Nutrition Case Reflection

Name Zac Williams / S0272671

/student
number
Patient/ Age / Sex
subject 82 Y/O male 
information
 
Presentation  Ongoing central upper thoracic spine pain with occasional radiation to
chest
 Postural changes
 Fatigue and lethargy

Investigations/approaches History / physical examination summary:

82 Y/O male retiree presents with 3/12 duration central mid thoracic pain
T3-T6 with noted hyperkyphosis, pain can occasionally be felt wrapping to
anterior chest on flexion. Onset occurred during a coughing fit 3/12 prior,
initial onset was a sharp 8/10 VAS and has slowly improved to a dull 4/10
VAS. Patient finds relief from laying down and taking ibroprufin
intermittently, the condition is aggravated by forward flexion, downwards
pressure on shoulders and lifting objects. Patient has limited thoracic ROM
with significant restriction and pain in flexion and extension.

Psychosocial – Patient’s partner passed away 1 year ago and has had low
levels of motivation to complete ADL’s and cook meals

Nutrition – Significantly changed in the last year, loss of appetite and

microwaveable meals now eaten once daily

Further investigations
 Thoracic X-ray (AP thoracic and lateral thoracic)
o revealed a decrease in anterior vertebral body height
“compression fractures” of T3-T6
o diffuse osteoporosis
 Dexa bone density scan
o T-score = -3.0 (osteoporosis)
 5-day food diary
o Nutritional deficits -
 35% of RDI of calcium
 50% of RDI of protein
Biometrics    weight BP Dexa T-score 5 Day food diary

pre Calcium = 455mg/day avg 

68Kg  156/104 T-score = 3.0  Protein = 40g/day avg

  post 72Kg  149/95 Calcium = 1350mg/day avg 

T-score = -2.55  Protein = 80g/day avg

Relevant Medication Dosage Before Intervention Dosage After Intervention

 
 Amlodipine 2.5mg NIL
Once daily

   
  Diagnoses  Chronic constant mild-moderate upper thoracic pain caused by
  resolved compression wedged fractures of T3-T6, with associated
upper thoracic hyperkyphosis.
 Patient has Osteoporosis with a T-score of -3.0

 
 

treatment/ Nutrition Patient was educated on the importance of a diverse nutritious diet and
intervention how this can help to improve bone health. An action plan was established,
making positive health changes and including more protein (lean meats,
  fish, eggs, nuts, wholegrain cereal), calcium (dairy, almonds, yoghurt,
  spinach) and vitamin D (egg yolk, butter, dairy foods) into the daily diet.
(Plawecki & Chapman-Novakofski, 2010) As the patient is cooking for only
himself, advice was given on making batches of food and freezing to assist
in the convenience of the plan. This new food plan was proposed to
integrate for 3 months and then reassessment of results.

Physical
activity/rehabilitation
Chiropractic Management
Co-
management/interdisciplin
ary management
A physical exercise plan was integrated into the patient’s recovery and was
broken down into
 Weight bearing aerobic exercise
o Walking and stretches in the sunshine 20min per day
 Strength and resistance exercise
o Group exercise class “fit and strong bones” 3 times
weekly – St George & Sutherland community centre
Fortnightly treatments were prescribed, and the treatments consisted of
mobilizations of the cervical and lumbar spine, active stretching of the
thoracic spine and soft tissue work of the postural stabilizing muscles.
Postural advice was given with simple tips to ensure this is managed in
ADL’s
 Co-management with orthopedist and GP was performed and case brief
performed at initial phase and at the 3-month mark.
 

Other  
 N/A
 Clinical Process /  The Patient was extremely compliant to the care plan provided. The care plan was only
summary management / changed when the patient progressed from the weight bearing aerobic exercise to the
review strength and resistance exercise phase.
 
 

Outcomes /  The patient responded well after the planned 3 months of care and felt as if they had
results made significant improvements to not only their initial complaint but also their overall
health.
The outcomes analyzed showed:
 further healing of the T3-T6 wedged compression fractures
 improvement in bone density from a T-score of -3.0 to -2.55
 Nutritional deficits rectified
 Improvement in blood pressure
 Increase in patients’ weight into healthy weight range
 Decrease in thoracic kyphosis
 Higher levels of stamina and energy
 Improvement of strength and stability of postural muscles
 improvement in the patient’s psychosocial health with the group fitness
classes allowing for socialization with individuals experiencing similar
circumstances.
Reflections/ The patient presented with a musculoskeletal injury with many associated symptoms. Through history taking
Notes and physical examination there was a suspicion of vertebral compression fractures with associated
osteoporosis. Further investigations were conducted to search for thoracic compression fractures, the bone
(500-750 words
density of the patient and also a 5-day food diary to assess if there are any nutritional deficits which could
as a guide)
be contributing to this issue. The Patient had a low intake of calcium, protein and vitamin D, these essential
(use a separate
nutrients are vital for bone health and have been linked to osteoporosis in the elderly if there is a deficit.
sheet if desired)
(Nieves, 2003). The treatment plan that was implemented covered all of the concerns that were outlined
from the interactions with the patient
 Nutritional changes – increase in calcium, protein and vitamin D to help
improve bone density and fatigue / low energy levels (Baum et al., 2016;
Nieves, 2003)
 Physical exercise plan – Physical exercise has been shown to stimulate
osteogenesis in osteoporotic patients, this has also been combined with
trying to uptake more vitamin D by performing some tasks outdoors.
(Benedetti et al., 2018; Nair & Maseeh, 2012; Wong & McGirt, 2013)
 Psychosocial changes – Group fitness classes were recommended in the
treatment plan with a similar demographic, this has shown to improve
mental well-being and assist in forming social connections. (Brady et al.,
2020)
 Physical therapy – Chiropractic mobilizations and adjunctive care has
shown to have positive benefits for elderly patients with osteoporosis and
compression fractures. (Roberts & Wolfe, 2012)

This patient showed signs of manifestations from malnutrition that was affecting their bone health, energy
levels and well-being, as chiropractors we are not qualified to write food plans but can give advice on how to
improve nutrition to achieve a balanced diet. Within this case study I believe it would have been wise for the
practioner to co-manage this case with a nutrionist to ensure that the patient was receiving the best care
possible in accordance with that deficit. Osteoporosis is a common condition in the elderly population and
increases the risk of fractures which can be serious for the elderly population, the patient presented above is
beyond the expected level seen in that age demographic. (Curtis & Safford, 2012) The treatment
implemented was not intended to ‘cure’ the patient of osteoporosis but to reduce the severity and improve
 the well-being. Many cases of osteoporosis are treated with pharmacological intervention and no physical
management. (Body et al., 2011) I believe that his case should have encompassed both to allow the patient
to achieve the most desirable results.
The limitations of this study were that there was no laboratory analysis of blood to determine if there was a
vitamin deficiency present and no baseline to see if the interventions implemented were assisting to adjust a
deficit.
The patient is still undergoing care and has stated that the treatment has not only improved their thoracic
pain but also improved their lifestyle. Ongoing evaluation of this patient is important to ensure that the
condition is continually improving. I believe that the inclusion of patient reported outcome measures would
have been beneficial to this case to objectively evaluate the improvement the patient is experiencing.

This case personally assisted me in understanding the critical role of nutrition in geriatric populations, it was
evident that nutritional deficits can manifest into quite severe musculoskeletal disorders and that
psychosocial factors can attribute to this occurring. I saw that care plans don’t only have to attempt to
rehabilitate a tissue in lesion but can encompass advice and strategies to improve lifestyle factors which may
be a causative factor of the injury presented. This case fits well with my ethical standpoint of a patient
centered approach and health care programs tailored directly to individual patient needs.

References
Baum, J. I., Kim, I.-Y., & Wolfe, R. R. (2016). Protein Consumption and the Elderly: What Is the Optimal
Level of Intake? Nutrients, 8(6), 359. https://doi.org/10.3390/nu8060359
Benedetti, M. G., Furlini, G., Zati, A., & Letizia Mauro, G. (2018). The Effectiveness of Physical Exercise on
Bone Density in Osteoporotic Patients. Biomed Res Int, 2018, 4840531-4840510.
https://doi.org/10.1155/2018/4840531
Body, J. J., Bergmann, P., Boonen, S., Boutsen, Y., Bruyere, O., Devogelaer, J. P., Goemaere, S., Hollevoet,
N., Kaufman, J. M., Milisen, K., Rozenberg, S., & Reginster, J. Y. (2011). Non-pharmacological
management of osteoporosis: a consensus of the Belgian Bone Club. Osteoporos Int, 22(11),
2769-2788. https://doi.org/10.1007/s00198-011-1545-x
Brady, S., D’Ambrosio, L. A., Felts, A., Rula, E. Y., Kell, K. P., & Coughlin, J. F. (2020). Reducing Isolation
and Loneliness Through Membership in a Fitness Program for Older Adults: Implications for
Health. J Appl Gerontol, 39(3), 301-310. https://doi.org/10.1177/0733464818807820
Curtis, J. R., & Safford, M. M. (2012). Management of Osteoporosis among the Elderly with Other
Chronic Medical Conditions. Drugs Aging, 29(7), 549-564. https://doi.org/10.2165/11599620-
000000000-00000
Nair, R., & Maseeh, A. (2012). Vitamin D: The "sunshine" vitamin. J Pharmacol Pharmacother, 3(2), 118-
126. https://doi.org/10.4103/0976-500X.95506
Nieves, J. W. (2003). Calcium, vitamin D, and nutrition in elderly adults. Clin Geriatr Med, 19(2), 321-335.
https://doi.org/10.1016/s0749-0690(02)00073-3
Plawecki, K., & Chapman-Novakofski, K. (2010). Bone health nutrition issues in aging. Nutrients, 2(11),
1086-1105. https://doi.org/10.3390/nu2111086
Roberts, J. A., & Wolfe, T. M. (2012). Chiropractic spinal manipulative therapy for a geriatric patient with
low back pain and comorbidities of cancer, compression fractures, and osteoporosis. J Chiropr
Med, 11(1), 16-23. https://doi.org/10.1016/j.jcm.2011.05.001
Wong, C. C., & McGirt, M. J. (2013). Vertebral compression fractures: a review of current management
and multimodal therapy. J Multidiscip Healthc, 6(default), 205-214.
https://doi.org/10.2147/JMDH.S31659