Question

Subjective

Medical History

Mrs. AB is a 28 yr old Caucasian bank worker. She has had recurrent back pain since the age of 16. At that time she had an awkward fall while playing softball. She was taken to her local emergency department, where she was given the diagnosis of muscle strain and treated with painkillers and muscle relaxants. Although her back improved quickly, she believes that the pain never completely resolved. As she continued through high school she noticed that although she had continuing periods of pain, they seemed to be less severe when she was physically active.

At age 21 she experienced another acute episode of back pain that began suddenly when she sat down on a couch. This time she did not seek medical help but treated herself with over-the-counter pain medication. The pain slowly resolved over several months.

Two years ago over the July 4th weekend, Mrs. AB was camping with her husband and daughter. On the morning when they were packing up to go home, she bent over to help her husband pick up the tent and had a sudden onset of severe back pain. The pain was in her back and right buttock. She saw both her physician and chiropractor for treatment. Her X-ray results were normal, but she was told that her MRI showed a bulging disc between the fourth and fifth lumbar vertebrae. All other medical screening was clear, and she was told that she did not have any serious medical problems. She was given a short course of muscle relaxants and stayed off work for 3 d. Her condition slowly improved but continued to bother her for the next several months.

In October the patient’s chiropractor suggested that she start fitness exercise. The previous January she had joined her town’s fitness center, but her attendance had been sporadic. She had completely stopped working out before she injured her back while camping, and the manager of the facility had put her membership on hold while she was receiving treatment for her back pain.

Objective and Laboratory Data

Exercise Test Results

Following her chiropractor’s advice, Mrs. AB returned to her fitness facility for a reevaluation and treatment program. Her physician had cleared her to begin an exercise program, and the fitness facility cleared her based on PAR-Q. The facility manager attempted a graded cycle ergometer test of aerobic capacity, but Mrs. AB was unable to complete it because of back pain. Similarly, muscle strength testing of back extensors and abdominal muscles was not possible. She was able to extend her hips only to neutral, and an attempt to test hamstring flexibility by reaching for her toes in sitting yielded a 13 in. (33 cm) distance from her fingertips to her toes.

She was able to do five repetitions of a trunk extension exercise from midflexion range to neutral spine position using a resistance of 30 lb (14 kg). She attempted latissimus pull-downs with 20 lb (9 kg) of resistance and a leg press that loaded through her shoulders, but she found the exercises too painful to continue to a formal strength evaluation. She was able to walk for 15 min on a treadmill with 0° incline at 3 mph (4.8 kph). She found this moderately painful.

Assessment and Plan

Exercise Prescription

Under the guidance of the fitness center manager, she began a program of treadmill walking to tolerance and resumed a modified version of the program of resistance exercise she had started when she joined the facility. Her walking started with 15 min at 3 mph (4.8 kph), and her goal was to increase to 4 mph (6.4 kph) and a distance of 2 mi (3.2 km). She did curl-ups using an exercise ball for the abdominal muscles, beginning with one set of 10 repetitions. She also started with one set of 10 repetitions of the following exercises: chest press (two varieties), seated rowing, leg curl, triceps pull-down, and knee extension. All were done on weight equipment rather than with free weights, and initial resistance was determined via selection of a weight that did not increase her back pain and allowed her to do the required number of repetitions without loss of form. On the back extension machine she started with one set of five repetitions with 30 lb (14 kg) of resistance in a very limited range.

The fitness center is adjacent to the bank where Mrs. AB works, and she now goes there after work several days a week. Her employer is a major corporate sponsor of the fitness center, so she is able to take advantage of a reduced membership rate. Currently, she experiences some back pain at least weekly. She does not take time off work for pain but may modify her activities slightly. On days when pain bothers her, she takes over-the-counter pain medication. With the severe episodes she had experienced in the past, she had returned to work despite considerable pain within 3 to 5 d of the episode. Her supervisor insisted on buying an ergonomic chair for her use at work, and Mrs. AB finds the chair helpful. Her job allows her to change position frequently, and she is never required to either sit or stand for long periods. She has noticed that any prolonged posture aggravates her back pain for several days.

Similarly, she has found that beginning any new sporting activity increases pain. Last summer she coached her daughter’s softball team and found that the frequent squatting activities caused her back to flare up considerably. Depending on the activity, days or weeks may pass before the pain settles down to the usual level. She continues to see her chiropractor once a month.

Mrs. AB normally exercises three or four times a week at the wellness center. She has found that her episodes of back pain worsen and the frequent low levels of pain increase in severity whenever she fails to exercise regularly. She believes that her back symptoms are still improving but extremely slowly. Her goal continues to be complete elimination of pain.

In the first 6 mo after her injury, Mrs. AB increased her exercise routine to include the following exercises: chest press (two varieties), seated rowing, leg curl, triceps pull-down, and knee extension. These exercises are all done on weight equipment rather than with free weights and she normally does three sets of 12 to 15 repetitions. Additionally she does two sets of 30 abdominal crunches. For the chest presses and rowing she now uses 40 lb (18 kg). The triceps pull-down is 20 lb (9 kg); the leg curls are 30 lb (14 kg); and the knee extension is 35 lb (16 kg). Her back extension exercises have increased to three sets of 20 reps with a resistance of 80 lb (36 kg), with extension only to neutral. She now walks 2 mi (3.2 km) on the treadmill at a speed of 4 mph (6.4 kph) and does light stretching of arms and legs before her workout. The flexibility of her spine has improved somewhat, but she is cautious of allowing extension of her back much beyond a straightened position with any exercise. Before the episode she had been using a leg press machine that loaded through the shoulders and a lat pull-down. Both were extremely painful after the injury, and she dropped them from her program. She has not attempted them since. Although she has continued to work out regularly, the weights have been the same on the machines for about a year. She uses the fitness center treadmill for a walking program. She still has tight hamstrings, fingertips 6 in. (15 cm) from toes, and reduced active and passive back extension.

Case Study Discussion Questions

1. How well does Mrs. AB fit the profile of the typical person with nonspecific back pain? In her presentation are there any red or yellow flags? What characteristics in her work and recreational situation have helped her deal with her pain?
2. Do you think her current back program will produce the desired outcome (pain-free spinal mobility and physical tolerance of all work-related tasks)?Do you believe, based on the recurrent nature of her symptoms, that present management strategies are adequate?
3. What specific recommendations for changes in her exercise program could you make for her based on the information provided? List general principles of exercise that Mrs. AB should follow to decrease her risk of recurrence.
4. What advice would you give her for a suitable aerobic conditioning program?
5. Write an outline of advice that you would give her for those days when her job requires a lot of sitting activity. Would you reintroduce the partial squats and lat pull-downs in her program? If so, what modifications could help her resume those exercises?
6. She wants to continue coaching her daughter’s softball team. What strategies should she use to prevent flare-ups of her back pain from this activity? How can she safely stretch into extension to regain some of the lost mobility in her spine? Are there any classes or activities that would help her with this?

Answer 1

LBP is an extremely common problem. It is characterized by attacks, remissions and exacerbations. It is best managed by a multidisciplinary team. Primary coordination of treatment may depend on the patient's need and the awareness of the treating physician of the importance of history and physicalexaminations. In her presentation there are yellow flag means can b managed by means of proper exercise. The characteristics of her work are walking after the work done, moving in managers office at a frequent time etc.

Yes the exercise programes alone will help her to correcting the disoder but she has to b punctual and practise the activities effeciently . The recommended form of exercise trainingExercise prescription is based on 5principles: type, duration, frequency, intensity, and volume with the main forms being aerobic (i.e. endurance training), resistance (i.e. strength training), flexibility, and balance.

The advice given will b ;;;

• Always start at a slow and easy intensity.
• Build up exercise duration over weeks and months (see the six week program below as an example).
• Keep your basic heart rate at about 60% maximum.
• Use 30 second periods of increased activity every 5-10 minutes (up to 70% maximum pulse rate). Exercise performed at work place The pulldown exercise works the back muscles, especially the latissimus dorsi or the "lats." It is performed at a workstation with adjustable resistance, usually plates.

Don’t bend over from the waist to lift heavy objects. Bend your knees and squat, pulling in your stomach muscles and holding the object close to your body as you stand up. Don't twist your body while lifting. If you can, push rather than pull heavy objects. Pushing is easier on the back