When Physiotherapy Hurts (Case study #1)

‘I have come to see you for a second opinion because i’m not 100% yet and I’m going on holiday in a couple of weeks time.’ Joe was in his sixties, tanned and sitting bolt upright. He had moved quickly into my room and got straight to the point. Pain for four months, over the right buttock. It had started after doing a new exercise in the gym. The leg press machine.

‘The physio told me that the muscles had slipped and disappeared from the right side of my body. He said I have to stop driving as soon as I feel the pain. So we have to stop every hour so I can stretch now. The physio also said I mustn’t sleep on my back if it hurts – it’s very difficult to stay still at night ‘cos you naturally roll onto your back – don’t you?’

I nodded slowly.  This was certainly impressive. Joe had undergone a kind of kinesiophobia implant: in one corner of the physiotherapy world hurt still equaled harm. But Joe was having none of it. That’s why he was here.

The physiotherapist had also suggested recently for him to return to swimming. I sighed a sigh of relief. Perhaps it wasn’t all bad. But then..

‘Only backstroke – I must not do breaststroke. Which of course is my…’

There was a heavy pause and we uttered in unison ‘…usual stroke’.

‘So, i’m going on holiday in a fortnight and I want to know if I swim – am I doing any damage?’ he asked.

I said ‘that’s a very important question’ and I suggested discussing exercise in a moment once we had established what the problem was now and what treatment he had received.

I asked Joe to talk me through his typical day. He said ‘sitting over an hour’ and ‘lying on my back’ appeared to him the most bothersome activities, ‘but that’s only because i’m not sure if it’s okay to do things that hurt’ he added.

‘Could you sit or lie on your back as long as you want, despite the pain?’ I wanted to get his view on the physiotherapists recommendations. ‘Yes I could tolerate it. But the physio said I absolutely must not do anything that brings the pain on.’

He walked over to his coat, reached into the pocket and pulled out four sides of A4 paper. The list of exercises he had been given numbered 15 in total covering all manner of piriformis stretches, pelvic tilts and the ubiquitous plank.

Full tilt

‘Some of these exercises were actually really sore to do,’ he said, ‘so I was told to stop them.’

I asked about his usual and current exercise and activity levels and Joe said he took the dog for a good walk each day and that was okay.

I asked if he did any other exercise at all. ‘Yes’, he said firmly ‘I normally swim and go to the gym.’ ‘How often?’ I asked. ‘Five or six times a week’ he replied. ‘but the physio told me to stop anything that hurts, so I haven’t been going.’

I was impressed at his previous levels of fitness but then it struck me…I said ‘You haven’t been to the gym for four months and you usually go 5 or 6 times a week?’ ‘Yes’ he replied. ‘How do you feel about that?’ I asked. ‘I feel terrible…I feel a bit flat to be honest and a bit achy.’ He frowned and shook his head.

I simply could not make sense of the reasoning. It was as if Joe had undergone de-motivational interviewing: the physiotherapist had stopped Joe’s usual exercise, had prescribed fifteen abstract new exercises – that were to be performed with ‘absolutely no pain’ – AND had turned his vigilance up to a 10. Or even an 11 (I know it’s controversial but it is possible to go ‘one louder’ and I do have a reference here).

I examined Joe. We analysed both his sitting and lying postures as these were his most bothersome positions. I watched him extend his lumbar spine and tilt his pelvis in different positions. Joe said the movements were ‘a bit sore’ but he displayed no anxiety or reluctance to move. I asked how confident he felt ‘moving backwards like that’. ‘It’s okay but i’m not sure if it is okay to move into the pain’ he replied.

Again and again the same question was filling the room.

It was markedly tender around L5 on the right and the buttock muscles were sore and tender to touch compared with the opposite side; clearly more sensitive on the right hand side lower lumbar area compared to the left.

My reasoning: a minor lumbar strain with clinician-instigated kinesiophobia.

I suggested to Joe that by not doing his usual levels of exercise, his body had become more sensitive and was probably taking much longer to ‘settle down’ what was clearly a simple low back strain.

I said to him, ‘if you completely immobilise a healthy wrist in a brace for 4 weeks, it not only becomes weaker and stiffer but it becomes more sensitive to touch and to movement. You haven’t moved your back into pain for months!’

We chatted about his confidence in the exercises. He hadn’t felt they had helped so we decided to stop the 15 exercises the physiotherapist had prescribed. I suggested a simple sustained lumbar rotation stretch to open up the sensitive area and – using the stiff wrist analogy again – reinforced that it was ‘likely to hurt a bit’ but that causing some discomfort was a perfectly normal part of recovery. We also discussed returning to the gym and swimming as soon as possible, in a graded fashion.

‘How do you feel about that?’ I asked. He said ‘that’s what I have wanted to hear for months.’

Joe had sensed the advice he had been given at his previous appointments didn’t ‘add up’ and I felt that my role here was simply to confirm for him that he could return to exercising.

Sometimes in clinical work, all that is needed is a lightness of touch. Less is more and in Joe’s case I was simply removing obstacles to movement, obstacles that had been put there by another health professional. He had consulted his previous physiotherapist with difficulties doing what he enjoyed in the gym i.e. a disability, but his disability had actually been increased by the physiotherapist.