University of North Dakota University of North Dakota

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Physical Therapy Scholarly Projects Department of Physical Therapy

5-2020

Physical Therapy Rehabilitation Following a Thoracic to Sacroiliac Physical Therapy Rehabilitation Following a Thoracic to Sacroiliac

Spinal Fusion: A Case Report Spinal Fusion: A Case Report

Ragen Wilson University of North Dakota

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Recommended Citation Recommended Citation Wilson, Ragen, "Physical Therapy Rehabilitation Following a Thoracic to Sacroiliac Spinal Fusion: A Case Report" (2020). Physical Therapy Scholarly Projects. 700. https://commons.und.edu/pt-grad/700

This Scholarly Project is brought to you for free and open access by the Department of Physical Therapy at UND Scholarly Commons. It has been accepted for inclusion in Physical Therapy Scholarly Projects by an authorized administrator of UND Scholarly Commons. For more information, please contact und.commons@library.und.edu.

Physical Therapy Rehabilitation Following a Thoracic to Sacroiliac Spinal Fusion: A Case Report

by

Ragen Wilson, SPT

Bachelor of Science University of Wyoming, 2017

Associate of Science Casper College, 2014

A Scholarly Project Submitted to the Graduate Faculty of the

Department of Physical Therapy

School of Medicine

University of North Dakota

in partial fulfillment of the requirements for the degree of

Doctor of Physical Therapy

Grand Forks, North Dakota May, 2020

This Scholarly Project, submitted by Ragen Wilson in partial fulfillment of the requirements for the Degree of Doctor of Physical Therapy from the University of North Dakota, has been read by the Advisor and Chairperson of Physical Therapy under whom the work has been done and is hereby approved.

ii

de½~~ Schawnn Decker, (Graduate School Advisor)

Dave Relling, (Chairperson, Physical Therapy)

Title

Department

Degree

PERMISSION

Physical Therapy Rehabilitation Following a Thoracic to Sacroiliac Spinal Fusion: A Case Report

Physical Therapy

Doctor of Physical Therapy

In presenting this Scholarly Project in partial fulfillment of the requirements for a graduate degree from the University of North Dakota, I agree that the Department of Physical Therapy shall make it freely available for inspection. I further agree that permission for extensive copying for scholarly purposes may be granted by the professor who supervised my work or, in her absence, by the Chairperson of the department. It is understood that any copying or publication or other use of this Scholarly Project or part thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and the University of North Dakota in any scholarly use which may be made of any material in this Scholarly Project.

Signature ~Jifl: Date lo/zq/lC>J

'

iii

(

TABLE OF CONTENTS

LIST OF FIGURES ...................................................................... .. v

LIST OF TABLES ......................................................................... vi

ACKNOWLEDGEMENTS ........................................................... .... vii

ABSTRACT ................................................................................. viii

CHAPTER I.

II.

BACKGROUND AND PURPOSE ........................ . 1

CASE DESCRIPTION ..................................... .... 5

Examination, Evaluation and Diagnosis .................. 6

Prognosis and Plan of Care ................................. 8

Ill. INTERVENTION ............................................. . 11

IV. OUTCOMES ................................................... 13

V. DISCUSSION .................................................. 15

Reflective Practice ............................................ 18

REFERENCES ........................................................................... 20

iv

LIST OF FIGURES

1. Self-reported ABC Scale and Modified Oswestry pre-treatment versus post 9 week Interventions ............................................................................ 13

2. Self-reported level of pain (pn) using VAS pre-treatment versus 9 week interventions ..................................................................................... 14

V

LIST OF TABLES

1. Patient Reported Goals ....................................................................... 8

2. Aquatic Therapy Interventions (Weeks 1-3; 1 hour sessions; 2x/week) .......................................................................................... 10

3. Land Based Therapy Interventions (Weeks 4-9; 1 hour sessions; 2x/week) .......................................................................................... 11

(

vi

ACKNOWLEDGEMENTS

This case report could not have been completed without the consent of the

patient. I would like to send my full appreciation to this patient for displaying

motivation and compliance throughout her plan of care and granting me

permission to use her outcome for this scholarly project. I would also like to

express gratitude to my clinical instructor (PT, DPT) for her guidance and

expertise in the overall physical therapy rehabilitation process of this diagnosis

which lead to a successful outcome. I would like to thank Schawnn Decker,

DPT/Assistant Professor, for her supervision and guidance while writing this case

report. Finally, I send appreciation to Kevin Hansen, Daniel Torok, and McKenzie

Klocke who provided insight and revision advice throughout the development of

this case report.

vii

ABSTRACT

Background and Purpose. This case study described the 9 week outpatient

physical therapy rehabilitation process of a 75 year old female following a

posterior thoracic spine (T9) to sacroiliac (S 1) spinal fusion as a result of adult

degenerative scoliosis and prolonged back pain (Type 1 ). The purpose of this

case report was to describe the overall outpatient physical therapy management

of this post-operative fusion. Description. The patient presented to physical

therapy with decreased mobility, decreased function, decreased balance, lower

extremity strength deficits, pain, and loss of independence. Intervention. Initially,

treatment occurred in a therapeutic pool and then progressed to a land based

setting. Treatments involved therapeutic exercise, therapeutic activities,

neuromuscular reeducation, gait training, and education. Outcomes. Following

PT intervention, the patient achieved all stated functional goals, increased LE

strength, improved confidence in balance, and re-gained independence of ADLs.

Discussion. Rationale for treatment was based on the spine surgeon's protocol

for multiple level spinal fusion, functional tasks the patient was unable to

complete, and impairments based on the initial evaluation. The patient was able

to improve function and mobility and regain independence following 9 weeks of

outpatient physical therapy treatments.

viii

Background

CHAPTER I

BACKGROUND AND PURPOSE

Adult scoliosis is defined as a spinal deformity in a skeletally mature

patient with a Cobb angle of more than ten degrees in the coronal plain. Adult

scoliosis can be separated into four major groups: Type 1, Type 2, Type 3a, and

Type 3b. Type 1 is known as a primary degenerative scoliosis affecting the disc

and/or facet joints predominantly with back pain symptoms. Type 2 is known as

idiopathic adolescent scoliosis of the thoracic and/or lumbar spine which

progresses into adult life. Type 3a is known as secondary adult curves due to leg

length discrepancy, hip pathology, or abnormalities in the lumbosacral junction.

Type 3b is in the context of metabolic bone disease combined with asymmetric

arthritic disease. 1

Furthermore, as individual's age, and without addressing these

asymmetries, scoliosis significantly progresses due to increased asymmetric load

and deformities.1 The progression of a curve is further supported by

osteoporosis, particularly in post-menopausal females. When surgeons decide

operative treatment for adult spinal deformity (ASD), main considerations were

pain and disability.2 Surgical management consists of either decompression,

correction, stabilization, or fusion procedures or a combination of some of these. 1

Most surgeons recommend decompression along with fusion, which has been

1

widely accepted to improve spinal alignment at the expense of mobility. 3

According to the American Academy of Orthopedic Surgeons, the basic idea of a

fusion is to fuse together two or more vertebrae so that they heal into a single

solid bone in order to eliminate painful motion or to restore stability of the spine.4

Typically, people try to avoid painful situations or pain provoking

conditions. When an individual moves into a certain position and pain is the

response, that individual is going to avoid that position. When people avoid

specific movements over a long period of time due to a painful response, a

sedentary lifestyle can become the result. People are motivated to avoid

activities in which they have experienced acute episodes of pain in order to

reduce the likelihood of re-experiencing pain or causing further physical damage.

This concept is known as the fear avoidance model of chronic pain. This basic

model proposes, that if one interprets the experience of pain as significantly

threatening and begins to catastrophize about it, then pain-related fear evolves.5

Individuals with spinal injuries and disease naturally come to avoid

behaviors and postures that provoke back pain. Such activity restriction, while

minimizing increases in pain, can have significant adverse physical, emotional,

and cognitive consequences when pain becomes chronic. Perhaps, patients can

develop strong fears that their actions will worsen underlying physical problems,

further restricting activities and heightening emotional distress.6 Fear-avoidance

beliefs have been found to be significant predictors of pain and functional

outcomes for up to 2 years after lumbar spine surgery. 7 Fear avoidance

behaviors can negatively impact mental barriers associated with pushing through

2

pain which can negatively affect exercise, mobility, and functional outcomes even

after surgical intervention.

Individuals who have received thoracic to lumbar spinal fusions are at a

potential risk to have decreased range of motion of the spine due to the

mechanism of surgery and the number of joints affected. The properties of water

provide many enticing qualities to help re-educate the body and promote early

range of motion when instances may be difficult to achieve initially on land. When

compared to land-based exercises, water exercises can offer some advantages

to overweight patients, with mobility difficulties, since the body weight relief

provided by the buoyancy reduces the impact on joints and the perception of pain

intensity.8 In addition, studies in healthy adults and older subjects have shown

that water exercises are effective to increase muscle strength. Once individuals

have plateaued in aquatic environments, treatments can progress to land based

therapy.

Physical therapists strive to create interventions that focus on improving a

patient's functional ability. Function gained during or after therapy is often

measured by change, over time, in score on a functional assessment instrument.

Functional outcome measures are important for physical therapists to administer

at initial evaluation and discharge in order to determine if treatments were

clinically significant. Determining whether an improvement is significant,

researchers need to provide minimal detectable change scores.9 Minimal

detectable change is defined as the minimal amount of change that is not due to

variation in measurement.10

3

The Activities-specific Balance Confidence Scale (ABC scale) is often

used by physical therapists to determine the patient's confidence in their balance.

The scale is comprised of 16 questions, where the patient self-reports their level

of confidence (0%-100%) on performing ambulatory tasks without falling. A

higher percentage indicates a higher confidence level. The ABC scale

demonstrates excellent reliability and validity in older adults. 11 Another common

functional outcome measure used by physical therapists is the Modified

Oswestry Low Back Pain Disability Questionnaire. This test assesses how an

individual's back pain has affected their activities of daily living. The

questionnaire is comprised of 10 questions, where the patient self-reports their

perceived level of disability on a O (no impairment) to 5 (maximum impairment)

scale. A higher score reflects a higher level of disability. The Oswestry Low Back

Pain Disability Questionnaire has good reliability and validity in measuring

disability in individuals with low back pain. 12

Purpose

There is insufficient research supporting the physical therapy rehabilitation

protocol of a post-operative thoracic to sacroiliac fusion due to degenerative

scoliosis. This case report details the 9 week outpatient physical therapy

rehabilitation of a 75 year old female who underwent a posterior thoracic spine

(T9) to sacroiliac (S1) spinal fusion as a result of adult degenerative scoliosis and

prolonged back pain {Type 1 ). The purpose of this case report is to describe the

outpatient physical therapy treatment of this post-operative fusion and provide

outcomes with completion of long term goals.

4

History

CHAPTER II

CASE DESCRIPTION

The patient was a 75 year old retired and widowed female who had been

experiencing low back pain for 40+ years. Previously, she had not received any

medical attention to address her pain and symptoms. In 2013, she went to a

spine center and discovered she had Type 1 adult degenerative scoliosis. Patient

did not seek any treatment and instead dealt with the pain due to fear of surgery.

In 2017, her low back pain became so severe, she noticed her function and

independence was decreasing if not completely absent. She was unable to walk

a block, bend over to take dishes out of the oven and/or dishwasher, reach into

her cupboards, or even dress herself due to pain. The only position she was able

to find relief was in supine. She eventually stopped leaving her house and

attending community and social events due to intense pain. After weighing the

options, the patient and her orthopedic spine physician agreed upon surgery as

the best option to restore function and relieve pain.

In February 2018, the patient underwent a posterior thoracic spine (T9) to

sacroiliac spinal (S1) fusion. Before being initially evaluated at the outpatient

orthopedic clinic, the patient spent ten days in an acute care spine center

hospital, five weeks at a long term care rehabilitation center, and six weeks

5

receiving home health. Prior to surgery, the patient was independent and active

within her community. She participated in multiple book clubs, line dancing class,

deep water swimming class, and church related activities weekly. The patient

expressed the importance the social aspects her community activities brought to

her life.

Examination, Evaluation, and Diagnosis

Prior to meeting the patient, the outpatient front desk staff copied

information from the patient's referred chart into the clinics documentation

software system. Such information included; height, weight, past/current medical

history and medications. As found in the electronic medical record (EMR), the

patient was 5'5", weighing 190 lbs, which equated to a BMI of 31.6 (obese

category).13 The patient's past/current medical history included hypertension and

osteoporosis. The patient was currently taking medication that controlled

hypertension, calcium and vitamin D supplements to address osteoporosis, as

well as an anti-inflammatory for pain management associated with the fusion.

Upon observation, the patient presented to physical therapy standing in the

waiting room, alone, and ambulated with a slow, step-to gait pattern utilizing a

front wheeled walker. The patient was not wearing a thoracolumbosacral orthosis

(TLSO) brace, which she had been prescribed immediately after surgery. Patient

displayed a forward head posture with an endomorphic body stature.

The patient was referred to physical therapy to evaluate and treat. The

patient reported to lived alone in a single story home with no steps to negotiate

into or within her home. Since the patient lived alone, she reported to have

6

friends help her with activities of daily living that she was unable to complete. At

the time of initial evaluation, the patient was unable to fully sit or lie supine due to

pain and decreased range of motion and had to sit at the edge of an elevated

plinth. Similarly, the patient was prohibited to bend, twist, or lift more than 20 lbs

due to the spine surgeon's protocol. Thus, range of motion, resisted isometrics,

myotomes, and manual muscle testing for all motions of the spine and lower

extremity were deferred. Thoracic spine and lower extremity dermatomes tested

negative and equal bilateral. The incision site was healed but scar tissue

remained which measured 27.9 cm long by 1.5 cm wide. The patient was not

tender to palpation along the adhered incision site. The patient reported she had

an appointment with a massage therapist to address hypo-mobility of scar tissue.

The patient completed two functional outcome measures; The Modified

Oswestry Low Back Pain Disability Questionnaire and the Activities-specific

Balance Confidence (ABC) Scale. 14,15 The patient reported to be 74% impaired

as a result of the Modified Oswestry Low Back Pain Disability Questionnaire. 14

The patient reported to have 3.4% (<50% = low level of physical functioning) self­

confidence as a result of the ABC scale. 15 Perceived level of pain was collected

using a visual analogue pain scale (VAS). The scale ranges from O to 10 with

zero being no pain and 10 being unbearable pain. The patient reported to have

6/10 pain at rest, 8/10 with motion, and 9/10 pain when attempting to bend. The

patient's complete and functional reported goals can be found in Table 1.

Physical therapy diagnosis found from the examination process included;

7

decreased mobility, decreased function, decreased range of motion, decreased

balance, lower extremity strength deficits, and pain.

Table 1. Patient Reported Goals

Goals 1. Following physical therapy intervention, the patient will be able to ambulate 4

miles/day without any assistive device in order to return to previous hobbies (9 weeks).

2. Following physical therapy intervention, the patient will be able to sit for one hour without pain in order to attend church services on Sundays (9 weeks).

3. Following physical therapy intervention, the patient will be able to stand for 2 hours without any pain in order to perform housework tasks independently (9 weeks).

4. Following physical therapy intervention, the patient will be able to get into/out of car independently in order to be able to complete grocery shopping independently (9 weeks).

Prognosis and Plan of Care

The total duration of physical therapy treatments could not surpass 9

weeks due to the patient's already purchased plane ticket to fly across the United

States to visit her family. The patient was actively involved in the plan of care

(POC) and treatments were determined to be 2x/week, 1 hour treatment

sessions, for 9 weeks with modifications if necessary or until goals were met The

patient was educated on the re-evaluation process for returning to physical

therapy once back home from her month long trip, if desired, but it was

anticipated that she would not need to return. Prognosis was good given the

patient's high level of motivation, age, health status and prior level of function.

Furthermore, this patient was appropriate for physical therapy and met the

physical therapist's scope of practice.

8

CHAPTER Ill

INTERVENTION

The patient was seen two times a week, with hour treatment sessions, for

a total of 9 weeks as per POC. In the first three weeks, interventions included

aquatic therapy treatments (Table 2). Aquatic treatments were completed in a

therapeutic pool (90 degrees) which featured a shallow (4 ft.) and deep (10 ft.)

end. Aquatic therapy allowed the patient to improve early range of motion and

strength by off-loading the spine. The Patient completed exercises while off­

loading 50% of her body weight in the shallow end or with complete submersion

in the deep end while using a foam pool noodle as a floatation device.

Treatments were progressed based on patient tolerance by increasing time,

repetitions, sets, and intensity. Soft tissue mobilizations were completed once a

week for 30 minutes by a massage therapist located in the same outpatient clinic.

The massage therapist and physical therapist stayed in communication regarding

the advancement of skin integrity. By week two, the patient progressed from

presenting to physical therapy ambulating with her FWW to ambulating with

bilateral walking sticks.

9

Table 2. Aquatic Therapy Interventions (Weeks 1-3; 1 hour sessions; 2x/week)

Interventions

1. Walking forward/backward/side to side shallow end - 3 min each Week 2. Hanging bicycles in deep end with floaty under arms - 3 min

1 3. Hanging knees to chest in deep end with floaty under arms - 3 min 4. Sitting on flotation device in order to balance deep end - 2 min

Addition of: 1. Mini squats shallow end - 3 sets x 10 reps

Week 2. 3 way hip shallow end- 3 sets x 10 reps 2 3. Marches shallow end - 3 sets x 10 reps

4. Standing heel/toe raises shallow end- 3 sets x 10 reps 5. Standing clock taps shallow end - 3 sets x 10 reps rep

Week Addition of:

3 1. Stair negotiation into and out of pool using single rail facing forward -

2 sets x 10 reps

In the following seven weeks, the patient progressed to land based

therapy (Table 3). The patient presented to treatments ambulating with bilateral

walking sticks but completed treatment without them. Similarly, the patient was

discharged by the massage therapist as their goals were met. Land based

treatments included therapeutic activities, therapeutic exercise, neuromuscular

reeducation, and gait training. Treatments were progressed based on patient

tolerance. Treatments were progressed by increasing time, repetitions, sets, and

intensity.

10

Table 3. Land Based Therapy Interventions (Weeks 4-9; 1 hour sessions; 2x/week)

Interventions 1. Recumbent stepper - 5 min

Week 2. Mini squats - 2 sets x 10 reps 4 3. Heel/Toe raises - 2 sets x 10 reps

4. Seated marches - 2 sets x 10 reps Addition of: 1. 3 way hip - 2 sets x 10 reps each leg

Week 2. Tandem balance on level ground - eyes open; 2 sets x 30' each 5 leg

3. Tandem balance on level ground - eyes closed; 2 sets x 30' each leg

Addition of: 1. 3 way hip - Green theraband - 2 sets x 10 reps each leg

Week 2. Stepping over 2" block independently - 2 sets x 10 reps each leg

6 leading

3. Step ups/Step downs on 3" step - 2 sets x 10 reps alternating lead leg each

4. Sit to stands w/ household chair with arms - 2 sets x 10 reps Addition of:

Week 1. Ascending/descending up 1 flight of stairs facing forward with two

7 rails - 2x 2. Ascending/descending up 1 flight of stairs facing forward with one

rail-2x 1. Parallel bar walking w/ perturbations - 20' x 5 laps (simulating

wind/busy environments) 2. Parallel bar walking carrying 2 lbs in one hand - 20' x 5 laps each

Week (simulating carrying grocery bags) 8 3. Walking while facing a mirror for self-correction of posture - 20' x 5

laps 4. Picking up a 10 lbs weighted laundry basket from a low plinth

(simulating oven height) - 1 set x 10 reps Addition of:

Week 1. Walking outside up a sloped sidewalk without assistive device -

9 50' x 2 laps

2. Walking up and down a curb without assistive device - 2 sets x 10 reps

It is important to discuss the fear avoidance behaviors the patient

displayed towards the end of the first four weeks of land based therapy. Six

weeks in to therapy, the patient's spine surgeon cleared her of all restrictions.

11

Unbeknownst to the physical therapist, the patient reported to still be using her

walker to ambulate to the bathroom at night, using the bench of her walker to

carry her laundry basket while ambulating, ambulating community distances with

her bilateral walking sticks, and completing other functional tasks at a level below

her true physical capabilities. The patient was educated on the importance of

challenging herself functionally and not relying on assistive devices because she

was cleared of all restrictions and was physically capable. In turn, the patient

presented to physical therapy without the use of her bilateral walking sticks the

following treatment. The last three weeks of treatments (seven, eight, and nine)

focused solely on simulating functional activities that the patient reported to be

afraid to complete. These activities included stepping up and down curbs without

using walking sticks, ambulating in busy grocery stores, ambulating in windy

environments without her walking sticks, ambulating within her house carrying

her laundry basket, loading/unloading the dishwasher, and negotiating stairs with

and without railings in buildings where her community activities were located.

12

CHAPTER IV

OUTCOMES

By the end of the 9 weeks, the patient made improvements in function,

mobility, LE strength, balance, and achieved all reported goals. As shown in

Figure 1, the patient had increased her ABC score from 3.4% (<50% = low level

of physical functioning)to 51.6 % (50-80% = moderate level of physical

functioning). As shown in Figure 1, the patient improved her Modified Oswestry

Low Back Pain Disability Questionnaire Score from 74% impaired to 10%

impaired. As shown in Figure 2, initially, the patient reported her pain levels to be

6/10 at rest, 8/10 with motion, and 9/10 when attempting to sit. The patient had

decreased her pain levels to be 1/10 pain at rest, 2/10 pain when moving, and

2/10 while sitting. The patient was able to fly across the U.S. independently to

visit her family without any restrictions or assistive devices.

80 £c (]) 00 70

g ~ 60 (]) (J)

;g O "O 50 C "O (]) 0 (]) .!:: 40

(_) t;::: cu ~ ~ Eo.. 30 0 0 -(]) ~ ~ 20

~ ~ 0 10 (/) C (_) CU 0 co cu <( co

Figure 1.

■ ABC Scale ABC Scale Modified Modified

pre post Oswestry Oswestry pre post

Self-reported ABC Scale and Modified Oswestry pre-treatment versus post 9 week interventions

13

(

10 0 C 9

I

8'28 CJ) Q. 7 ~~ > .0 6 O)~ C CO 5 ·- (]) CJ) .0 4 ::::IC

,!:; =? 3 co 0 a. ..- 2 4-

0 C i a3 a. > 0 (])

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Figure 2.

Pn at Pn at Pn with Pn with Pn with Pn with rest pre rest post motion motion bending bending

pre po~ pre po~

Self-reported level of pain (pn) using VAS pre-treatment versus post 9 week interventions

Throughout the 9 weeks, the patient did not have any adverse effects to

the therapeutic pool or land based interventions. The patient was on time and

present at every treatment. Sessions were modified and/or progressed based on

patient's tolerance. Compliance and understanding of the HEP was

demonstrated by the patient over the course of treatment. The patient was

extremely satisfied and grateful for the care of therapy received as well as the

improvements she made in her function.

Improvements were made through skilled physical therapy intervention,

education, as well as the patient's high level of motivation and determination to

return to independent function. Once the patient's psychosocial factors and fear

avoidance behaviors were addressed, the patient made fast gains in functional

capabilities. At discharge, the patient was educated on the importance of

continuing her HEP and challenging herself with functional activities in order to

maintain advancements made through physical therapy.

14

CHAPTERV

DISCUSSION

Operative treatments are on the increase because the demand for quality

of life is increased and surgical techniques are improved.2 Spine surgery

involving decompression and fusion is safe and recommended in the setting of

degenerative scoliosis treatment.3 Even for patients 75 years and older, surgery

provides significant improvements. After long level fusion, ADLs can be impaired

but gradually improved over time.2 This patient's ADLs were greatly impaired

following a T9 - S 1 fusion and did return as time passed with the aid of physical

therapy intervention and determination from the patient.

Factors such as fear of movement and low self-efficacy are identified as

barriers to physical activity.7 Fear avoidance beliefs may play a significant role in

the outcome of surgery for adult degenerative scoliosis. There is a strong

correlation that movement will increase pain and the individual avoids moving. 6

The movement may or may not create pain, but the fear of producing pain is the

main factor limiting mobility. This patient used shortcuts and assistive devices to

complete functional tasks because she wasn't aware of her therapeutic gains.

She was stuck on the fear of producing pain while completing these tasks

independently which prevented her from trying them. Once she was educated on

this concept and worked on functional activities, she became aware that she

15

could physically do these tasks without pain and that the mentality of fear was

the driving forces preventing movement.

Aquatic exercise may have advantages in acute therapy compared to

land-based exercise due to the physical properties of water. The execution of the

movements can become easier, decreasing also the sensation of pain. 8

Introducing this patient to aquatic therapy in the early phases of treatment proved

beneficial and promoted early increases in range of motion and mobility due to

the characteristics and buoyancy water possesses. Similarly, off-loading the

patient's body weight made it possible for her to complete treatment with

decreased pain levels.

Currently, there is no minimal detectable change to compare the ABC

scale to, as there is no gold standard for a subjective questionnaire such as

this. 16 Perceived physical capabilities rather than actual physical abilities is more

predictive of completing a behavior. Working on the functional tasks that the

patient was unconfident to complete, made her more confident. The patient self­

reported to have an increased confidence in daily activities by 48%. According to

the Modified Oswestry Low Back Pain Disability Questionnaire score sheet, the

minimum detectable change (90% confidence) is a decrease of 10% impairment.

The patient had a decrease of 64% impairment indicating clinical change. Lastly,

pain is subjective and perceived differently for every individual. The patient had a

decrease in pain by an average of 6 points. Based on this author's clinical

judgement and feedback from the patient, the patient made clinical

16

improvements in decreased level of pain from initial evaluation to the time of

discharge.

Health care providers should strive to base treatment around functional

tasks. Individuals may be able to complete therapeutic exercise and activities,

but this does not equate to direct cross over to functional demands. As

demonstrated with this patient, once treatments focused around functional tasks,

the individual's confidence and mentality greatly improved. The patient was able

to prove to herself that she was physically capable of completing functional tasks

that she perceived she was not capable of completing.

The outcome of this patient's 9 week experience proved to be

encouraging. Promoting early off-loading in aquatic settings and transitioning to

land based therapy, understanding the psychosocial factors associated with fear

avoidance behaviors, utilizing multiple functional outcome measures to assess

clinical change, and adapting treatments to the individual are key components of

a successful outcome. Based on the outcome of this patient, this case report can

be used as a reference for an outpatient rehabilitation process of an individual

following a multilevel spinal fusion due to Type 1 scoliosis.

17

Reflective Practice

The outcome of this case report, as stated in the discussion, was

encouraging given the lack of research on this topic. However, there are some

areas in which I would have done differently. One of these areas being -

addressing the patient's psychosocial factors much sooner compared to when

they were addressed in real life. Knowing that the patient's POC was set at 9

weeks due to her pre-purchased plane ticket, there were many goals we (the

therapist and patient) were trying to accomplish in a short period of time. The

patient's fear-avoidance behaviors could have had a negative impact on her

outcome if they were never addressed. Luckily, they were addressed in an

appropriate amount of time, but potentially addressing these factors sooner

would have been more beneficial for the patient's quality of life.

The experience and process of this case report will positively impact my

future practice. This case report taught me the importance of embodying

evidence based practice as well as centering treatments around the patient.

Every individual is unique and different and there is not one formula that works

for everyone. There are many factors to consider when developing treatments

and a plan of care. This patient instilled in me the need to address health as a

whole. Enhancing health must focus on all components of the mind, body, soul,

and understanding the multidirectional relationship between physical, emotional,

and psychological factors. Similarly, this case helped me to create my PT

18

practice philosophy. Given the little research on this topic as a whole,

administering a wide range of "tools" that do have evidence based outcomes is

important. As a future clinician, I will strive to utilize a variety of techniques to

help promote a successful outcome and this patient's complexity helped me

understand the necessity of this concept.

Limitations of this case report include; lack of research on the

rehabilitation protocol per this diagnosis, potential alternative outcomes following

a patient with comorbidities, and failure to understand the maintenance of this

patient's advancements made through physical therapy long term. Following a

standardized protocol possesses many benefits as health care providers are able

to provide evidence based practice, speed recovery time, and decrease health

care associated costs. This patient did not possess any comorbidities. At this

time, it is unclear as to whether following a patient with comorbidities would

negatively impact the outcome or how said comorbidities would affect POC,

clinical judgement, and treatment activities/progressions. Finally, this case report

did not conduct any follow up treatments assessing the patient's function after

discharge. Perhaps, a six month follow up would show 100% return to function or

indicate a need for a longer POC.

19

REFERENCES

1. Aebi M. The adult scoliosis. Eur Spine J. 2005;14(10):925-948. Accessed Jun 25, 2019. doi: 10.1007/s00586-005-1053-9.

2. Kim WJ, Lee JW, Hwang SY, et al. Activity of daily living after long level fusion in adult spinal deformity: Compared with over 60-year-old degenerative spine patients without adult spinal deformity. Spine. 2018;43(23):1638-1647. Accessed Jun 25, 2019. doi: 10.1097/BRS.0000000000002676.

3. Phan K, Xu J, Maharaj MM, et al. Outcomes of short fusion versus long fusion for adult degenerative scoliosis: A systematic review and meta-analysis. Ortho Surg. 2017;9(4):342-349. https://onlinelibrary.wiley.com/doi/abs/10.1111/os.12357. doi: 10.1111/os.12357.

4. Orthoinfo.aaos.org. (2019). Spinal Fusion - Ortholnfo -AAOS. [online] Available at: https://orthoinfo.aaos.org/en/treatment/spinal-fusion/ [Accessed 25 Jun. 2019].

5. Gatchel RJ, Neblett R, Kishino N, Ray CT. Fear-avoidance beliefs and chronic pain. The J Orthop Sports Phys. 2016;46(2):38-43. https :/ /www.ncbi.nlm.nih.gov/pubmed/2682823 6. doi: 10 .2519 /j ospt.2016.0601.

6. Haddas R, Lieberman IH, Block A. The relationship between fear-avoidance and objective biomechanical measures of function in patients with adult degenerative scoliosis. Spine. 2018;43(9):647-653. Accessed Jun 25, 2019. doi: IO .1097 /BRS. 00000000000023 81.

7. Lotzke H, Jakobsson M, Gutke A, et al. Patients with severe low back pain exhibit a low level of physical activity before lumbar fusion surgery: A cross-sectional study. BMC Musculoskelet Disord. 2018;19(1):365. Accessed Jun 25, 2019. doi: 10. l 186/s12891-018-2274-5.

8. Mattos Fd, Leite N, Pitta A, Bento PCB. Effects of aquatic exercise on muscle strength and functional performance of individuals with osteoarthritis: A systematic review. Rev Bras Reumatol Engl Ed. 2016;56(6):530-542. Accessed Jun 25, 2019. doi: 10.1016/j.rbre.2016.09.003.

9. Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified parkinson disease rating scale in people with parkinsonism. Phys Ther. 2008;88( 6):733-746. https:/ /academic.oup.com/ptj/article/88/6/733/27423 l 7. Accessed Jun 25, 2019. doi: 10.2522/ptj.20070214.

10. Haley SM, Fragala-Pinkham MA. Interpreting change scores of tests and measures used in physical therapy. Phys Ther. 2006;86(5):735-743. https://academic.oup.com/ptj/article/86/5/735/2857473. Accessed Jun 25, 2019. doi: 10.1093/ptj/86.5.735

11. Raad, Jason, MSIMoore, Jennifer, PT, DHS, NCSIHamby, Julie, SPTJRivadelo, Ryan Lainez, SPTIStraube, Don, PT, PhD, NCS. A briefreview of the activities­specific balance confidence scale in older adults. Arch Phys Med Rehab. 2013;94(7): 1426-1427. https://www.clinicalkey.es/playcontent/1-s2.0-S00039993 l3003663. doi: 10.1016/j.apmr.2013.05.002.

12. Lee C, Fu T, Liu C, Hung C. Psychometric evaluation of the oswestry disability index in patients with chronic low back pain: Factor and mokken analyses. Health

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I \

Qua! Life Out. 2017;15(1):192-7. https://www.ncbi.nlm.nih.gov/pubmed/28974227. doi: 10.l 186/s12955-017-0768-8.

13. Nhlbi.nih.gov. (2019). Calculate Your BMI - Standard BMI Calculator. [online] Available at: https :/ /www.nhlbi.nih.gov/health/ educational/lose_ wt/BMI/bmicalc.htm [Accessed 25 Jun. 2019].

14. St-marys.org. (2019). [ online] Available at: https:/ /www.st­marys.org/assets/pdfs/2017 /back-pain-questionnaire.pdf [ Accessed 25 Jun. 2019].

15. Drayerpt.com. (2019). [online] Available at: https :// drayerpt.com/ content/uploads/2015/10/Balance-Gait-Falls-ABC-Scale. pdf [Accessed 25 Jun. 2019].

16. Steffen T. Activities-Specific Balance Confidence (ABC) Scale. https:/ /pdfs.semanticscholar.org/172a/3dbe594a09108933701 aa3de9c20b4a98206 .pdf. 2012. [Accessed 25 Jun. 2019].

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