How manual therapy provided a gateway to a biopsychosocial management approach in an adult with chronic post-surgical low back pain: a case report

ABSTRACT

Background

The management of patients with chronic post-surgical low back pain can be very challenging to surgeons, physiotherapists, and patients alike. Subsequent surgery is often associated with post-operative complications and even lower levels of success than the initial spinal surgery. Physiotherapy is often recommended as the first-line management, however, debate exists amongst physiotherapists regarding the optimal treatment strategy. A key focus of this debate has been the use of manual therapy in chronic pain populations, leading clinicians to reevaluate its use.

Case description

A 44-year-old female presented to physiotherapy with a 13-year history of persistent pain, having had a spinal fusion 12 years prior, following a skiing accident. Her primary complaints were pain and decreased self-efficacy. The patient was treated with a 12-week multimodal approach consisting of manual therapy, exercise rehabilitation, and pain neuroscience education.

Outcomes

The patient had a significant reduction in the Numerical Pain Rating Scale (NPRS), the Oswestry Disability Index (ODI) and the Fear Avoidance Belief Questionnaire Physical Activity Subscale (FABQ-PA) scores following the intervention. She returned to running and cycling, reporting that pain was something she would ‘work with instead of against’.

Discussion

This case study suggests that manual therapy can enhance an individualized biopsychosocial approach in the physiotherapy management of a patient with chronic post-surgical low back pain. Further research is needed to evaluate optimal intervention dosages and effective strategies in the management of patients with chronic low back pain following spinal surgery.

KEYWORDS:

• Chronic pain
• manual therapy
• pain neuroscience education
• exercise rehabilitation
• biopsychosocial

Author contribution

Only the authors listed contributed to the article; there were no additional contributors.

Disclaimers

The views expressed in the submitted article are his or her own and not an official position of the institution or funder.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics approval

Subject gave written informed consent.

Additional information

Funding

This work was not funded.

Notes on contributors

David Toomey

David Toomey received his Bachelor of Science Physiotherapy degree (Honours) from University College Dublin in 2012, prior to working in private practice and with high-performance sports teams for several years. He earned the designation of certified orthopedic manual therapist (COMPT) through the New Zealand Manipulative Physiotherapists Association (NZMPA) in 2017 before completing a Postgraduate Diploma in Health Science (Musculoskeletal Physiotherapy) in 2018. David is currently completing his clinical PhD through Auckland University of Technology in the area of exercise induced hypoalgesia (EIH) having been awarded an AUT Doctoral Scholarship. David is a Senior Physiotherapy Clinical Educator and Presenter for an online education company as well as being active in clinical practice on Waiheke Island, Auckland.

Duncan Reid

Duncan Reid is a Professor of Physiotherapy within the Faculty of Health and Environmental; Science, Auckland University of Technology. Duncan has had 38 years of clinical experience in Musculoskeletal and Sports Physiotherapy. His main areas of interest are in manual and manipulative therapy especially manipulation to the cervical spine, a topic he has taught both nationally and internationally. His research interests have also included sports injury incidence and prevention, sports related concussion, the management of knee injuries, and has completed his doctoral thesis investigating the effects of lower limb stretching interventions on patients with OA of the knee. He is a Fellow of the New Zealand College of Physiotherapy and a life member of NZMPA and Physiotherapy NZ. Duncan’s experience in Sports Physiotherapy is also extensive. He has been a member of the Olympic and Commonwealth Games Medical team from 1988 until the Sydney Olympics in 2000 and was Chief Physiotherapist for the 1992, 1994 and 1996 Games. Duncan is the Physiotherapy Advisor for High Performance Sport NZ. He has over 300 peer review journal and book publications and is on the editorial panel of the journals Musculoskeletal Science and Practice, Manual and Manipulative Therapy and the Journal of Orthopaedic and Sports Physical Therapy.

Steven White

Steven White is a physiotherapist and senior lecturer at Auckland University of Technology where he is the Paper Leader and lecturer for the postgraduate and undergraduate musculoskeletal physiotherapy papers. Prior to his academic appointment in 2003, Steve had 27 years’ experience in his private practice managing patients with musculoskeletal pain. Throughout that time, he had a passion for teaching and since 1982 has tutored on the NZ Manipulative Physiotherapists Association continuing education program. Steve has also been invited to speak and run courses throughout New Zealand, in Australia and the USA. Steve’s key area of interest is the diagnosis and management of musculoskeletal pain, with a particular emphasis on diagnostic accuracy and clinical reasoning. His PhD explored the diagnostic accuracy of the clinical examination for determining the presence of symptomatic intra-articular pathology of the hip. He is currently supervising a number of doctoral and master’s students.