Effects of an Aquatic Therapy Program EFFECT OF AN INITIAL ... · Aquatic therapy is a good initial rehabilitation intervention for THA patients. Water offers unique properties that

Effects of an Aquatic Therapy Program

EFFECT OF AN INITIAL AQUATIC THERAPY PROGRAM WITH

PROGRESSION TO LAND PROGRAM FOR ADULT FOLLOWING THREE

TOTAL HIP ARTHROPLASTY REVISIONS

________________________________________________________________

A Case Report

Presented to

The Faculty of the College of Health Professions and Social Work

Florida Gulf Coast University

Submitted in partial fulfillment of the requirements for the degree of

Doctor of Science in Physical therapy

________________________________________________________________

By

Kristin Mortenson

2015


APPROVAL SHEET

This Case Report is submitted in partial fulfillment of the requirements for the

degree of

Doctor of Physical Therapy

__________________________________________

Kristin Mortenson

Approved: May 2015

___________________________________________

Kathleen Swanick, DPT, MS, OCS

Committee Chair/Advisor

____________________________________________

Stephen Black, DS.c, MeD, PT, ATC/L, NSCA-CPT

Committee Member

The final copy of this Case Report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above-mentioned discipline.


Acknowledgements

I would like to thank several people for assisting in the development and final

completion of this scholarly paper. Firstly, to a wonderful and knowledgeable

committee, specifically Dr. Kathleen Swanick and Dr. Stephen Black, who

provided me with great insight and inspiration as I began to narrow the focus of

my Independent Study, and with finalizing this paper, I sincerely thank you. I also

would like to thank Gaynell Anderson and Andy Hovanec who were the case

patients primary PT’s they provided all the information for the case and

encouragement to pursue the idea for the paper. Finally, the greatest amount of

appreciation and thanks goes to Todd Mortenson, my husband, Logan

Mortenson, Colin Mortenson, and Justin Mortenson, my sons for always being

there for me, encouraging me to pursue my dreams and for putting up with me as

I underwent this great undertaking in the development of this paper. I cannot

thank you enough for providing me with the love and support I needed to achieve

my dreams.


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Table of Contents

Abstract 3

Background and Purpose 5

Review of Literature 10

Case Description 11

Test and Measures 12

Differential Diagnosis Screening 12

Observation 12

Cardiovascular Screening 13

Neurological Testing 13

Strength Testing 14

Active Range of Motion 14

Palpation 15

Pain intensity Level 15

Functional Screen 16

Special Tests – Trendelenberg Test 16

Evaluation 17

Interventions 18

Results 20

Discussion 22

Study Limitations 24

Conclusions 25

References 26


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APPENDIX A – Home Exercise Program 31

APPENDIX B – Interventions 32


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Abstract

Background and Purpose: According to the Centers for Disease Control

and Prevention (CDC) Osteoarthritis (OA) is the most common form of arthritis, it

affects 33.6% of adults aged 65 and older an estimated 26.9 million adults in the

US in 2005, which is up from 21 million in 1990. Eighty-eight out of ten thousand

of these patients will suffer from hip OA leading to hospitalizations and potentially

hip replacement procedures. Patients suffering from OA who have opted to have

a total hip replacement may present with barriers to conventional land based

therapy due to inability to bear full weight on the affected extremity. Evidence

has shown that aquatic therapy is a good initial intervention for THA patients.

The unique qualities of water make it well matched for patients who are unable to

exercise on land, or find land-based activity too demanding. Aquatic therapy

provides an alternative strategy (Batterham, Heywood & Keating, 2011). Case

Description: The purpose of this case study is to describe the evaluation,

intervention, and outcome of a patient following a THA with 3 subsequent

revision surgeries who successfully participated in an aquatic therapy program.

The patient is a 54-year-old male referred to physical therapy following a THA

and 3 revision surgeries resulting in impaired gait positive Trendelenberg,

impaired balance, and overall decrease in functional mobility and subjective pain

stated 10/10 at worst and average of 6/10. The aquatic therapy sessions were

three times per week for the initial 4 weeks then the patient was progressed to

land based therapy for an additional 8 weeks. Results: The aquatic program

included progressive strengthening, gait training, and balance activities. After


4

three weeks, the patient reported a significant decrease in subjective pain levels

and demonstrated increased static standing balance with improved hip

stabilization. He also demonstrated improved strength, increased weight bearing

tolerance, and increased functional mobility. Demonstrated by manual muscle

testing, improved activities of daily living, and subjective increased functional

mobility. Conclusions: This case report advocates that aquatic therapy may be

valuable for patients with impaired weight bearing tolerance that would not be

able to progress with land therapy or are unable to tolerate land activities...


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Background and Purpose

Total hip arthroplasty (THA) procedures are one of the most common and

successful orthopedic surgeries for patients suffering from osteoarthritis (Passias

& Bono 2006). Approximately 1-3% of the senior adult population will elect to

have a THA at some point making it one of the most prevalent elective

orthopedic surgeries (Passias & Bono 2006). Most frequently reported

complications following THA include dislocation, pulmonary embolism and deep

infection. These complications are highest immediately following surgery

however; they continue to rise over the first three months post surgery (Phillips et

al., 2003). The economic burden of arthroplasty revision has yet to be

systematically studied however it is considered to be substantial and if the

incidence of revision surgeries is not controlled it will likely continue to increase

(Ong et al., 2006).

Revision surgery can be defined as a procedure in which the exchange of

the acetabular components and/or liner, or the femoral or modular head, or any

combination thereof is involved (Wetters, et.al. 2012). Dislocation is said to be

the most frequent complication following revision of a total hip. A study was done

in 2012 to determine the risk factors involved in dislocation. Possible risk factors

were divided between patient factors and surgery specific factors. Patient factors

included age, sex, BMI, the femoral and acetabular classification, history of

instability prior to revision, number of hip surgeries, and abductor integrity.

Procedure-specific factors included cup diameter of the acetabular, femoral head

diameter, head to cup ratio, length of the femoral neck, use of constrained or


6

elevated rim liner as well as the type of procedure performed (Wetters et.al.,

2012). Results showed that femoral head size appeared to cause the highest risk

for dislocation along with trochanter nonunion/abductor deficiency, and previous

revision surgeries. Further analysis demonstrated that for patients receiving the

anterior surgical approach BMI was the only risk factor for dislocation (Wetters,

et.al., 2012).

The revision of THA poses a challenge for even the greatest qualified

surgeon. Common indications for THA revision surgeries include loosening of the

implant resulting in pain, infection in the joint, or fracture (Drake, Ace & Maale,

2002). Frequent dislocations often contradict the overall benefit of THA. A

recent study from Hip International showed dislocation rates with the posterior

approach to be 4.1%, while the transgluteal approach was 3.4% (Rogers, Blom,

Barnett, Karantana, & Bannister, 2009). There are many revision strategy

procedures currently being performed.

However, regardless of the method

successful surgery for recurrent dislocation

cannot be guaranteed. Outcomes will

depend on the initial approach used and

the direction in which the dislocation

occurred (Rogers et al., 2009).

There are two standard surgical approaches that are currently used for

THA procedures they include posterolateral approach (P-L) and the anterolateral

approach (A-L) (Madsen et.al. 2004). The P-L approach is the most common

Figure 1 - Posterior Lateral

Approach


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approach. This approach affects the posterior

joint capsule the gluteus maximus, which is

separated in line with the fibers, and the

external rotator group (figure 1). The

external rotators (ER) are principally

responsible for stability laterally and

posteriorly. The ER’s are bisected near the

insertion. This method subsequently spares

the gluteus medius and vastus lateralis

muscles (Madsen et.al., 2004). Another

benefit is that a trochanteric osteotomy is

not performed. The main disadvantage in this approach is the high incidence of

joint instability resulting in dislocation or subluxation of the hip (Kisner & Colby,

2007), (Madsen et.al., 2004). Due to the proximity of the sciatic nerve to the

surgical field using the posterolateral approach there is an increased potential of

damage to the sciatic nerve (Lohana, Woodnutt, & Boyce, 2010). he A-L

approach typically affects gluteus minimus, gluteus medius, tensor fasciae latae

and vastus lateralis muscle function. Much of the torque necessary for hip

abduction and pelvic obliquity control during normal gait comes from the gluteus

medius and minimus (Madsen et.al., 2004). The A-L approach has been revealed

to yield more positive Trendelenburg signs (figure 2) (Madsen et. al., 2004). The

anterior lateral approach has gained in popularity in some populations due to the

decreased incidence of dislocations (Palan, Beard, Murray, Andrews & Nolan,

Figure 2 - Positive

Trendelenberg sign


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2008). The advantages to the A-L approach include a reduction in leg

discrepancy length, decreased sciatic nerve damage, and dislocation due to

preservation of the posterior hip musculature (Pour, Parvizi, & Rothman, 2005).

In more recent years minimally invasive hip replacement procedure have been

introduced with some controversy in respect to the benefits. However, studies

have shown that these procedures can improve the immediate outcomes in

regard to decreased blood loss, shorter hospitalization and a faster recovery for

the patient (Pour et.al., 2005).

Physical therapy following THA is a significant component in improving

overall functional outcomes of patients. In the acute care phase physical therapy

may decrease the cost of care and accelerate the time to discharge, thereby

decreasing the length of stay in the hospital (Freburger, 2000). Numerous

studies have been conducted to determine discharge destination. One study

done in 2001 looked at 541 patients following THA, total knee replacement or hip

fracture. The research reviewed clinical outcomes and reimbursement for care

either at an inpatient facility (IPR) or skilled nursing facility (SNF). The

researchers determined that patients admitted to an IPR had shorter lengths of

stay and substantially better functional outcomes than those who were

discharged to SNF. However, the downside to the IPR was that it was

significantly more expensive that the SNF (Herbold, Bonistall & Walsh, 2001,

2011). Regardless of the location of discharge for rehabilitation or the surgical

approach used it is clear that patients require skilled rehabilitation following THA

to regain functional abilities.


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The principal goals of physical therapy after THA are to reestablish

function, reduce pain, and increase muscle control in order to return the patient

to his/her prior level of function (O’Sullivan & Schmitz, 2007). Standard initial

physical interventions include therapeutic exercise, gait and transfer training and

ADL instruction and precaution education. A targeted strengthening program in

the postoperative rehabilitation period has shown to be effective in improving

muscle atrophy and weakness in the affected lower extremity (Galea et.al.,

2008). In order to improve gait and decrease pelvic drop during the swing phase

of gait the rehabilitation should include hip abduction specific strengthening

(Madsen et.al., 2004).

Aquatic therapy is a good initial rehabilitation intervention for THA

patients. Water offers unique properties that make it well matched for

rehabilitation of a variety of disorders. These properties include: buoyancy,

resistance, hydrostatic pressure, specific heat, and thermal conductivity

(Cameron, M.H., 2009). The buoyancy effects in particular allows for decreased

weight bearing, off loading joint compressive forces and relieving stress on

connective tissues which provides benefits to patients in the early stages of

rehabilitation and provides gradual transition from non weight bearing to full

weight bearing. When patients are unable to exercise on land, or find land based

activities too demanding, aquatic therapy programs provide an alternative

strategy (Batterham, Heywood & Keating, 2011). Recent evidence shows there is

an increase in skin blood flow to the affected tissues due to the moisture content


10

of the heat of the water as it interacts with the tissue leading to faster healing

(Petrofsky et.al., 2010).

Review of Literature

A review of the literature demonstrates that aquatic therapy has shown to

be an effective treatment for patients with a variety of conditions such as

osteoarthritis, balance deficits, musculoskeletal conditions, and post-surgical joint

replacement rehabilitation. Many researchers have sought to show that there is a

significant benefit to aquatic based therapy over land-based therapies.

However, most research has been unable to show a difference between the two

interventions.

Studies reviewed comparing aquatic therapy to land based therapy using

outcome measures such as pain, flexibility, and strength did not exhibit

statistically significant difference between the therapies. However, aquatic

therapy was found to have fewer adverse effects on patients (Lund et al., 2008).

One study used a two group randomized control. They chose 38 subjects from a

local community and assigned them to either a 12-week aquatic program, a land

based therapy group, or a non-exercise control condition. The results showed

that the aquatic exercise had statistically significant improvement in knee

flexibility, strength, and aerobic fitness. However, it did not show improvements in

function or pain (Wang, Belza, Thompson, Whitney & Bennett, 2006).

Another study showed that both land and aquatic therapies showed

improvements in quality of life, knee range of motion, and reducing pain.

However, aquatic therapy was not superior to land therapy when it came to


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reducing pain (Wang et al. 2011). A third study however, showed that even

though there were no clinical benefits detected when compared with the control

group, there were significantly fewer adverse effects when compared with the

land therapy group (Lund et al., 2008). Aquatic therapy appears to provide short-

term benefits for patients with knee of hip OA suggesting it as a viable initial

treatment option particularly with patients with severe disease (Hammer, Naylor,

Crosbie & Russell, 2009). Aquatic programs are expensive and potentially labor

intensive. However, the benefits to the patients, and potential for business

diversification can make an aquatic program a successful one.

Case Description

The case patient was a 54-year-old male referred to outpatient physical

therapy five months after undergoing a third revision of his total hip arthroplasty

secondary to anterior dislocation. Following surgery patient was non-weight

bearing for 2 month. Patient reports recent MRI of spine showing signs of lumbar

stenosis. Prior to surgery patient was independent with ambulation, able to work

full time as a financial planner, and golf without any functional limitations pain

free. Patient presented with a chief complaint of inability to ambulate

independently without crutches. Since returning to weight bearing he reports

bilateral buttock and hamstring pain 6/10, which is aggravated with sit to stand

transfers and walking. Alleviating factors include the use of pain medication, and

cold pack as per patients report. He also complains of left plantar foot

numbness, which occurs intermittently with sitting and is alleviated with walking.

Patient has returned to work progressively working part time as tolerated.


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Specific occupational requirements as a financial planner include long durations

of sitting and standing. He is independent with self-care utilizing adaptive

equipment for showering. He requires a modified sitting position for dressing and

needs assistance for don/doff socks and shoes. Past medical history includes

spinal stenosis and recent pulmonary embolism. Patient is currently taking

Gabapentin for peripheral neuropathy, tramadol for pain and Xarelto for

pulmonary embolism.

Tests and Measures

Differential Diagnosis Screening

The initial examination included a differential diagnosis consistent with

clinical practice guidelines. A system review was completed including screening

of the cardiopulmonary, neurological and integumentary systems. The screening

was found to be unremarkable for any systemic pathology. The patient was

considered appropriate for physical therapy.

Observation

Following the subjective interview portion of the initial examination

the physical exam was started with a postural assessment including sitting,

standing posture and gait analysis. Patient showed both sitting and standing

postures to be unremarkable. Gait analysis showed the patient ambulated with

an antalgic gait utilizing bilateral crutches demonstrating an alternating gait

pattern. During the initial contact phase of gait the patient displayed right-sided

foot drop. Initial contact also called heel strike occurs when the first limb

contacts the ground. Normal initial contact is with a heel strike however in an


13

abnormal gait the entire foot may initially make the first contact. Dorsiflexors

muscles weakness, peroneal neuropathy, or a nerve root lesion at L4 can all lead

to foot drop (Magee, 2008). The patients BMI was found to be 31.19 (Obese

Class 1). According to the Center for Disease Control and Prevention anyone

who is overweight is at higher risk for other conditions such as high LDL

cholesterol, high blood pressure and diabetes (Center for Disease Control,

05/04/2011). Also, this puts the patient at risk for dislocation (Wetters, et.al.,

2012).

Cardiovascular Screening

Baseline vital signs were taken at the initial exam. Blood Pressure was

assessed in the sitting position back supported and arm supported at the level of

the heart. It was 128/82 this recording falls within the normal range for adults.

The normal range for adults is systolic 110-130 diastolic 80-90 (Magee, 2008).

Neurological Testing

Bilateral muscle deep tendon reflexes were tested at the patella, tibialis

tendon, and Achilles tendon. The patella and Achilles were rated 2+ (normal)

and the tibialis was diminished, rated 1+. Reflexes are graded on a scale from 0

no response to 4+ being hyperactive. Normal deep tendon reflexes are 2+

(O’Sullivan & Schmitz, 2007). Sensation was assessed using light touch over the

lower extremity dermatomal distribution and found to be intact, however, the

patient complained of intermittent left plantar foot numbness.


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Strength Testing

Manual muscle testing was performed to assess gross strength deficits in

the lower extremities. Manual muscle testing is subjective therefore it is accepted

that for conventional reliability the examiner should adhere to the same

procedure for each test (Hislop & Montgomery, 2007). The 0-5 rating scale was

used. Initial and follow up findings are provided in Table 1.

Table 1 - Manual Muscle Testing

Table 1 -Strength Initial Exam Discharge

Right Lower Extremity

Right Lower Extremity

Hip Abduction 2+/5 4/5

Hip Flexion 3-/5 4/5

Hip External Rotation 3-/5 4/5

Knee Flexion 3/5 4+/5

Knee Extension 3/5 4+/5

Dorsiflexion 3-/5 5/5

Platarflexion 4/5 5/5

Gr. Toe Extension 3-/5 5/5

Active Range of Motion

Flexibility of the hamstring muscles was tested by performing the straight

leg raise (SLR). A positive SLR done unilaterally is a sign of possible nerve

entrapment. The SLR can also be performed bilaterally one leg at a time to

assess flexibility and extensibility of the hamstrings as compared bilaterally.

When performing the test the patient’s leg is passively lifted off the table with

knee maintaining full extension and hips remain on the table. Test results for the


15

case patient we 90 degrees bilaterally, therefore showing no soft tissue limitation.

Dorsiflexion was measured using goniometry and found to be 0 bilaterally.

Palpation

Fascia restrictions were found at the thoracolumbar junction. Tenderness

was discovered at spinal segments of L5-S1, and at the lateral insertion of the

right hamstring. The patient also noted aching over the posterior lower

extremities with a stabbing pain along the lateral border of bilateral thigh and

legs. Patients also noted some numbness over the left anterior thigh. (Figure 3)

Figure 3 – Palpation chart

Pain intensity level

Pain intensity was quantified using a 10-mm visual analogue scale (VAS).

The patient reported a level of 10 at worst, and on average 6 occurring at mid

range squat during sit to stand transfer Figure 4.


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Figure 4 – Pain Rating Scale

Functional screening

The patient works as a financial planner but has been unable to return to

work full time since the surgery. Patient is unable to ambulate independently

without bilateral crutches. Patient has difficulty transferring from sit to stand

independently, requiring the use of his upper extremities to initiate movement.

Patient has adapted his activities of daily living and self care by utilizing adaptive

equipment for showering, dressing and don/doff socks and shoes. Patient’s prior

level of function included working full time, golfing with no functional limitations

and pain free. No functional outcome measures were taken at initial examination.

A recent study showed that 50% of physical therapists do not use functional

outcome measure despite much development and testing of its effectiveness

(Jette, Halbert, Iverson, Miceli & Shah, 2009).

Special Tests - Trendelenberg Test

The Trendelenberg sign (Figure 2) is a respected test used to assess the

external rotators of the hip. (Asayama, I., Naito, M., Fujisawa, M., & Kambe, T.,

2002). A positive Trendelenburg sign accompanies gait abnormalities. The test

can be used to determine the condition of the mechanics of hip function. In many

patients with hip dysfunction the pelvis on the non-stance side moves downward

beneath the level of the stance side in comparison to the severity of the abductor


17

dysfunction (Asayama, et. al., 2002). The test when used to predict a tear of the

gluteus medius is neither sensitive nor specific, however the likelihood ratio is fair

(Cook & Hegedus, 2013). The case patient displayed a positive right

Trendelenberg sign when tested at the initial examination the patient was unable

to perform the single leg stance. The patient’s left side demonstrated hip

instability; patient was able to stand for 2 seconds on the left side.

Evaluation

Findings from the initial examination, the patient in this case report

presented with a primary chief complaint of the inability to ambulate

independently without the use of bilateral crutches. Aquatic therapy decreases

axial loading of the spine and peripheral joints through the effects of buoyancy.

By using the unique properties of water rehabilitation program coupling the

aquatic setting with land-based exercises will provide the patient the desired

outcome of independent ambulation and reduced pain.

Prior to the initiation of any aquatic program it is imperative to question the

patient about potential contraindications to aquatic therapy (Table 2). Preferred

practice pattern: Musculoskeletal H: Impaired joint mobility, motor function,

muscle performance, and ROM associated with joint arthroplasty. The

rehabilitative prognosis considered good potential to reach the established goals.


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Table 2 – Contraindications for Aquatic Therapy

Contraindications for Aquatic Therapy

• Fever

• Incontinence of bowel

• Uncovered open wounds, incisions, or skin lesions

• Blistering

• Boils that have the potential to rupture soon

• Any communicable disease

• Skin infections

• Uncontrolled seizures

• Untreated Cardiac conditions

• Intolerance to water pressure, impaired vital capacity

• Acute lung infection

• Catheter or other lines that cannot be clamped off, or covered

• Tracheotomies

• No internal protection during the menstrual cycle

• Excessively high or excessively low blood pressure

• An extreme fear of water

• Patients that show an inappropriate or disruptive behavior that is uncontrolled

Interventions

A plan of care was established for three times per week for 4 weeks. At

the re-evaluation additional visits were recommended. Aquatic sessions were

introduced initially followed by land-based therapy. Early goals included reduction

of swelling reduce pain, offload the joints and facilitate comfortable correct

biomechanical ROM training. According to a study with 71 subjects randomly

chosen for a six-week aquatic therapy program the results showed decreased

pain and joint stiffness, greater physical function and increased hip strength

(Hinman & Heywood, 2007). The water temperature in the pool was maintained

at approximately 90 degrees. Research shows that aquatic exercise can be

performed in a wide range of temperatures however; warmer temperatures

appear to be more favorable for nonswimming activities (Becker & Cole, 2003).


19

According to the American Arthritis foundation water temperatures between 83

and 92 degrees are ideal and are a safe range for patients with arthritis and up to

100 degrees for patients with cardiovascular concerns (Arthritis Foundation). The

pool depth was up to the patient’s xiphoid thus providing joint off loading of

approximately 67%. The sessions were guided by a physical therapist with

experience in aquatic therapy.

Aquatic therapy interventions were initiated at the second visit. The

aquatic portion of the rehabilitation focused on decreasing pain and introducing

exercises that improved hip girdle strength, muscle control, core stabilization and

gait training. Each session consisted of a 5-minute warm-up period that included

walking forward and backward. Aquatic walking provides resistance as the

patient walks through the water. Studies have shown that walking in the water

burns more calories than water jogging (Melillo, 1991). Patient was instructed to

roll from heel to toe going forward and toe to heel moving backward to engage

the pelvic and core stabilizing musculature. Backward walking as compared to

forward walking can result in significantly higher muscle activation (Masumoto &

Mercer, 2008). Side stepping and heel raises were also included in the aquatic

program. Patient was given a home exercise program consisting of land based

supine exercises including bridging, supine marching and lumbar rotation

exercises. (Appendix A) As the patient progressed balance activities were also

incorporated. A study done in 2000 compared 24 women with lower extremity

arthritis either Rheumatoid or osteoarthritis. Subjects were randomly assigned to

an aquatic therapy group or a control group. Pretest and posttests were done to


20

assess postural sway before and after a six-week program. Results showed that

the aquatic therapy group significantly reduced lateral sway and total sway

scores. Scores were higher under the no-vision condition than under the vision

condition in each group for both sessions (Suomi & Koceja 2000). Improving

balance has also been linked to improved psychological benefits (Colcombe &

Kramer, 2003). Balance activities included progression of narrow stance coupled

with upper extremity motions to challenge the core stabilizers.

At 3 weeks the patients reported subjective pain levels had significantly

decreased with patient also reporting that he felt much stronger since starting PT.

Land-based therapy began with therapeutic exercise including upright bike, total

gym mini squats, and heel raises, and hamstring curls and 4-inch step-ups

forward. Verbal cueing was given to engage gluteal and quadriceps muscles.

Exercises were progressed to include standing marches, sidestepping at cables;

hip abduction resistance training, marching on blue foam, and outside ambulation

among other exercises and progressed accordingly as patient strength

progressed (Appendix B).

Results

Patient adherence was 100% with the patient completing 25 visits none

missed. Upon discharge patient reported only occasional soreness in posterior

thigh mainly in the morning. Patient’s strength in lower extremities has improved

significantly right hip abduction strength improved by 67%, hip flexion 44%,

extension 44%, knee flexion 40%, extension 40%. Dorsiflexion improved by 55%

and great toe extension improved by 55% (Table 3). Patient reports ambulating


21

independently without a cane 100% of the time this is progressed from the

patient needing to use bilateral crutches to ambulate. Sit to stand transfers have

improved to maximum level of function independently without upper extremity

use. Activities of daily living and occupational activities have improved to 90% of

prior level of function. Patient demonstrated increased walking tolerance and the

ability to walk and stand for longer periods of time before fatigue. Trendelenberg

sign is negative bilaterally patients able to perform single leg stance right side for

8 seconds, left side for 14 seconds. Patient was discharged to the land and

aquatic HEP with excellent adherence.

Initial Exam

Discharge

Table 3 - Strength Comparison of Right Lower Extremity Initial exam to Discharge


22

Discussion

Initiation of the rehabilitation program with aquatic therapy allowed the

patient to fully benefit from the therapeutic effects of buoyancy, hydrostatic

pressure and viscosity. Buoyancy decreases weight bearing and joint

compression forces along with decreasing the risk or fear of falling. The property

of hydrostatic pressure supports the resolution of edema, helps to

counterbalance blood pooling in the lower extremities, and aids in the

strengthening of the muscles of inspiration and assists with exhalation. Viscosity

provides resistance to movement and increases with speed. This property gives

the patient more response time to counteract for balance or equilibrium deficits

(Schoedinger, 2002).

The findings in this case report indicate that a 12-week program

combining aquatic and land based therapy is beneficial in improving pain levels,

strength, mobility, and functional outcomes. Objective measurements such as

increased strength ratings, increased single leg stance time and negative

Trendelenberg sign show evidence of significant improvement.

Upon discharge the patient reported decreased subjective pain response

to mobility at 1/10, as compared to levels reported at the initial evaluation when

the patient reported average pain to be 6/10 and 10/10 at its worst. A study by

Hinman, Heywood, and Day found that compared with the control group which

received no therapy, a 6-week program of aquatic physical therapy resulted in

significantly less pain. Although, it is undistinguishable whether the benefits were


23

causal to effects of the intervention or a placebo response (Hinman, Heywood &

Day, 2007).

In the 3-month time period the patient showed increased strength

measures in both lower extremities. The patient went from a 2+/5 manual muscle

testing in his right hip abduction to a 4/5 rating which is considered “good” the

improvement is 67% from the initial evaluation. It has been theorized that the

primary function of the gluteus minimus and medius is to act as the prime femoral

head and pelvis stabilizer (Levangie & Norkin, 2011). The patient’s gait was also

improved. At the initial evaluation they patient was unable to ambulate

independently without bilateral crutches this was due to extreme hip abductor

muscle weakness causing the pelvis to drop to the unsupported side. Prolonged

gait abnormalities can lead to knee, ankle and foot problems as well (Levangie &

Norkin, 2011).

The case patient attending all of his scheduled visits demonstrated

adherence in the program. A study by Resnick and Spellbring showed that there

are 6 main factors that affect adherence in adults to improve rehabilitation. The 6

factors are 1) beliefs about exercise; 2) benefits of exercise; 3) past experiences

with exercise; 4) goals; 5) personality; and 6) unpleasant sensations associated

with exercise (2000). To promote our patient’s adherence we discussed the

benefits of exercise. He was a believer in exercise and his goal was to improve

his lower body strength to be able to return to his previous level of function. Our

case patient also loved to play golf, so we came up with an exercise program that

incorporated lower extremity strengthening and activities that would enhance his


24

golf game. We used our client’s goals to tailor an exercise program that was

specific for him. The case patient also has a great social support network with his

family, which helped to enhance his rehabilitation.

Study Limitations

Although this case study obtained relevant objective findings there were

some limitations to be considered when interpreting the results and making

assumptions. The study was lacking the use of outcome measures. A study was

done in 2009 to determine the extent of using standardized outcome measures in

outpatient clinics and the opinions regarding the benefits and difficulties of their

use by therapists (Jette et.al., 2009). The researchers found that more than 50%

of the respondents in the study reported that they do not use the standard

outcome measures. The most common response was that they were not familiar

with the measures or that they did not feel they had sufficient time to complete

the testing (Jette et. al., 2009).

Self-reporting outcome measures such as the Lower Extremity Functional

Scale (LEFS) can be a convenient way to track improvement. The patient is

asked a series of questions regarding their activities of daily living and the degree

of difficulty. Patients rate the difficulty on a scale of 0-4 with 4 being no difficulty

and 0 being extremely difficult. Scores are figured the higher the score the better

the function of the patient. Internal reliability of the LEFS test is excellent, and

validity is comparable to the SF-36. The limitations in using self-reporting

questionnaires to measure the outcomes include self-reporting may be

inaccurate if the patient does not fully understand the questions. As well as


25

adherence and subjective information may be over-estimated or under-

estimated. The case patient likely would have showed significant improvements

in regard to his activities of daily living however.

In this particular case patient scenario the use of the Dynamic Gait Index

(DGI) may have enhanced the overall outcome by demonstrating significant

improvement before and after rehabilitation. The DGI is used to assess an

individual’s ability to modify balance when presented with external demands. It is

specifically designed to assess postural control during gait. The test includes 8

gait activities. The results determine risk of falling. Interrater/Intrarater reliability

is excellent as well as concurrent validity (Jonsson et. al., 2011). It is likely the

case patient would not have been able to perform most of the test prior to

therapy but would have made significant improvements following the 12-week

therapy program. It is unclear why the patients did not begin lateral step-ups

upon his initial treatment of land-based therapy. However, following that initial

land treatment a focus on hip abduction strength was implemented and

progressed throughout. It may have been beneficial for the patient to combine

aquatic and land based activities.

Conclusion

In conclusion, the results in this case report indicate that physical therapy

interventions consisting of an aquatic and land-based therapy exercise program

positively impacts decreased pain, strength, and functional measures.


26

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Appendix A – Home exercise program

Supine marching

Supine Bridging

Supine Lumbar Rotation


32

Appendix B - Interventions

Intervention week 1 – Aquatic

• Forward Walk

• Backward Walk

• Weight shift gluteal isometrics

• Side step

• March (hip flexion to approx. 60 degrees

• Heel raises with gluteal squeeze

• Corner cycle

• Conclude with cold pack and e-stim to R hip and low back Intervention week 2 – Aquatic

• Forward walk focus on heel strike

• Backward walk

• Weight shift gluteal isometrics

• Side stepping

• March to approximately 60 degrees of hip flexion

• Heel raises with gluteal squeeze

• Balance challenge shoulder horizontal abd/add verbal cues for gluteal squeeze

• Balance challenge shoulder horizontal abd/add with staggered stance

• Mini squats

• Deep-water exercises o Leg scissoring abd/add o Leg scissoring flex ext. o Corner cycle

• Conclude with cold pack and e-stim. To R hip and low back Intervention week 3 – Initiation of land based program

• Upright Bike 5 minutes

• Standing Calf Stretch

• Total Gym mini squats with yellow Spoband around knees

• Total Gym heel raises

• Total Gym march with verbal cueing to stabilize using gluteal and quadriceps

• Hamstring curls concentric /eccentric


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• Forward and lateral step-ups to 4-inch step verbal cueing to engage gluteal musculature

Interventions – Progression of Land program re-evaluation 4 weeks

• Upright bike 6 minutes

• Standing Calf Stretch

• Total Gym mini squats with yellow Spoband around knees 3x15

• Total Gym heel raises 3x10 level 2

• Total Gym march with verbal cueing to stabilize using gluteal and quadriceps 2x20

• Hamstring curls concentric /eccentric 3x10.

• Stand march with cane

• Ambulation gait training 2x around gym with standard cane left hand Interventions - Progressed of Land program re-evaluation at 8 weeks

• Upright bike 6 minutes

• Hamstring curls concentric /eccentric 3x10

• Stand march with cane

• Side step at cable 6 each direction

• Forward/ backward walk cables 5x

• Backward/forward walk cables 5x

• Hip abduction 2x10

• Sit to Stand 10x

• March on blue foam 2x10 verbal cues to stabilize gluteal muscles Interventions – At Discharge 12 weeks

• Hamstring curls concentric /eccentric 3x10

• Side step at cable 6 each direction

• Forward/ backward walk cables 5x

• Backward/forward walk cables 5x

• Hip abduction 2x10

• Sit to Stand 10x

• March on blue foam 2x10 verbal cues to stabilize gluteal muscles

• Cable march 5kg 10 steps x2

• Side step over cups on green foam 3 minutes

• Side shuffle with green spoband around knees

• Cable down swing focusing on engaging abdominal muscles 2 x15

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