episodes of debilitating back pain.

The client’s journey began with a gradual onset of back pain, with no specific injury or trigger to pinpoint. His pain was exacerbated by activities such as cycling and weightlifting, leading to frustration and a cycle of temporary relief followed by recurrent pain. Despite seeking help from physiotherapists, massage therapists, and other practitioners, a lasting solution remained elusive.

Upon closer examination by our expert, Jacob Steyn, certain key findings emerged. Despite the client’s seemingly healthy and active lifestyle, a notable flattening of the lower back curvature was observed, raising suspicions regarding the root cause of his pain. Further assessments, including palpation tests, provided valuable insights into the client’s condition.

One significant moment during the examination was when the client experienced intense discomfort while simply placing a dumbbell back on the rack at the gym. This incident highlighted the fragility and vulnerability of his back, shedding light on the intricate nature of his condition.

Join us on this enlightening journey as we demystify common misconceptions about back pain and empower individuals to reclaim control of their health and well-being. Together, let’s pave the path to a stronger, healthier back the smart way.

Tune in to our podcast, Back Pain Solutions, to discover more inspiring stories, expert advice, and practical tips to help you overcome back pain and embrace a life of vitality and movement.

Remember, your back health matters, and with the right guidance and support, you can embark on a transformative journey towards a pain-free and active lifestyle.

Episode Highlights

The case study presented in our podcast episode serves as a poignant reminder of the multifaceted nature of back pain and the importance of individualised care. Through in-depth assessments, expert insights, and a holistic approach to treatment, it is possible to unravel the complexities of chronic back pain and pave the way for effective solutions.

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Episode Transcription

Intro 0:00
When we’re young, we move with freedom and confidence with a great resilience to injury. But somewhere along the line we develop poor habits and become more vulnerable to back pain, back pain solutions features evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better back healthy movement. So join us as we demystify some of the commonly held beliefs about back pain and build your confidence to a stronger back the smart way.

Ben James 0:29
Alright, welcome back to the back pain solutions podcast everybody, for those that are listening or watching. In fact, now that we’re recording, as well as our video, as well as he is the audio from previous previous session. So today, we thought we’d do a bit of a case review. And Jacob, as a client, obviously won’t mention any names. But just to give you an example of some of the ways that these patients clients, present to us in clinic, some of the things that we do, and also also the outcomes that we get, because often, we see those patients that are tricky patients, long history, low back pain, chronic low back pain, periodic episodic, low back pain, and they can be quite challenging. And sometimes it’s good just to get an insight into some of those clients might give you some reassurance, but also give you some confidence that there is a strategy or strategies that you can adopt with the right advice to make your own recovery. So Jacob, welcome back to another episode. How are you?

Jacob Steyn 1:31
I’m good. Thank you, man. Thank you. Yeah. Nice to be good.

Ben James 1:36
Good. Yes. It’s always good to chat. So tell me, this client? Where do we start? When did when did the client present to you? How long have you been seeing them? And what were the main what were the main challenges and things that they were saying when they came to see?

Jacob Steyn 1:52
So this this specific person came in about three months ago, and they he is about 50 years of age, came to me with a long history of low back pain, never really resolving. And you had no accidents?

Ben James 2:12
The history is long history is how long? years? Yeah, we told you the following 10 years plus or 20 years or

Jacob Steyn 2:22
10 years plus, absolutely, of falling back getting a little bit better trying stuff. Soon as he would exert themselves, especially in the gym or doing sport, he likes to cycle long distances, then he runs into a barrier, and that is low back.

Ben James 2:41
Okay. Yeah. Okay. And what were the what the some of the things that that he tried and some of the things that he was doing in the, in the gym or training? Or is it sounds like, from what you’ve said, there was a bit of a sporadic approach to his trading and to his kind of recovery. Is that, is that right? Would you say is that fair?

Jacob Steyn 3:04
I would say he would, you know, um, he’s a long term cyclist, so he likes to go mountain biking in the winter, and he likes to road bike in the summer. But he also likes weight training. And so he, he would either start cycling longer distances, and he’d have a fallback. So build it up, and he’d fall back, he doesn’t understand why. And at the same time, when he would go to the gym, he starts lifting weights doing weight training. And I think he, you know, like a lot of guys have the idea you got to deadlift to get strong, you know, you got to squat to get strong, and sees that as the sort of holy grail to building real strength. And as he would build up his deadlift, or squatting, he will always run into falling back and going through his back or hurting himself. And typically, he would do stretches and stuff like that, but it wouldn’t resolve.

Ben James 4:02
Okay, so he’s got a he’s got a 10 year plus history of back pain. And his back pain is by the sounds of it episodic? How did it kind of how did it start? Did it just gradually come on? Did he do something specifically 10 years plus ago that he specifically remembers how did it how did it begin? What’s the journey he’s been on until that initiate No,

Jacob Steyn 4:22
no accidents? gradual onset can’t really remember when and how just to it’s been there for years, many years. And, yeah, I think as we go through the case, we’ll understand why there’s been no accident and why it actually just had a gradual onset. Posture wise.

Ben James 4:49
Okay. Okay. So, he’s come in with a 10 year history. It’s a gradual onset. There’s no, there’s no red flags there. What are the things that aggravate The things that relieve the pain for him when you first saw it, was there any kind of any kind of common factors or again, was it difficult to pinpoint for him subjectively, at least?

Jacob Steyn 5:10
Yeah. So when he came in he, he couldn’t really find a comfortable position with his back. So no position was comfortable sitting lying down, he would feel it. Lying down was the most comfortable, but he would still feel it walking. He said, he would actually feel it. Whereas usually when you have low back pain, we’re usually quite often walking would actually help you to not feel very much. And train. Yeah, absolutely. The slow train and cycling was painful, but he tried to do short distances. And I think he thought that it would just go over, but it didn’t go over this time, or it didn’t. It took a long time to get less. And that’s why he came to see me.

Ben James 5:55
Okay, and have you seen anybody? Anybody else physios otherwise had he had he had treatment?

Jacob Steyn 6:02
Yes. He’s said in the past, he’s been to physiotherapists, he’s been to massage therapists. He’s been to osteopaths personal training, he’s done quite a few things. And none of it seems to ever really solve the problem. So it always, you know, build it up again, take especially I think from taking rest as a big part of the treatment, he had it get better and build it up again. And then he’d fall back.

Ben James 6:31
Okay, would you say rest restaurant training or rest from treatment?

Jacob Steyn 6:37
Restaurant training or rest from probably the aggravating factors cycling training? exerting myself.

Ben James 6:45
Okay. Okay. And was there anything else that you you asked him during the history that you thought was, was was quite telling in this case? Or you were you were intrigued by or really was was next steps? Examination? Is there anything else to share on that initial history? Maybe

Jacob Steyn 7:07
you’re the the thing that I didn’t understand initially was why would he have so much pain, if he’s training if he’s not really using his body to he’s not a builder, he doesn’t sit long hours. He works with his body, but it’s not. I don’t want to give away his profession. But he doesn’t. He seems to get a bit of everything, you know, all kinds of movements not sitting too much. Not working or lifting too hard or heavy. And so it didn’t make sense why he had so much pain and why it wouldn’t resolve. And I looked at him he had a he looked seemed to have a great posture, a very healthy, sporty fit nearly 50 year old. So it didn’t make a lot of sense. I mean, so I knew I had to go a bit further and really investigate and find the cause.

Ben James 8:03
Okay, yeah, sure. So he’s got a variable posture, which, you know, arguably in many cases is better for most people and that sustained sitting or whether you’re, you know, carpenter tradesmen, arguably, at times, you’re, you’re maybe bent over, particularly through the lower back for long periods of time, although I would argue that, that tradesmen have that that variability to an extent, but could be, you know, more vulnerable in terms of loads that are lifting etc. And it sounds like this guy is not lifting heavy, he’s got a got a variable posture, he’s not sitting for long periods. So in many ways, that’s, that’s quite helpful. That’s quite good. And yet, he still is still struggling. And he seen various practitioners and he’s, he’s getting persistent pay. Okay. Exactly.

Jacob Steyn 8:45
And still Still, he seems to be very, you have seems to have a low tolerance. So there seem to be a reason why he would fall back very easily. And it didn’t make sense.

Ben James 8:57
So did you did you pinpoint anything? You mentioned cycling, were there any specific movements in the gym that were aggravated? Or could he not really tell whether squats or deadlifts or anything like that was particularly about problem as the last time he

Jacob Steyn 9:12
went to the gym? It was actually putting a weight back putting a dumbbell not too heavy back on the rack. And then he went through his back.

Ben James 9:22
Okay, and when you say went through his back he it felt felt the back go as it in this

Jacob Steyn 9:29
folder but go cramping since then. Very uncomfortable.

Ben James 9:35
Got it. Okay. And no leg pain? No kind of ridiculous pain very much. Low back.

Jacob Steyn 9:40
Very much local. Lower back. Yeah.

Ben James 9:43
All right. Okay, and what so where did you go next? Obviously examination that’s what we that’s what we would do. But what were the findings? What was what was evident for you? Yeah. So,

Jacob Steyn 9:54
you know, first of all, when I looked at his posture, looked at his back I realized that he had a very good shallow, lower back. So the typical rounding hollowness of the low back, which we don’t see, all too often, but in a more or less healthy back, we’ve got a little bit of a hollow, there was more it was more or less missing, it was very flat. And so that already raises suspicion to me, which elaborate on a little in a little bit. But then I did all the other tests, you know, I palpated palpation, when he was lying on his tummy, palpating on his spine actually didn’t hurt.

Ben James 10:33
When you say palpating you’re talking, you’re talking kind of pressing and challenging that despite its processes, feeling that movement in the low back?

Jacob Steyn 10:40
Exactly, exactly. So translation between the spine, this the vertebrae, seeing if I can trigger or look up pain at a disk or something like that, I couldn’t find anything there. Then I went on to do the McGill instability, lumbar instability test. So hanging him over the end of the bench, seeing if I can get some movement between the vertebrae there, no reaction. And then I did the heel drop test to see if there’s some axial compression compressive problems in the spine, and that was fine. And the lumbar extension, distraction test where I could maybe pick up some instability between the vertebrae. I know I’m using some big terms here. But I want to say those tests were all fine. They were all not a problem. So I couldn’t find any serious pathology, any serious problems in the spine. From those tests,

Unknown Speaker 11:39
okay, but I didn’t.

Jacob Steyn 11:43
Yeah, go for orthopedic

Ben James 11:44
tests, classic, kind of classic orthopedic tests, if you like. Pretty negative, pretty, pretty much insignificant. Yeah.

Jacob Steyn 11:54
Yeah. And also, what I didn’t mention, or didn’t mention what I did notice and palpating his spine, that he had a very rigid, stiff spine, so they there wasn’t a lot of play. In the spine. Okay, nope.

Ben James 12:08
Okay, okay. Okay. But not painful, but just notably, stiff? Yes. Yeah. Okay. All right. So so where’s your kind of head at that point? If you’re finding, because for a lot of practitioners that’s like, Oh, God, I can’t I can’t elicit the pain. What do I do here? So what did that make you think? What was what was your thought process at that point?

Jacob Steyn 12:36
Yeah, so you know that, luckily, I’ve seen this before. So I didn’t freak me out. And I, something I look for, but I realized, okay, so there’s no direct lumbar or low back disc that I can find that’s really irritated when I spring on it, when I push on it. That which I generally reproduce if I have a typical low back patient, but I, like I mentioned before, he had a very flat low back spine. And then I know that that makes him more vulnerable. When he bends forward, for example, or any lift something heavy from the ground, obviously bending forward, that the bending forces are going to be different in the low back, and especially where the low back meets the ribcage of the spine. So I know that that’s going to most likely be a more vulnerable place if your low back is flatter than the general low back. Okay, so then my, my, my hypothesis goes to the diagnosis of a ti l hinge. So hinging too much at the crossing of the ribcage and begin beginning of the low back, spine.

Ben James 13:52
Okay, so that makes sense. So, so where that kind of more kyphotic mid back if you like that kind of generally arches back as that transitioned into the lumbar spine, which generally is more of a lordosis curves, the the other way, that transitional zone was was the point of concern or, or kind of that was the question mark in your head more, more as a result of this more flattened, flattened spine in the in terms of the lower values? Yeah, okay. Okay. Yeah. And so, at that point, what was there was the next step then in terms of, of eliciting discomfort in that area are challenging movement patterns, etc, in that area?

Jacob Steyn 14:34
Well, I, I couldn’t really elicit it with the tests because the tests are generally not designed to pick up on a typical to hinge irritation at that part of the spine. So then I went on and I looked a bit further and I saw that he has something overlaying this problem which is called a lower cross, lower lower cross syndrome. Shall I just say Explain what that is. So basically, if you look from the side of the spine, yep. So if you look, if you look from if you look at the spine or the pelvis from the side, you can see that the belly where you can, you can draw a cross over the, over the pelvis. And so you have the low back, you have the anterior hip flexors, you have the stomach or abdominal wall. And if you follow this line, you have the glutes, the buttock muscles. And so typically you’ll have tightness or tightness of the low back muscles, hip flexors, weakness or less communication from the from the brain to the abdominal muscles and gluteal, buttock muscles. So I noticed he had very stiff hip flexors, I noticed that he quite quickly wants to hang in the low back, when especially goes into a plank by making him do a plank. So I noticed by looking at those aspects that the abdominal wall and the gluteals are not firing, they’re not doing the job. So there’s so more pressure to the low back from low back.

Ben James 16:08
So when he’s doing when he’s doing a plank, when you say hang, he’s kind of a sagging through the tummy a little bit. Yes. Yeah.

Jacob Steyn 16:17
Yeah. And so so then I think, okay, abdominal wall in the front, not doing his job properly.

Ben James 16:24
Okay. Okay. Yeah.

Jacob Steyn 16:28
So yeah, so I noticed this, what we call lower cross syndrome, overlaying this problem, I looked at his hip flexors, very taut and tight, you know, hip extension limited. And if his hip extension is limited, I know that his buttock muscles are probably not doing their job properly.

Ben James 16:49
Okay. Makes sense? And so, and so at this point, where did you go next? In terms of further examination, just to kind of make what what would we would describe as a as a working diagnosis, if you like?

Jacob Steyn 17:06
Yeah. So in terms of testing, I had them sitting down, and I had him bending forward, I could really feel a bumpy, a bumpiness, or a bit of a bump in the area of the transition between the ribcage and the low back. So I noticed that it really changes in position from standing to sitting down and actually slouching. So my hypothesis went to the fact that he’s got a steel hinge, you know, and I realized that that is, his weak spot, tender spot, gets irritated there very easily. And my thought process went to, okay, we’ve got to address this lower cross syndrome situation. And we need to really talk about posture in all sorts of positions. So we can give that TL hinge area, a break, allow it to recover. And we’ll have less low back muscular tightness if we fix this lower cross syndrome.

Ben James 18:07
Okay. And so were you. Were you suggesting, or is the suggestion that the pain coming from that kind of thoracolumbar? Or that transitional zone? Was that come in from from the disk? Do you think was that coming from joints? Was it a combination? Was it muscular? What would what would you say was the kind of pain drivers there? In terms of tissue?

Jacob Steyn 18:28
That’s a good? That’s a good question. I would think that it’s disc could be more than disk. So I didn’t actually mention I sent him for an x ray. X ray came back. This space is was were good. So no changes there. But it confirmed a very flat and low back.

Ben James 18:51
Okay. And what was your What was your kind of clinical rationale for the X ray? Was that just to kind of was there were you concerned about ruling anything else out like such as something like a in a spondylitis thesis, whether there can be that transitional segment that segment kind of slipping forward? Anything like that? Or was this just more of a confirmatory examination, just based on this been, let’s say, maybe a little bit more unique versus other other cases?

Jacob Steyn 19:23
I think the X ray was more to assist my, my treatment, but also I also wanted to know, you know, if he’s had so many years of pain, and he has it to hinge, has it developed to lots of disc height? Is there a degeneration of the disc? In other words, are we dealing with a hot desk, you know, it just has degenerated? So if we know that there’s a considerable loss of disc height, he’s going to be quite sensitive to anything or long postures, that’s anything that’s going to be irritate that area, and then the management of that product is going to be different with this knowledge. And when it came back we saw Okay, actually disk space is looks very good. But he has, he has a very flat flat low back. So we’re going to talk about the management of that in a moment.

Ben James 20:19
Okay. And in terms of that that flatness, that’s just normal for him? Or was there any other reason for that? Historically, injuries? Otherwise, it could have accounted for that?

Jacob Steyn 20:34
Like I said, In the beginning, he mentioned, he said, there were no, no has no history of accidents or anything like that. And that’s a very good question that, you know, is it just his body type being or having a flat low back? I don’t know, it could be something that developed from childhood. You know, it could be postural from childhood onwards. It could be genetic. It could be both. But difficult to say, okay.

Ben James 21:06
So you’ve you’ve done the examination, you’ve you’ve set it for x ray before doing any next steps, or if you give him a few things to do on the back of that first session to see if that influence his pain, what’s what’s kind of the been the process at that point where you’re thinking, this, this seems to be the area of concern, there’s this this lower cost, posture, this kind of classic muscular imbalance, for want of a better description, gone to X ray, X ray is clear, have you done anything in the interim, or if you just waited for that? Clarity, the X ray first, straightaway,

Jacob Steyn 21:39
before the X ray, we started with posture. So we made sure that he understood, it’s got to stay neutral. So if he’s going to bend forward, there’s going to be more bending forces through his T L. area. So top of his low back. And that’s what we don’t want, we want to leave that area with rest. So we went through squat technique, bending through his hips, made sure he understands that he’s a good mover, so he picked it up very quickly, then we looked at the best way you can sit. So I made I made him, I helped him to understand, look, if you’re going to slouch on the couch, you’re basically rounding your mid back, that’s going to come through that area, you’re going to put pressure on that disk. So we don’t want to, we want to try and avoid the couch. And if you sit at a chair, you got to have low back support, we’ve got to have something because it’s quite flat, we don’t want to have too much of a support, but we need some support to take the back a little bit into a resting, slightly hollow position. And we tried that in my practice, and it felt very good straightaway. So a little Lumbar Cushion that’s supporting his low back in some chairs. Otherwise, some chairs already offer him that little bit of low back support that and that that’s key that was key. So he’s he’s doing that all the time now. And he’s noticing that that’s really making a big difference to allow for the recovery.

Ben James 23:13
Okay, so the immediate first thing was, let’s manage these aggravating factors and, and teach train educate, or the neutral spine, the importance of bending through the hips, so that actually, we minimize that bend through the lower back. And what we’re not saying is you cannot bend to your low back forevermore, that, you know, we’re designed to move. But when there’s something that sensitized and irritating, we’ve got to limit the movement through that area to allow it set.

Jacob Steyn 23:43
Okay. Yeah, because it’s, it’s been all the movement before, that’s kept it irritated. And it’s never really allowed it to heal and to recover and to build tolerance, in order to stress the area without getting a reaction. But I also explained to him that he he is more vulnerable to getting a reaction at area. So things like squatting or dead lifting, you know, he doesn’t have the typical squat as low back advantage, or typical dead lifters, low back advantage because his back is so flat, the muscles that actually come into the low back vertebrae. They’re supposed to stop the vertebrae from sliding on top of each other. And because of his, his, the flatness of his low back, he doesn’t have that support as well as somebody else. And so he’s much more likely to fail earlier with not such a heavyweight, if he’s going to lift something off the ground like a deadlift.

Ben James 24:46
Okay, so So what we’re saying in that situation is with that classic curvature going kind of back the way in a lower back, the lower back muscles, generally with a neutral spine act around a 45 degree angle and therefore limit the slide the anterior translation interior slide a vertebra one over the other. But what we’re saying here is structurally with a flattened back, those muscles are arguably potentially acting more in line with the spine and therefore potentially loading the spine more. And so that’s making him more vulnerable because of those potential structural differences.

Jacob Steyn 25:25
Yeah, absolutely. And, and that’s something that he did not know before, you know, and that’s something that I think a lot of people don’t know, if they have that type of back, because, you know, in your practice, you see it a lot, you see the typical, quite hollow low back, sometimes way too hollow. And you see the, the, you know, the other end of the spectrum, they’re quite flattened back. And if people know what they’re back has an advantage for, or not, you got to be careful in what you’re going to do with it. So I just educated them on the fact that look, we can deadlift, but we’re gonna have to do it in a way where you, you lift between your legs a heavy kettlebell, so you’re, you’re more upright than forward. And it’s a matter of building it up, you know, knowing where you how you position your low back, your upper back. And from there, if you drive, and you teach yourself and you get strong in that position, you could definitely deadlift, but it’s got to be adapt, it’s got to you’ve got to be a little bit more careful than somebody else.

Ben James 26:32
Okay, that was going to be my next question was the advice, don’t do these exercises will choose you and educate you some on some better ones. Or just actually, we’ve got to adapt the way that you do these exercises. But absolutely, you know, you can keep doing them.

Jacob Steyn 26:50
Adapt him. But let’s recover first. And so, yeah, so, yeah, it’s gonna take some time, it’s gonna take a few months to recover fully, because there’s a chronic situation. Maybe some central sensitization, I don’t know, didn’t look like it was, it was anything in that direction. But the point is that, you know, he has time he wants to get better, that’s his main priority. So let’s give a time build some strength with other exercises, you know, there’s loads of anti flexion, anti extension, anti lateral flexion, anti rotation, exercises, you know, let it heal properly. And then if he has the any, if he has the drive, or the motivation to go and do deadlifting, or squatting or anything like that with a bar, then we make sure that he does it in the right way.

Ben James 27:42
Okay, okay. So it was, it was it was a case of removing the exercises in the short term, let the back recover. And then, okay, when we go back to these exercises, will really educate on how you adapt them to do them better, based on your spine and your individual structural scenario, situation, whatever you want to call it. Okay. All right. So what were the first things that you gave him to do at this point, then, as the kind of initial initial treatment plan, if you like, Did you do any kind of passive hands on treatment? Or was it very much active exercise movement based advice? Initially, yeah,

Jacob Steyn 28:24
so initially, movement, posture, exercise based. And what I started with was, like I mentioned posture. And then after that, we went on to very simple core exercises, the bird dog side planks. Then we stuck to those to start with, Oh, yeah. And then we also address the lower cross syndrome. So we, I use a half kneeling hip opener, you know, where you really engage the glutes to open up the front of the hip, with a little bit of a balancing aspect to it. So we you know, just to get to get you to work harder with the coordination of staying upright while you’re squeezing the glutes and out opening up the hip. And then we we started with planking on the knees because it was very tolerable, felt good. And we made sure that by blanking on the knees, we have a short lever on the knees and we don’t hang on the low back. And by I think the fourth or fifth treatment we started loosening the low back so we started loosening especially the TL area because I mentioned it was it was very stiff in the beginning when I felt these lumbar spine, low back spine. And so we I started loosening specifically the Yeah, the upper low back, transitioning point of the beginning of the ribcage. That area I loosened All right. And it seemed to work very well. What

Ben James 30:03
was okay, great. Great. And the response so we, after a few sessions, how was he? How was he feeling? And and where did you go from there?

Jacob Steyn 30:16
She did very well, from the get go. It obviously took a few days. But when I saw him, he said, Yeah, you could really with, you know, with the exercises, especially the the posture and the advice and the chair and filling up his low back. And yeah, we looked at a few more postural aspects, but he said that it felt good to start from the start. But after I think, three, four weeks, it was he was, he had no more pain. He was really good. And then not too long ago, he before the last time I saw him, he did something at home because they’re still building. they’re extending their house. And he lifted something heavy, and that was not a good idea. And he had a little fall back. And now he’s just, he’s already good again. But he knew after that, it wasn’t a good idea to do that.

Ben James 31:12
Okay. Okay, so here’s a guy with 15 plus 1010 plus years of, of chronic episodic low back pain, and he’s tried to work through it a bit with exercise he seen physios, osteopaths otherwise and within within the couple of weeks, few sessions just by identifying that, that that specific point and that that movement, irregularity, if you like or, or or area where there’s that, that overuse, shall we say and then limiting that and just removing the aggravating factors that that irritating constantly sensitized in that area, alongside some, some good core exercises, say core exercises. He was pretty quickly painfree Yeah,

Jacob Steyn 32:01
absolutely. And I think painfree maybe still a little bit vulnerable. But for a big part he was functioning without pain. Yeah.

Ben James 32:12
Amazing. And is he now back doing doing squats? deadlifts Is it is it kind of, as he progressed to, to doing some of those, some of those movements again yet or are we still at the stage where he’s just in that kind of recovery phase of building that core strength, building those healthier movement habits and kind of rectifying this lower cross posture before then, kind of going to the next level, if you like, exactly

Jacob Steyn 32:39
the last one, when he’s not dead lifting or squatting, it’s never been really a goal of is it was more the idea of I need to strengthen my back. So it was also told them you need to strengthen your back. But you know, that’s generally advice, we get told to do something, but we don’t get told how to do it. And so he’s just mainly staying in the working with his core building, strengthen it with a neutral spine, making sure he is giving his back a rest when he sits down in the correct way or when he stands in the correct way. So he’s, we’ve agreed that he’s not going to do anything like that very soon, it’s just going to use his real goal is to get back on the bike in the summer, next year. So he’s staying off the bike for now, building building up some more tolerance, and then later, he will, you will get back on the bike.

Ben James 33:34
And just on that note, because I think this is an interesting point when, when a lot of cyclists are adopting that kind of racing posture, you see a lot of flexion through the back, which is a, which is a kind of a posture that we often advise to avoid, persistently, consistently when it comes to discount and otherwise, particularly through the lower back. Is the advice for him going to be to try and better hinge through the hips and keep a straight or back on the bike or is it? Is it allowing that tissue to to resolve enough and rehab enough and desensitize that then we can reintroduce? Training that allows him to be in that more kind of rounded cycle classic cycle imposture? Or is he going to have to adapt that as well? What’s the thought process that because there is an element of certain sports, certain risk in terms of back health, muscular skeletal health and otherwise? Whereas for many patients, they’re gonna be really happy and they’re gonna say, I’m not going to do I’m not going to do cycling.

Jacob Steyn 34:35
Yeah, so he likes cycling too much to stop. And we we he’s not a professional cyclist, so but he cycles a lot. So you would like to cycle a lot more regularly. And we agreed that he’d sit less bent forward and raise or change his bikes position. So he’s actually more upright to a degree, which is lower quite forward. But so that’s gonna take off pressure from his low back. And otherwise, we just agreed that he’s going to keep working with building strength around his core, you know, with, specifically site blanking, planking, bird dog, your typical typical approach that we use, for example, but also, you know, I said to him, You got to be mindful, if you have lower tolerance, when you’ve been bending for a long time, because it’s that long sustained period of forward bending, that’s really causing the trigger, that after cycling, you, you know, you should relax, and relax is not hanging in a couch, because that’s gonna put even more pressure on that area, it’s actually do Tommy lying, take the pressure off your back, or, you know, sit in a proper chair, make sure your upper back makes contact, so your lower back is in a neutral, you know, make sure you’re filling up your low back with a bit of support. You’ve got to be mindful, if you’re going to challenge that vulnerable part of your spine. And he’s fully on board with that.

Ben James 36:05
Yeah, and I think that that, that kind of is a great, great stage to kind of conclude, because I think that that there’s an element there of management of a back versus this kind of thought process sometimes of do this, do that do the other. And now you’re cured for life. There’s that element of let’s manage tobacco. And that’s some active work, but also maybe some passive work that is every now and again, to check in a challenge, a review of exercises and things that just ultimately helps to manage that individuals back versus this thought process of cure it forever. Yeah, but but me mindful of those individuals having the tools that they can look after their own backup. And I think that’s, and I think that’s key, it’s the ultimately the, the empowering those individuals to understand them better educate them that on the things that could be aggravating could be problematic for them, such as cycling in this case, and then building a plan that helps that individual to manage their their back health, I think this is a great example of, of how just passive treatment alone would not have been beneficial for this individual, because outside of the clinical setting, they’re continually doing things that are aggravating the problem. And unless we can remove those things and identify those things, then you’re not really setting a platform for effective rehabilitation. Ultimately, you’re that individuals just having a bit of pain management by having treatment, but we’re not helping to resolve manage the long term issue. So yeah, I think that’s a that’s a great example of, of identifying those problematic irritants, removing them, and then building a rehabilitation program to manage that back in the long term, which is a collaborative process, which, which is a great example of a of a successful outcome. Yeah, anything else to add, Jacob, before we wrap up, just

Jacob Steyn 38:07
want to say that part of what you just to add on to what you’ve just said, it’s helping him to understand his back. That was key for him, because he was searching for a long time for a solution, but he didn’t understand his back. And then by helping him to understand what was going on with his back. I saw it also in his face, he understood it, and that meant he could do something with it.

Ben James 38:34
Nice, nice. Yeah. And that is ultimately the aim isn’t it certainly, from the work that we do is to empower the individual to to better understand and manage their own back health and, and in so many cases, that is achievable, but unfortunately, the the advice and the approach that people are getting is just not conducive to to those favorable outcomes. So awesome result is great to great to share that case is certainly something we’ll be doing more of I think it’s really helpful. It’s helpful for people to listen in, it’s helpful to, to educate and and inform on on the individual differences that people can experience and can expect to experience and, but also demonstrate just how effective a good rehabilitation program can can be. So appreciate your sharing, Jacob, great to jump on again. And we’ll wrap up there and we’ll be on again soon with with another episode. I’ll speak to you again soon.