Six physiotherapists over four years. Each course of treatment produced a little improvement, then plateaued. Each new clinician largely repeated the previous one's approach with minor variation.
When somebody has seen that many practitioners without lasting progress, the answer is almost never a seventh round of the same thing. It is usually that a piece of the picture has been consistently missed, because everybody has been looking at the same place.
In this case the back was not the primary problem. It was the area taking the load because something else was not doing its share. His hips had almost no rotational tolerance, so every rotational demand across a normal day, getting out of a car, reaching behind, turning to look, was being absorbed by his lumbar spine.
Treat the back and it settles briefly, because you have reduced the irritation. Then the same demand arrives again the following week, absorbed by the same place, and back it comes. That is the plateau, and it is entirely predictable once you can see the mechanism.
The plan addressed the hips first, then reintroduced rotational load through the spine deliberately rather than accidentally. He was noticing a difference within three weeks, which after four years felt fairly dramatic to him.
If treatment has repeatedly not worked, the useful question is not what else to try on the painful area. It is what has not been looked at at all.
Worth adding a note on what this means if you are in the same position. The instinct after several failed courses of treatment is to look for a better clinician or a newer technique. Occasionally that is the answer. Far more often the issue is that nobody has stepped back far enough to ask what the painful area is compensating for.
That question takes time to answer, which is precisely why it so often goes unasked in a fifteen minute appointment.