The Use Of Postural Reeducation And Strengthening Exercises In The Reversal Of Functional Scoliosis: A Case Report

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University of New England DUNE: DigitalUNE Case Report Papers Physical Therapy Student Papers The Use Of Postural Reeducation And Strengthening Exercises In The Reversal Of Functional Scoliosis:
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University of New England DUNE: DigitalUNE Case Report Papers Physical Therapy Student Papers The Use Of Postural Reeducation And Strengthening Exercises In The Reversal Of Functional Scoliosis: A Case Report Cory Marcoux University of New England Follow this and additional works at: Part of the Physical Therapy Commons 2015 Cory Marcoux Recommended Citation Marcoux, Cory, The Use Of Postural Reeducation And Strengthening Exercises In The Reversal Of Functional Scoliosis: A Case Report (2015). Case Report Papers This Course Paper is brought to you for free and open access by the Physical Therapy Student Papers at DUNE: DigitalUNE. It has been accepted for inclusion in Case Report Papers by an authorized administrator of DUNE: DigitalUNE. For more information, please contact The Use of Postural Reeducation and Strengthening Exercises in the Reversal of Functional Scoliosis: A Case Report 5 Cory Marcoux, BS, SPT C Marcoux, BS, is a DPT student at the University of New England, 716 Stevens Ave. Portland, ME Please address all correspondence to Cory Marcoux at: The patient signed an informed consent allowing the use of medical information for this report and received information on the institution's policies regarding the Health Insurance Portability and Accountability Act The author acknowledges Amy Litterini, PT, DPT, for assistance with case report conceptualization, Theresa Johnson, PT, for supervision and assistance with data collection and conceptualization, and the patient for her cooperation and insight. Abstract: Background and Purpose: There is a multitude of research regarding structural and idiopathic scoliosis, but very minimal literature about non-structural (functional) scoliosis and more importantly, how to treat it. The purpose of this case report was to examine the use of stretching, strengthening, and postural reeducation for a patient who presented with a non-structural scoliosis. Case Description: The patient was a 37-year-old female who underwent a left-sided lumbar discectomy at level L5/S1 following an acute onset of left foot-drop. The patient later presented with severe back pain and spasms from an infection of the disc at the surgical site that resulted in an abnormal protective posturing. The patient was seen for a total of eight weeks and treated with interventions including pain management, postural reeducation, and strengthening exercises in the home health care setting. Outcomes: After the patient s therapy course, she was found to have overall decreased pain from 4/10 to 0/10, a decreased fall risk based on her Tinetti score, improving from 13/28 on initial evaluation to 28/28 at discharge, improved postural control and increased activity tolerance, from walking three minutes with a walker to walking up to 15 minutes without an assistive device. Discussion: The findings suggest that postural reeducation and strengthening exercises may be a viable method of treatment for patients with non-structural scoliosis, leading to neuromuscular changes in the body and maintenance of neutral posture. More investigation should take place to determine if specific interventions are more effective than others. Manuscript Word Count: 2,701 40 Background and Purpose A herniated lumbar disc occurs when the material of the intervertebral disc becomes displaced beyond the intervertebral disc space. According to research by Jordan et al, 1 between one and three percent of individuals have symptomatic lumbar disc herniations, with the majority being between 30 and 50 years of age, and affecting males twice as often as females. Typically, surgical interventions are only considered after a symptomatic period of six weeks. A literature review by Chaudhary et al. 2 found the incidence of surgical site infection after a discectomy to be three percent or lower, however, the incidence increased to as high as twelve percent with the addition of instrumentation. The body has many coping mechanisms to compensate when these infections occur and there is typically an increased amount of pain associated with these infections. Occasionally, when the body senses this increased amount of pain, it may spasm and posture around the pain, causing a non-structural (functional) scoliosis. A non-structural scoliosis is defined as abnormal spinal curvatures that have sufficient mobility, and can therefore resolve with postural change. There is a multitude of research regarding structural and idiopathic scoliosis but very minimal research about what non-structural (functional) scoliosis is and more importantly, how to treat it. By sharing this uncommon case, and the plan of care used to manage it, it will help other clinicians who may come across a similar presentation and perhaps inspire more research in the future if it is deemed necessary. The question as to whether or not there is a correlation between infection and subsequent scoliosis appears to remain unanswered. The purpose of this case report was to document the use of stretching, strengthening, and neuromuscular reeducation on a patient experiencing what presented as a non-structural (functional) scoliosis. Case Description: Written informed consent was obtained from the patient for publication of this case report and a copy of the written consent is available for review. The patient was a 37-year-old female who was a Doctor of Osteopathic Medicine (DO). The patient lived with her very supportive husband, her stepson, and an easily excitable dog in a twostory home with a bedroom on the first floor. The patient was generally healthy overall and she was active in her job, where her duties required significant upper body strength to perform manipulations. She also participated in an exercise regimen, which included yoga and running on a weekly basis. She did have a history of significant anxiety, but otherwise nothing to impede her progression back towards health. This patient underwent a left (L) sided lumbar discectomy at level L5/S1 following an acute onset of L foot drop. The surgery resolved the L foot drop and numbness; however, three weeks post-surgery the patient presented with severe back pain and spasms. She was treated with a dose pack of Medrol but the pain only progressed and started radiating downward into her right (R) hip, posterior leg, and lateral malleolus. The patient had an MRI six and seven weeks post operatively, and only the seven-week MRI showed edema and slight end enhancement of the intervertebral disc between the L5/S1 segments, likely indicating infection. The patient was admitted to the hospital for her diagnosed infection at the L5/S1 vertebral segment and subsequently treated for pain management, antibiotics were initiated, and a PICC line was inserted. The patient was discharged home three days later with her physical therapy (PT) evaluation completed one day after her return home. The patient was referred to PT to increase her functional mobility, decrease her pain, and improve her posture that was affected by spasms and severe pain. The patient s medical and surgical history included a left-sided laminotomy and microdiscectomy, back pain, anxiety, eosinophilic esophagitis, insomnia, neck pain, and a septoplasty. Appendix 1 provides the patient s extensive medication list throughout her episode of care. The patient s prior level of function included running and yoga on a weekly basis. The patient was independent with all activities of daily living (ADL s). At evaluation, the patient was homebound, unable to drive, unable to complete weekly exercises, ambulated with a walker * and required varying levels of assistance for transfers and ADL s. The patient, her caregivers, and PT were in agreement with the established goals to return to complete independence equivalent to her prior level of function. Clinical Impression #1: The patient s primary problem stemmed from an infection at the L5/S1 vertebral junction. She presented with severe back pain and muscle spasms that altered her posture. These impairments led to limitations with walking, running, ascending and descending stairs, sleeping, bed mobility, cooking, cleaning, and driving. The patient was also unable to work or participate in her routine yoga classes and running. She was unable to perform work-related tasks due to the high physical demands of her profession. The patient was very physically active and healthy overall. Due to the patient s experience as a DO, she was very knowledgeable about the medical treatment she was receiving, as well as her diagnosis. She also had a very supportive and helpful family. Some differential diagnoses that were possible included idiopathic scoliosis, posturing due to pain, or a reaction of the somato-somatic reflex. * Invacare Front Wheeled Walker, Model #6291-JRF5, 1 Invacare Way Elyria, OH The plan for the examination was to assess whether the patient s posture was fixed or flexible, to examine what positions made the client s pain better or worse, and to assess her strength functionally as well as her bed mobility. Specific tests to gather data included the Tinetti Performance Oriented Mobility Assessment (POMA) to assess balance and fall risk, the Numeric Ten Point Pain Scale, and goniometric measurements. This patient was selected for her unique presentation due to the fact that neither the author nor the supervising clinical instructor had ever seen this particular diagnosis. This patient was appropriate for a case report and further analysis due to her atypical course of treatment, fluctuating medical stability due to her infection, and the homebound limitations on her intervention approaches. Examination: The tests and measures that were performed at the patient s initial evaluation and at discharge to track progress can be found in Table 1. Gait analysis and bed mobility were observed functionally. Overall, her systems review revealed that her musculoskeletal system and neuromuscular system were impaired. Please see Appendix 2 for Systems Review data. Goniometric measurements of the patient s resting, standing posture were taken. The intraclass correlation coefficients (ICC) for goniometric measurements ranged from 0.88 to 0.94 and the test-retest reliability from 0.82 to 0.90, dependent on which joint was being measured. 3 The axis was placed on the patient s surgical incision scar over the L5/S1 spinal segment, the movable arm in line with the spinous process of C7, and the stable arm perpendicular to the floor. The POMA, a commonly utilized test to assess a patient s balance, consists of both a gait and balance portion, which assesses both static and dynamic balance. Scores indicate a low fall risk ( 24), a moderate fall risk (19-23), or a high fall risk ( 18). There is an excellent correlation between the POMA and the Activities Specific Balance Confidence Scale (r = ) and an excellent test retest reliability (r = 0.96). 4,5 Lastly, the Numeric Ten Point Pain Scale (NPRS) was used to obtain a subjective, verbal assessment of the patient s pain level during each visit. It uses a zero to ten scale, with zero indicating no pain and ten indicating the worst possible pain. This scale has excellent interrater reliability with 100% agreement between two raters scoring the zero to ten point NPRS. There is also excellent correlation between the NPRS and Verbal Descriptor Scale (r = 0.88). 6 Please see Appendix 3 for other correlating values. Clinical Impression #2 Evaluation: The examination confirmed the initial impression that the client had posturing that was abnormal due to increased pain and her attempt to avoid future spasms, but the posturing was flexible and correctable. The client took excess time to move into and out of bed, transfer to standing to and from sitting, as well as for general mobility. The intensity of the client s pain limited her from participating in all usual activities of daily living (ADL s) such as cooking, cleaning, exercise, and her moderately active job as a Doctor of Osteopathic Medicine. The patient presented with pain levels ranging from 4/10 to 10/10 on the NPRS. The patient s bed mobility and transfer abilities were decreased, she had an altered gait pattern with a rolling walker (RW) at supervision level, an abnormal trunk flexion and right trunk rotation posture, and needed assistance on stairs. Based on the patient s POMA score of 13/28, she was a high fall risk. The patient s activity limitations included walking, running, ascending and descending stairs, sleeping, bed mobility, specifically rolling and getting into and out of bed, cooking, cleaning, and driving. The patient s participation restrictions included the inability to work or participate in her yoga class. The patient continued to be appropriate for the case because she demonstrated that she had the flexibility to move into a normal posture and research shows that appropriate strengthening and stretching can improve abnormal posturing. 7 Physical Therapy Diagnosis (ICD-10): The patient s diagnosis per the nursing admission was an unspecified disc disorder of the lumbar region (722.93). The physical therapy diagnosis, however, was abnormal posturing (781.92). Prognosis: The patient s prognosis for improvement, barring gaining control of her infection, was excellent. Research outcomes by Estadt 7 demonstrated that strength training is recommended to restore muscle function in patients after spinal surgery. The student physical therapist (SPT) believed that the main cause of pain was due to the patient s infection, which led to the abnormal posturing. Once the antibiotics were able to get the infection under control, the SPT treated the subsequent back and core strength deficits that developed from inactivity due to pain. The patient was an overall healthy and motivated individual. One comorbidity that the SPT thought might negatively affect the patient s prognosis was her anxiety. The SPT believed that this might have caused excess fear to move and participate willingly in the treatment sessions. At that time, there were no additional referrals or plans for additional testing. Plan of Care: The initial plan was to start with gentle stretches until the patient s pain was manageable. As she improved, the plan was to introduce neuromuscular reeducation techniques to allow her body to relearn correct posture using feedback, such as mirrors. As this became more natural, the SPT incorporated strengthening to allow her returning range of motion to be more easily maintained. Please refer to Table 2 for short-term and long-term goals. Interventions Coordination, Communication, Documentation Coordination occurred with the other discipline in the home, which was nursing, to be updated on new medications and infection status. Communication occurred with the patient s doctor and surgeon to inform them of the plan of care and to get their permission and further recommendations. Patient/Client/Family Related Instruction The patient was provided instruction that included the importance of an ongoing fitness program, her impairments regarding her infection, her plan of care, psychosocial influences such as pain coping, and transitioning to outpatient physical therapy for work hardening to return to her occupation. Procedural Interventions The patient was provided with postural, gait, and balance training which included postural awareness, postural control training, postural stabilization activities, neuromuscular reeducation, training of specific gait components, and motor control retraining for balance with correct posture. The patient was provided therapeutic exercise that included endurance conditioning through gait training and increasing workload over time, flexibility exercises via stretching, relaxation techniques and breathing strategies, as well as resistive and isometric strengthening exercises. The patient s orders for physical therapy at the start of care were for an initial evaluation, visits three times a week for three weeks, two times a week for four weeks, and two visits as needed for additional education, exercise training, or if an unforeseen change in status occurred. The rationale for this frequency and duration was to taper visits to allow for increased stretching and retraining at the beginning to halt any further postural changes and to correct the patient s posture. The patient had very good carryover of learning. As she developed a sufficient routine and her posture was improving, she required less skilled PT and only needed further strengthening in her correct posture. In addition, she required balance reeducation and increased activity tolerance, which required less visits per week. Overall, the chronology was to start with stretches and mild postural retraining in pain-free ranges until the patient s infection was managed. As the patient acquired correct posture to neutral, strengthening exercises were added in her new ranges to reinforce it. As the patient required less cues and was able to get into neutral posture on her own without feedback, endurance training was initiated in the new range to get the patient ready to return to work. Hawes 8 reports that postural imbalance that provokes pain can cause structural scoliosis that is reversible when postural balance is restored. Using this information and theoretical argument, the author concluded that retraining the patient s perception of correct posture to anatomic neutral and then enhancing that with strengthening exercises in the opposite direction of the spinal curvatures would normalize the patient s posture to neutral. Occasionally, primarily in the beginning of the episode of care, the patient was having increased spasms and pain due to her infection not yet being adequately managed, as there was still testing being done on which antibiotics she was resistant to. When this occurred, the plans for the day were adjusted to stretches to decrease pain and minimal postural retraining. Other than these few minor setbacks, we were able to maintain the predicted progression of activities. Please refer to Table 3 for a summary of daily visit interventions and parameters. 226 Outcomes The patient received 15 total visits, for an average of 45 minutes each visit, including her Start of Care and Discharge. The initial orders for physical therapy were for an evaluation, three times a week for three weeks, two times a week for four weeks, and two visits as needed. Due to some cancellations for other medical appointments, the patient was seen for her evaluation, three times a week for the first week, two times a week for the next two weeks, one time a week for the fourth week, two times a week for the fifth week, then one time a week for the last three weeks, plus discharge. The total length of treatment was eight weeks in duration. At discharge, the patient s pain, resting posture, and balance had improved and her fall risk was reduced. Based on the POMA score, her classification changed from a high to a low fall risk. Her pain, though still occasionally with 10/10 spasms as rated on the NPRS, was significantly less often, for shorter duration, and at times she reported no pain. At evaluation, her spasms were multiple times a day and lasted up to ten minutes. At discharge, she had only had one 10/10 spasm over the previous three weeks that lasted less than one second. The client was independent with all household ADL s and ambulating without an assistive device for bouts of 15 minutes. The client was independent with her home exercise program given a pictorial handout with correct parameters. Discussion Estadt 7 reported that up to 3% of patients undergoing a discectomy result in an infection, leading to unwanted symptoms. The patient in this case followed a slightly atypical course of treatment due to the seemingly slow process of determining the correct antibiotic. After the infection was better controlled, the interventions used seemed to show positive results for this patient. The ma
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