BY ZAC MACKENZIE
Today I had the pleasure of treating a patient who had been suffering from 2 years of persistent mid back and rib pain commencing from a skiing accident which resulted in multiple fractures to his thoracic. The patient told me that pain seemed to be worse when sitting for long periods which was required for his job, and his pain also seemed to increase gradually throughout the day. He also complained of chronic stiffness around the mid back region and rib area which he did seem to find relief with stretches but often returned shortly after. He had seen multiple health with only short-term improvements in symptoms. He said he wasn’t as physically active as he would like to be but felt interested in beginning gym exercises and getting back to swimming which occasionally caused him increased pain.
During assessment, he seemed to have a very stiff mid back region worse so on the left compared to the right with provocation of his rib pain. He also seemed to be quite stiff through the shoulders as he was unable to raise his arms fully. He also experiences pain when palpating his mid back joints as well as his upper ribs. From these findings, it was clear that he needed to improve his range of motion to reduce both stiffness and pain as well as improve his overall upper body strength to tolerate the hours of sitting that he was currently doing. We established some goals around becoming more physically active, with an aim to get into gym type exercising and back to swimming.
During our treatment, we talked about how we could begin to move more throughout the day, as often it’s the prolonged positions throughout a day that increase pain and stiffness. We established that every 30mins he will get up and move, perform some general stretches for a couple of minutes before returning to work. We also spoke about general activity such as a morning or evening walk and how that could also help improve pain and stiffness. We spoke about that the best exercise for him is one that he enjoys and one that he would be happy to do often and that it’s important that exercise is increased gradually as often it’s not necessarily the specific exercise that we are doing that is the problem but the amount that we are doing that is increasing pain.
We planned to gradually increase daily exercise over the coming weeks and look to begin swimming again at a low intensity. We combined this plan with some releases and mobilizations for pain relief as well as some general mobility exercises to be performed throughout the day and some upper body strengthening exercises which we will progress next week with an aim to getting into the gym in the future.
Next week we will discuss the strategies that we put in place around general activity and identify any barriers that he experienced. We will also look to progress his strength exercises.
I look forward to treating this patient and seeing how he progresses.
I was looking forward to reviewing this patient as I was eager to see how the changes we had made had affected his symptoms and function. The patient said that he was diligent most of the time with our goal of getting up to move every 30 mins throughout the day. This helped to ease pain at the end of a work day, however pain did not completely resolve. There were still some occasions of significant rib pain which occurred in the mornings.
He said that he really enjoyed the exercises which he found to be pain relieving and that he was happy with the strength exercises. Our plan for the session was to progress his strength exercises whilst continuing to work on his range of motion.
During our session, we regained a good amount of movement through his mid back and shoulders which we aimed to consolidate with a couple of new mobility exercises. We discussed how often the mornings can be worst for these type of issues as being stationary during sleeping can increase stiffness when waking. The best strategy to combat this was to get up and perform the exercises we had went through to help ease the tension as early as possible.
We progressed our strength exercises and discussed our goals this week to maintain the level of movement throughout the day and walking at night. I encouraged him to look up potential gyms for him to go to and that we would look at some exercises that he could do next week. We also set out a goal to go for 2x swims this week, performing breast stroke as it required less above head shoulder movement which could induce some symptoms.
I looked forward to hearing how he’s going next week.
Again, I was looking forward to seeing this patient and hearing of his progress this week. He said that this week he had struggled again with some early morning pain and stiffness on a couple of occasions however doing the exercises did relief some of the pain. He said that pain throughout the day was manageable and only on one occasion did have significant pain at the end of the day, although he stated that this was a heavy work day. He could only get to the pool to go for one swim however didn’t experience any increase in pain afterwards. He had located a suitable gym close by that he could go to.
I was really pleased with this despite a couple of painful mornings and one afternoon. We discussed that often stress can increase pain and how it’s really important that on these days that he schedule breaks. I took this opportunity to also bring up the importance of sleep on pain, and that especially when we are working hard that sleep should be prioritized.
During our session, we again worked on his range of motion which seemed to be improving and spent the last part going over some exercises in the gym. Our goals for the next week were to maintain 1x swims and I encouraged 2x gym sessions which he could walk to and from.
This week the patient advised me that he was feeling good with now only having minimal pain on occasion throughout the day and the intensity of the morning pain had diminished with some days where he felt nil morning stiffness. He also informed me that he and his family were moving away in one month.
It seemed that symptoms and function were moving in the right direction so we planned to reduce our sessions to once every two weeks. We again looked at progressing his gym exercises. Our plan was to keep his gym sessions to 2x a wk and try for 2x a wk swim, with one of these including some freestyle.
The patient informed me this week that his symptoms had been steady over the past two weeks however he was feeling stronger and more resilient when having busy days at work. He found that he rarely had significant pain, and that most of the time it was quite manageable. He said he had some minor pain after performing freestyle swimming.
We spoke about that it was okay to have some soreness after the freestyle swimming and that to continue at this volume and intensity of swimming whilst performing some mobility exercises prior and after the swimming. Often previously provocative exercises still can produce some soreness and that often the body just needs time to adapt to the new load.
We planned that our next session will be our last before he goes away. I said I would refer him to a physiotherapist that looked suitable in his new area so he can continue his rehab.
This was our last session. We used this time to go over our exercises for self-management and looked at progressing his gym exercises. I encouraged him to make contact with the new physiotherapist in his area and that he should continue his current level of activity and understand that if he does have periods where he isn’t able to be as active then he may experience some increase in pain however this doesn’t reflect a worsening of any structural problem, more so that the sensitive areas will just like to be kept moving.
We discussed how he was on the right track in terms of dealing with his pain and should continue to progress as he feels comfortable with exercises and activity level. He seemed happy with his progress so far.
I wished him all the best and urged him not to hesitate in giving me a call if he was having any problems.