Exploring The Source Of Persistent Back Pain

PATIENT PROFILE

Age: 25 years

Gender: Female

Occupation: Teacher

Chief complaints

Persistent low back pain for the past 2 years, with intermittent flare-ups, particularly worse at night.

HISTORY:

Two years ago, the patient experienced a sudden “catching” sensation in her lower back while participating in a tug-of-war event during a school celebration. Despite the discomfort, she continued the activity. After a few days of rest, the pain reduced slightly but did not completely resolve.

She consulted an orthopaedic doctor, and an X-ray revealed no abnormalities. Pain medication was prescribed, which provided temporary relief. However, the pain returned after completing the medication course. She was then referred for physiotherapy, following which her symptoms improved significantly within three weeks.

Now, for the past 2 months, she has experienced intermittent episodes of low back pain, with increased discomfort at night. Concerned about the persistence of her symptoms and with her marriage approaching in 12 days, she sought a physiotherapy consultation with us to understand the cause of her pain and ensure recovery.

Objective:

The patient strongly believed that her ongoing pain indicated serious spinal damage. Her anxiety was heightened due to:

The long duration of symptoms
Fear that pain may affect her married life.
Family history of breast cancer in her mother, leading to catastrophic thoughts about serious illness.

Her main goal was to be pain-free and reassured before her marriage.

Physical Activity Status:

Previously performed exercises until one year ago; currently limited to walking 2–3 days per week

Sleep:

6-7 hours a day

Stress Level:

High stress, related to health anxiety and upcoming marriage

PAIN ANALYSIS:

Intensity: 3/10 during the day, 7/10 during the night

Aggravating factors: Prolonged walking, sustained forward bending during household work like washing vessels and brooming.

Relieving factor: Rest and exercise

Location: lower back, left side>right side

Irritability: Moderate

Sensitivity: High

Fear of movement: Present while doing forward bending

Lifestyle impact: Reduced household activities due to fear of pain

TAKEAWAY FROM HISTORY AND PAIN ANALYSIS

Although the patient’s pain had persisted for two years, there were no red flags or signs of serious pathology. Her symptoms were strongly influenced by:

Fear-avoidance behaviour
Negative beliefs about pain
High stress and anxiety, especially due to her upcoming marriage
Reduced physical activity

PHYSICAL EXAMINATION:

Observational findings:

No visible postural deformities

No swelling or signs of inflammation

Mobility screening:

Forward bending: Good range, limited mainly by fear rather than pain

Overhead squat: Reduced depth with a slight right-sided weight shift

Strength analysis:

Break test:

Muscle group	Right	Left
Hip flexors	Strong and painless	Weak and painless
Hip extensors	Strong and painless	Weak and painless
Hip abductors	Strong and painless	Weak and painless
Hip adductors	Strong and painless	Strong and painless
Knee flexors	Strong and painless	Strong and painless
Knee extensors	Strong and painless	Strong and painless

Note: There is a significant strength deficit on the left side in the

break test, especially on the Hip flexors, extensors, and abductors.

Special tests:

SLR: Negative

Cross SLR: Negative

Slump test: Negative

INVESTIGATION:

X-ray: No significant structural changes in the spine.

ESR and CRP: Within normal range

DIFFERENTIAL DIAGNOSIS:

Lumbar Radiculopathy:

Absence of radiating symptoms
No cough or sneeze pain
Negative cluster special tests

Ankylosing spondylosis:

Absence of morning stiffness
No bamboo spine appearance in X-ray
Normal ESR and CRP levels

Spondylolisthesis:

Absence of radiating symptoms
Normal appearance of the spine in X-ray

DIAGNOSIS:

Belief and expectation of the patient:

The patient’s goal is to be free from pain and get better before marriage. She wants to know the reason behind her pain and wants clarification of her doubts.

Patient’s perception of pain:

She has a bad experience and understanding of pain. She is afraid that she might have some big issues like cancer because her mother had suffered from breast cancer.

Psycho-social factor analysis:

Cognitive: Affected, she is concerned about the recurrence of pain

Affective: Affected because of pain her daily activities are affected

Social: Not affected

Diagnosis with Clear Explanation:

NON-SPECIFIC LOW BACK PAIN.

The pain is associated with multiple factors, including :

Lack of physical activity
Improper sleep hygiene and hydration
Fear avoidance behaviour
Negative association of pain because of a family history of cancer.
Lots of stress and anxiety due to the upcoming marriage
Negative beliefs and a lack of understanding about pain

So there are multiple factors contributing to her pain, which suggests her low back pain is not only because of tissue damage but also associated psychologically.

TREATMENT PLANNING:

Detailed treatment Strategy

Session	Intervention
1–2 sessions	Patient education: Making sure the patient understands that the pain is not always dangerous and is reversible with appropriate treatment. Education on the importance of sleep hygiene, proper nutrition, and adequate water intake to aid recovery along with regular physical activity. Lower limb mobility exercises. Graded exposure to lower-body exercises in a comfortable range to reduce fear and build confidence. Initiate treadmill walking and cycling.
3–5 sessions	Progressive strength training based on the patient’s capacity, focusing on both lower limbs. Education on proper load management principles. Mobility and breathing exercises prescribed as a home program. Walking is also included as part of the home exercise program.
Home Programme	Made the patient independent to do exercise by herself. Initiated light jogging and gradually progressed to running. Encouraged home-based resistance training with weights at least 3 days per week.