Months of Morning Back Stiffness That Eases with Exercise — Free SCA Practice Case

Character Overview: You are Dylan Sarkar, a 27 year old data analyst at a logistics company. You work at a desk, three days in the office and two at home. You share a house in Norwich with two friends and your parents live in Wymondham. You are sporty and easy going. You go to the gym four times a week (weights, the rowing machine and a spin class) and you have an obstacle race booked with your mates in about four months. About two years ago your lower back started to feel stiff, with no injury and no single moment you can point to. You paid for four sessions with a physiotherapist, who said your desk posture was the problem. You did her exercises every day for a month and the morning stiffness did not change. You are not alarmed, but puzzled and a bit fed up, and you worry about wasting the doctor's time over "just posture". You talk in a relaxed, chatty way.

Opening Sentence: "Hi, doctor. It's my lower back, really. It's been stiff for about two years now, especially first thing in the morning. A physio told me it's my posture, but it hasn't got any better, so I thought I'd get it looked at properly."

History if Asked (Data Gathering Phase)

• ●How it started: "It crept up on me. There wasn't a moment where I did something to it, no lifting injury or fall. About two years ago I noticed I was stiff getting out of bed, and it's been there ever since."
• ●Where it is: "Low down in the middle of my back. There's also a deep ache in my bum, sometimes on one side and sometimes the other. It moves about."
• ●Morning stiffness: "A good hour, sometimes an hour and a half, before it frees up. It's a tight, achy feeling, like I'm eighty."
• ●Better and worse: "Moving about makes it better. Once I'm up and walking it loosens off, and it's at its best after the gym. Sitting still makes it worse, like a long meeting or a long drive. If I stay in bed late on a Sunday I feel horrible, so resting doesn't help me at all."
• ●Night: "I wake most nights in the early hours, well after the middle of the night, because it's aching and stiff. I get up and shuffle about for ten or twenty minutes, then I can get back to sleep. The first half of the night is fine, I drop off and sleep straight through." If asked when: "It's never just after I've gone to sleep. It's always the early hours, towards morning."
• ●Ibuprofen (if asked about painkillers): "I buy ibuprofen 400s at the chemist. I take one or two in the morning, about four or five days a week, for around three months. It helps within an hour or two. If I take it a couple of days in a row it's properly better, and if I stop it creeps back within a day or two."
• ●Physio (if asked): "Four sessions at a clinic in town. She said my hip flexors were tight and my desk posture was poor. I did her exercises every day for a month and it made no difference."
• ●X ray and bloods (if asked): "The clinic did an X ray and it was normal. A locum GP did blood tests afterwards and they were normal too. That's what puzzles me."
• ●Heels and joints (if asked about pain or swelling anywhere else): "No swollen joints, and nothing in my hands, knees or hips. My right heel has been sore for about five months though, at the back where the tendon goes in. It's worst for the first few steps out of bed and eases after a few minutes."
• ●Eyes (if asked about eyes, vision or eye problems): "Actually, yes. About a year ago my left eye went red and sore and the light really hurt it for a few days. The optician sent me straight to the eye department at the hospital and they gave me drops. They said it was inflammation inside the front of the eye. It cleared in a couple of weeks and I haven't had it since."
• ●Skin, nails, bowels, infections (if asked): "No rashes or flaky patches, nails are fine, bowels normal with no diarrhoea, blood or mucus. No recent tummy bug or urine or sexual infection."
• ●Family (if asked): "My mum has had psoriasis for years, on her elbows and scalp. My dad's fine. Nobody has had arthritis or back problems that I know of."

Ideas, Concerns, Expectations

Gating note: Dylan does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: He assumes it is posture from sitting at a desk, or maybe a disc he has done at the gym, but he is no longer sure. "I thought it was my posture, like the physio said, or maybe I've done something to a disc. But I've done everything she told me, so I'm not sure."
• ●Concerns: "I'm 27 and my back feels like an old man's. A lad at my work had a slipped disc and was off for six months. And I've paid for the physio, done everything she said and I'm still no better. I'm a bit worried I'm just wasting your time." If the doctor explores further: "I've got an obstacle race booked with my mates in about four months and I don't want to pull out."
• ●Expectations: "I was hoping for a scan, an MRI or something, so someone can actually see what's going on. And I don't love taking ibuprofen every day. I've read it can mess up your stomach."

If Asked: Medical History and Medications

Gating note: Dylan answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Nothing really. Just the eye thing last year."
• ●Stomach: "No indigestion or heartburn. I've never had an ulcer or black poo."
• ●Asthma, kidneys, blood pressure: "No asthma or wheeze, no kidney problems, and my blood pressure was fine when they checked it."
• ●Other medicines and allergies: "Only the ibuprofen. No supplements, no steroids. No allergies."
• ●Mood, weight, appetite: "Fed up with the bad sleep but I'm not low, and I'm still out with my mates. Weight and appetite are steady."

Social History and Lifestyle Impact

• ●Work and home: Desk job. He sees his parents most weekends. No money or work worries.
• ●Exercise: "Gym four times a week. I don't want to stop, because it's the one time my back feels loose. The race is in about four months."
• ●Sleep and energy: "I'm waking most nights and a bit flat in the afternoons, but it's not stopping me working."
• ●Alcohol and smoking: "A few pints at the weekend, about eight units a week. Never smoked."

If Asked: Red Flag Screening

• ●If asked about an injury, a fall or a sudden onset: "No, it crept up on me."
• ●If asked about leg weakness, numbness or tingling, numbness around the bottom or genitals, or problems passing urine or opening bowels: "No, my legs are fine and nothing like that."
• ●If asked about weight loss, fever, night sweats, past cancer, injecting drugs or treatment that lowers immunity: "No, none of that."
• ●If asked whether the night pain is constant or settles: "It's not constant. Getting up and moving settles it within twenty minutes or so and then I sleep."

Responses to Management (The Negotiation Phase)

• ●If the doctor says it is posture or mechanical, says the normal X ray or bloods mean nothing is wrong, or suggests more physio only:
  • ●Reaction: Deflated and confused. "That's what I was told four months ago and I've done all of it. If nothing is wrong, why do I wake up in the early hours and why does the gym make it better?"
• ●If the doctor suggests referral to a rheumatologist, or names an inflammatory back condition:
  • ●Reaction: Surprised, then quiet. "Rheumatology? Isn't that for older people with arthritis? What will they do, and how long will it take? Will they write to me? Will I still be able to train and do my race?" He is relieved to hear it is not confirmed, is treatable and exercise helps.
• ●If the doctor wants a scan or blood tests before referring, says the specialists will choose the scan, or offers a gene marker test:
  • ●Reaction: Willing but checking. "Fine, I'd like the scan anyway, but will that hold up the specialist? I've had this for two years already. So you don't need an MRI first? Is the gene test a genetic test, and what does it tell you?" He is happy once he hears the specialist will arrange the right scan.
• ●If the doctor offers regular anti inflammatory tablets, stomach protection, naproxen, or says to stop ibuprofen, or suggests paracetamol or opioids:
  • ●Reaction: Wary. "Is it safe to take every day? I'm worried about my stomach. Do I really need another tablet as well? Is naproxen stronger?" He accepts a stomach tablet if the doctor explains why, or is happy without one if the doctor explains he is low risk. If told to stop ibuprofen: "But it's the only thing that helps." If offered paracetamol or an opioid: "Paracetamol does nothing for me. Is a stronger painkiller sensible at my age?"
• ●If the doctor advises rest or cutting out the gym, or says to keep exercising:
  • ●Reaction: If told to rest, alarmed: "Rest makes it worse. I feel loosest after the gym. Are you sure?" If told to keep exercising, relieved: "So I don't have to stop? Is there anything I should avoid, like heavy lifts?"
• ●If the doctor asks him to bend, press on his back or heel, or examine himself on camera, or gives vague or red eye safety netting:
  • ●Reaction: Declines to examine himself: "I wouldn't know how to do that properly on camera. I'd rather you saw me in person." To "come back if it gets worse": "Worse how? It's already stiff every day. What would mean I should come in straight away?" To a red, painful or light sensitive eye: "That happened last year, actually. Should I have said? So if it happens again do I go to A and E?"