Question

Subjective

Medical History

Mr. BC is a 45 yr old African-American construction worker and home builder. He is happily married with two middle-school aged children. His wife is a practicing nurse and is encouraging him to improve his lifestyle by quitting smoking and initiating a regular exercise program. He has a positive smoking history of one pack/day for 25 yr. He has had occasional occupationally related lower back pain with heavy lifting and static postures at work over the last 6-7 yr. By self-administering Tylenol and ice packs to his back and being mindful of lifting postures, his intermittent episodic pain has resolved without formal medical attention. He denies episodes of back pain during his high school wrestling career, but recalls some stiffness in his back during off-season farm chores at his father’s farm.

Mr. BC’s recent episode of lower back pain began 4 wk ago in early November during a stressful time both at work and at home. At work, he was pressured into working 12 h days to complete frame building on two homes simultaneously because the home buyers were anxious to assume residency and the house building season was coming to a close due to the threat of inclement weather. He felt a sharp stabbing pain in his lower back when heavy winds shifted support framing in one of the houses and he had to secure the structure of the frame. He reports difficulty with standing up straight, felt twinges of pain with lifting and carrying wood, and noticed morning stiffness when waking up. Seeing his physician, he was given Motrin, told to use ice packs on his back and stay off work for 5 d. No diagnostic tests were ordered, as the physician believed these symptoms were likely muscular in nature. He rejected the work restrictions and continued to work long hours, continuing to experience intermittent lower back pain, which has worsened since initial injury.

In December, when snowfall limits Mr. BC’s outdoors construction tasks, he concentrates on finishing work inside the houses that have been framed and sided. This affords him continued work but less heavy lifting and more flexibility to engage in rehabilitation for his back pain. He was an athlete in high school but hasn’t been active since high school and doesn’t exercise outside work presently, as he considers his job strenuous. He would be amenable to exercise if it reduced his back pain and improved his function at work. Despite several efforts, he has been unsuccessful at smoking cessation independently, but also stated he would consider a program to quit smoking as part of his lifestyle changes.

Objective and Laboratory Data

Exercise Test Results

After getting cleared for exercise by his personal physician, Mr. BC went to a local gymnasium to be evaluated by a personal fitness instructor for strength and conditioning. General lumbar flexibility was observed to be 50% of typical motion for forward bending and sidebending and lumbar extension was limited to 20° with reports of localized pain. Static side planks could only be maintained for 5-10 s before slumping. In performing an aerobic fitness test on a standard treadmill, Mr. BC became SOB (short of breath), his HR rose to 125, and his perceived rate of exertion on the Borg RPE scale was 15/20 at a treadmill speed of 5 mph with 0° incline for 5 min.

Using resistance machines to evaluate strength, he was able to perform trunk extension with 120 lb of resistance times 15 repetitions, trunk flexion with 40 lb resistance times 8 repetitions, and trunk rotation with 40 lb resistance for right rotation times 8 repetitions and 30 lb resistance for left rotation times 8 repetitions. Lower extremity tests on the machines for leg press (130 lb), knee curls (80 lb) and knee extensions (120 lb), times 10 repetitions each, seemed reasonable for his age and body weight of 182 lb.

Assessment and Plan

Exercise Prescription

The personal fitness instructor identified trunk extensor, sidebending, and rotational strength deficits and aerobic conditioning as targets for strength and conditioning program at the gymnasium. She suggested dropping machine resistance loads to 70-80% of tested resistance settings to facilitate higher repetition exercises at 12-20 repetitions until the client got used to strength training, and a lower rep/higher resistance load at 6-10 reps could be tolerated. She suggested standing sidebending with 15 lb dumbbells to strengthen lumbar sidebenders as a substitution for planks. Aerobic conditioning would be initiated at a fast walking pace of 4-4.5 mph on the treadmill times 15 min, targeting 12-14 on the Borg RPE scale initially. Stationary bike or elliptical trainer could be substituted for treadmill as a way to reduce boredom. The patient was instructed to take HR readings from his radial artery, or using the built-in machine equipment, during exercise, targeting a HR range of 110-120 bpm initially. After 3-4 wk of aerobic conditioning, they would target 70-80% of maximum HR of 175 to a range of 120-140 bpm.

The personal fitness instructor offered Mr. BC a short-term membership at the gym for 3 mo to evaluate consistency of attendance and adherence to her prescribed initial strength and conditioning program. Mr. BC continued to work at his construction job during his rehabilitation phase of training, performing light-duty inside framing tasks and lighter lifting loads. He was consistent about coming to the gym for the first 2 wk on a M/W/F schedule at midday, but his frequency reduced during weeks 3-4 to twice a week, as noted on his personal fitness plan sheet at the gym. His trunk extension increased to 130 lb times 12 reps, trunk flexion to 60 lb times 12 reps, trunk rotation bilaterally to 65 lb times 12 reps, and trunk sidebending with dumbbells at 20 lb times 12 reps. Knee curls and knee extensions continued at 80 lb and 120 lb, respectively, times 12 reps. He independently added bench press (100 lb × 12 reps), latissimus pull-downs (80 lb × 12 reps), and seated pulley rows (90 lb × 12 reps) by the end of the third week of his program. He varied his aerobic conditioning and warm-up for resistance training between the treadmill (5° incline at 5 mph slow jogging) and stationary bike (midpoint resistance setting) by the fourth week and could tolerate 15 min of exercise on each device with no greater than 130 bpm HR recordings. He reports improved tolerance for lumbar motion, and a visual observation by the personal fitness instructor judged him at 75% normal mobility, so gentle warm-up and cool-down stretches in all directions for the lumbar spine were added after the second week of training. Mr. BC seemed amenable to the stretching exercises but appeared to rush through these exercises, as he was more interested and motivated to use the exercise machines.

Case Study Discussion Questions

1. How well does Mr. BC fit the profile of the typical person with nonspecific back pain? How are his situation and circumstances different from Mrs. AB? In his presentation are there any red or yellow flags?
2. Do you feel that Mr. BC has more of a strength, endurance, or general conditioning/cardiovascular fitness problem that contributes to his episodic lower back pain? How successful do you think Mr. BC will be with his attempts at smoking cessation, given his 25 yr history of smoking? How can the exercise specialist influence his decision to quit?
3. Do you think that complete resolution of lower back pain and continuance of work for another 20 yr is possible for this client, given his history?
4. How successful do you think Mr. BC will be in sticking with his strength and conditioning program in the future? What barriers to adherence do you think are at play here, and how can you entice Mr. BC to commit to a longer gym membership than the 3 month trial period?

Answer 1

How well does Mr. BC fit the profile of the typical person with nonspecific back pain?

answer:

The typical Profile of a person with non specific back pain includes obese person, person having strenuous physical jobs. person working in awkward postures for long hours. heavy weight lifting, prior history of trauma. person driving for long hours, person sitting in single place for long hours and Middle aged and postmenopausal females

.Mr typically fits the profile of a person with low back pain as he has occupational  history of strenuous physical activity and awkward postures at work with heavy weightlifting.

As the profile of Mr BC is a very congruent to that of a person with non specific lower back pain;he fits the profile of person with non specific back pain perfectly

.How are his situation and circumstances different from Mrs. AB?

answer: The circumstances and situations for Mr BC is that of non-specific low back pain on the background of highly strenous physical nature of his job with which involves awkward postures and lifting heavy weights with chronic smoking as compounding factor..As the the situation and the circumstances of Mrs AB are not detailed in the case study, the difference between his situation and circumstances from those of Mrs AB cannot be stated

In his presentation are there any red or yellow flags?

Answer:

introduction:The Red flag signs are the pathological conditions leading to lower back pain like infection metastatic cancer,disc herniation which cause the back pain while the yellow flag signs are the psychosocial factors.which can influence chronic diseases, their assessment, treatment and outcomes and include negative attitude ,avoidance behaviour, seeking passive treatment, withdrawal or depressive tendencies and socio economic problems.

yes, in Mr BC's presentation there are yellow flags. the social and occupational conditions at work which causes Mr BC to work for long hours doing strenous physical activity .The occupational factor is the yellow flag in his presentation.They are likely to affect his therapy and cause chronicity of the low back pain.

Do you feel that Mr. BC has more of a strength, endurance, or general conditioning/cardiovascular fitness problem that contributes to his episodic lower back pain?

answer:

Mr B C has more of a strength endurance problem than general conditioning/cardiovascular fitness problem that contributes to h:is episode of lower back pain as he has history of lifting heavy weights strenuous physical activity and excessive lumbar mobility and strain at work which has caused muscular strain on his back muscles limiting muscular  strength and endurance causing him pain.

Mr BC also has a cardiovascular fitness problem that could be related to his lack of exercise and chronic smoking but it is the the lack of strength and endurance which is the immediate contributory factor for the lower back pain.

How successful do you think Mr. BC will be with his attempts at smoking cessation, given his 25 yr history of smoking?

answer: Mr BC may be moderately successful with his attempts at the smoking cessation given his 25 year history of smoking. The following are the reasons for his limited success at attempt to stop smoking

1. motivational factors: Mr BC is aware of the problem of smoking and has been constantly motivated by his wife who has urged him to stop smoking however he has continued smoking due to poor motivation. motivation is the key to the success that efforts to stop more smoking. due to poor motivation Mr BC attempts at smoking season may meet with limited success.
2. cognitive factors :Mr BC has been educated about the need to stop smoking by his wife but does not seem to understand the importance of stopping smoking and the dangers smoking can have on his health His restricted knowledge and information about the dangers of smoking could be a limiting factor to smoking cessation efforts
3. social and occupational factors: Mr BC is involved in highly strenuous physical activity and may be using the effects of smoking for obtaining the stress relief from his work. the continued strenuous nature of his work may cause him to to relapse back to smoking habit during his the efforts of quitting smoking thus meeting with limited success

4.chronicity and risk of dependence:Mr BC has been smoking for 25 years and that can cause nicotine dependence and difficulty in quitting smoking.

How can the exercise specialist influence his decision to quit?

The exercise specialist can influence Mr BC decision to quit smoking by providing a strong motivational background to him citing the positive benefits of quitting smoking and the harmful effects that smoking has on his health at present and likely disease conditions that can develop in the future if he continues smoking. Consistent motivation and comprehensive education and knowledge about the methods along with information about the facilities available to quit smoking including the various quitting programs and support groups by the exercise specialist can positively influence Mr. BC' s decision to quit smoking.

Persistent motivation, holistic education, cognitive behaviour therapy,positive reinforcement and intensive mentoring are the strategies which the exercise specialist can use to influence Mr BC's decision to quit smoking during the course of their interaction,

Do you think that complete resolution of lower back pain and continuance of work for another 20 yr is possible for this client, given his history?

answer:yes,i thinkMr BC will have complete resolution of lower back pain and continuance of work for another 20 yr is possible for this client, given his history in the case study which describes him positively respondind (positive responder)to the strength and endurance exercise training program. However consistency being an issue ,if  mister BC is consistent with exercise schedules, he can get relief from his symptoms and continue to work for long.

discussion:Mr BC has shown remarkable improvement in the strength and conditioning program by increased lumbar mobility and stretch and improved exercise tolerance in the cardiovascular exercises.He also has a history of Athletic School background. if Mr BC is a persistent in his exercises, there is a possibility that he will recover from the lumbar strain and pain that he is experiencing and will be able to continue his physical effort at work for another 20 years. Consistent strength and endurance training will enable Mr BC to resolve his back pain and continue his work for another 20 years.

How successful do you think Mr. BC will be in sticking with his strength and conditioning program in the future?

answer:

Mr B C may be moderately successful at in sticking with his strength and conditioning program in the future because of the following reasons.

motivational factors: He has shown a decrease in the frequency of attending his exercise schedule after the first two weeks of exercise which may be due to poor motivation or fatigue or lack of discipline.

occupational factors:he has a highly strenuous job which is physically exhaustive and that may limit is attending his exercise program due to the lack of time or lack of energy. there is a possibility he may discontinue the exercise program after obtaining relief from the pain and this explains the moderate success in sticking with his strength and conditioning program.

What barriers to adherence do you think are at play here, and how can you entice Mr. BC to commit to a longer gym membership than the 3 month trial period?

answer:

The barriers to adherence here at play are the occupational barriers, motivational and psychological barriers. Mr BC is engaged in a highly strenous job and may not find the time to stick to his schedule of exercise strength training and endurance program. His motivation to stick to the program may also decrease on account of his work schedule and he may get irregular after he has had some relief from his pain.

The following are the way in which Mr BC can be enticed to commit for longer gym membership

1. providing flexibility in the timings.
2. positive motivation and encouragement
3. charting of the results of progress and discussion about improvement in health and mobility.
4. education about the health benefits with continuation of the exercise programs. Explaining the positive effects of exercise to improve the muscle strength and endurance which will enable him to continue his work for longer. Mr BC must be explained that in case he is a regular to his exercise schedule. there is a possibility that he may have to quit his work involving highly physical strain is activities after a few years due to persistent low back pain
5. persistent positive reinforcement .