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L.B. is a 54-year-old man who works in the shipping and receiving department at a state university. His job entails transporting mail and equipment to and from various locations around the campus. Two days ago, he strained his back while moving several boxes. Because the pain has prevented him from doing his job, L.B. was referred to the university-associated rehabilitation clinic. His medical chart states that he had asthma in childhood, and that he is a current smoker with a 30-pack-year history of smoking. His medication includes nadolol combined with bendroflumethiazide (Corzide) for essential hypertension and ipratropium combined with albuterol (Combivent) as needed for dyspnea. At the initial physical therapy evaluation, L.B.’s blood pressure and heart rate were 138/82 mm Hg and 79 bpm, respectively. The therapist chose to use the university pool, kept at 34°C, to initiate functional pain-reduced movement. A small pool to the side of the main pool has a shallow end with a depth of 2-4 ft and a deeper end at 6-10 ft. On his way from the rehabilitation clinic to the pool, the therapist observed L.B. smoking a cigarette. The therapist wanted to start the treatment session with spinal traction, using the buoyancy of the water with strategic placement of weights. In the shallow end of the pool, the therapist attached a float to the L.B.’s upper chest under his axillae to keep his head out of the water. Next, the therapist attached a 4-kg weight to each ankle and gently guided the patient toward the deeper end of the pool until his feet did not touch the bottom. The therapist asked L.B. to relax, allowing the weight on the ankles to provide gentle spinal traction. After 10 minutes, the patient stated that the pain decreased and the therapist instructed him to begin slowly walking in place. Approximately 4 minutes into this part of the therapy, L.B. complains of shortness of breath. He becomes pale and frantically attempts to reach the shallow end of the pool. The therapist quickly assists L.B. to the side of the pool and a therapist’s aide helps get him out of the water. Once safely at the edge of the pool, the therapist takes his vital signs; blood pressure and heart rate are 153/90 mm Hg and 89 bpm, respectively.


Patients may be taking over-the-counter (OTC) drugs for respiratory disorders without consulting healthcare professionals, and some of these drugs can have significant interactions with rehabilitation therapy. For example, decongestants such as oxymetazoline, a common nasal spray, can increase blood pressure and cardiac workload. Clinically, these effects may manifest as exertional angina during aerobic activities or painful procedures. In addition, decongestants may cause orthostatic hypotension, though this adverse effect is more common with opioid antitussives and antihistamines. Opioid antitussives may also depress respiratory drive, resulting in hypercapnia during aerobic activity. Last, antihistamines and opioid antitussives also cause sedation, ...

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