There is a version of physiotherapy that treats exercise as the whole answer. If it is not working, do more of it. Add another set. Add another movement. When that fails, the implication, sometimes unspoken, is that the patient has not tried hard enough.
Laura had tried hard enough. What she had not had was anybody asking why a back that was doing all the right exercises was still flaring up every few weeks.
The assessment took a different route. Rather than starting with what she should be doing, we started with what her back was actually being asked to tolerate across a normal week, and what capacity it currently had to meet that. The gap between those two numbers was the problem. No amount of additional exercise closes that gap if the exercises are not loading the right tissue in the right way.
We also looked at the parts that had never come up. She was sleeping badly. She had been through a genuinely stressful eighteen months. Neither of those things causes back pain on its own, but both change how much a nervous system will tolerate before it protests.
The plan that followed was smaller than what she had been doing. Four movements rather than fourteen, progressed deliberately, with clear markers for when to move up. Alongside that we addressed sleep and gave her a way of understanding flare ups that meant they stopped being frightening.
Six weeks in she was doing things she had stopped attempting. Not because she found the magic exercise, but because the loading finally matched what her body needed and the rest of the picture was no longer working against her.
If you have been given more and more exercises and the pain keeps returning, the answer is rarely another list. It is usually that something in the assessment was missed.
