Background and Purpose

Motor vehicle accidents (MVA) are a leading cause of spinal injuries.1 One such injury is

a spinal burst fracture, which results from axial loading through the spine via high-energy

impact. These frequently occur at the thoracolumbar junction (T12-L2) due to its inherent

mechanical instability as the transition between the stable thoracic spine and flexible lumbar

spine,2 and often adjacent segments. In a MVA crash statistics study, it was found that burst

fractures were the second most common type of spinal injury after compression fractures,

especially in 40-49 year olds.1 They are usually associated with passengers restrained by 3-point

seatbelts, which also tends to prevent more serious injuries such as traumatic brain injuries or

fatalities.1

As a result of the high-energy impact, burst fractures are considered more severe than

compression fractures because the vertebrae are crushed in all directions and fragments are

widespread.3 This may lead to muscle paralysis or impaired sensation.3 The presentation of burst

fractures may vary greatly as a result of the spinal cord’s termination anywhere between

segments T11-L2.2 Typically, signs and symptoms include moderate to severe back pain

exacerbated by movement, numbness, tingling, muscle weakness, and bowel and bladder

dysfunction.3 That being said, a majority of thoracolumbar injuries may not present with

impairments.2

Neurological screening, which includes dermatomes testing, muscle action testing, and

deep tendon reflexes, is considered a preliminary part of the diagnosis for burst fractures but

alone cannot completely rule out the potential for a spinal fracture.2 Anteroposterior and lateral

radiographs, computerized tomography (CT) scans, and magnetic resonance imaging (MRI) are

used to examine potentially affected segments and visualize the degree of spinal canal

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compromise.2 Radiographs, as part of standard practice, can show deformities such as loss of

vertebral height or subluxation but may fail to show more crucial aspects of the fracture.2 CT

scans allow for greater visualization of the spinal canal, and fractures to the laminar and articular

processes.2 MRI is the most efficient in visualizing soft-tissue deformities, such as disc

herniation, hematomas, ligament damage, and spinal cord injuries.2

While some spinal injuries are stable and may be treated with conservative treatment,

unstable spinal injuries, which are indicated by neurological or mechanical instability, typically

require surgical intervention.4 The goals of surgery are to decompress the nerve roots and spinal

canal, promote neurological recovery, and maintain vertebral integrity, alignment, and stability.4

The anterior approach is indicated when there is nerve compression secondary to the disc or

fragments.4 The anterior approach efficiently and greatly decompresses the neural tissues and has

the advantage of limiting how many segments undergo fusion.2 This approach, however, requires

increased time necessary for surgery,2 and has greater risks of visceral organ injury, bleeding,

and pulmonary complications, and is therefore the less familiar approach for surgeons.2,4 In

contrast, the posterior approach is indicated in fractures without neurological impairments

despite presence of a neurological injury.4 The segments may be fixated with pedicle screws,

vertebroplasty, bone grafting, or posterolateral or posterior fusion.4 While it is the more common

procedure, there are risks of inadequate decompression, hardware failure, and deformities may

reoccur.2 Despite this, it has the advantage of fixating multiple segments of the spine and

typically good biomechanical stability.4

Surgical intervention is followed by conservative management including bracing and

physical rehabilitation.4 Post-surgical precautions for the spine are typically established, which

include restrictions on excessive flexion or bending more than 90 degrees, lifting more than 5-10

2
lbs, and excessive trunk rotation.5 With these precautions in mind, exercise such as walking, and

light lower extremity strengthening exercises and stretching are typically recommended during

the first three months post-surgery.6 Furthermore, patients who experience multiple traumas and

orthopedic surgery can be at risk for physical decline or complications as a result of prolonged

immobility or decreased activity.7 There is potential for declines in gross motor strength, muscle

mass, muscle flexibility, balance, coordination, and endurance, as well as complications such as

deep vein thromboses, blood pressure fluctuations, issues with lung clearance, and orthostatic

intolerance.7 All of these factors may contribute to a patient’s decreased tolerance for activity

and exercise. Therefore, it is imperative for patients to undergo active rehabilitation in order to

minimize these deficits and have good functional outcomes.

Physical Therapists possess the qualifications and expertise to examine, evaluate, and

treat these functional impairments experienced by patients who undergo this type of injury and

surgery. Literature generally supports physical therapy rehabilitation after fusion surgeries leads

to better outcomes, such as decreased pain, timelier attainment of functional milestones,

increased function, and decreased time taken off work.8 That being said, however, most studies

examine the effects of elective fusion surgeries for chronic pain and degenerative burst fractures.

More high-quality evidence is needed to determine stronger guidelines for intervention and

determine the effectiveness of physical therapy for individuals who experience traumatic burst

fractures.

The purpose of this case report is to document the interventions used in treating a middle-

aged male’s functional impairments as a result of traumatic spinal burst fractures sustained in a

motor vehicle accident. This case report will add to literature supporting post-operative physical

therapy for spinal fusion surgery secondary to traumatic burst fractures, and potentially

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contribute to guidelines for rehabilitation protocols. These interventions would be designed with

consideration to the patient’s back precautions and would address the functional impairments

that resulted from the patient’s period of decreased activity following the orthopedic traumas and

subsequent surgery.

Prior to preparing this report, consent was obtained from the patient to proceed. All

information contained in this case report meets the Health Insurance Portability Accountability

Act (HIPAA) requirements of the clinical agency for disclosure of protected health information.

This case report was completed in accordance with procedures approved by the Institutional

Review Board at Central Michigan University.

Case Description

Patient History and Systems Review

A 47-year old Caucasian male presented to an inpatient rehabilitation facility 2 weeks

post-motor vehicle accident. As a result of the MVA, the patient sustained several fractures

including: sternal fracture, left ribs 4-12 fractures, L4 burst fracture, T10-T12 transverse process

fractures, T12 spinous process fracture, L1-L3 spinous and transverse process fractures. Surgical

repairs to the patient’s spine occurred 1 day post-MVA, including L4 vertebroplasty, L4 dural

repair, L3-L5 decompressive laminectomy with reduction of retropulsed fragments, bilateral

cannulated pedicle screws to L2-L3 and L5-S1, bilateral rods at L2-S1, and posteromedial

fusion. The patient’s medical chart also noted left iliopsoas hematoma, left hepatic lobe

contusion, urinary retention and pulmonary embolism occurring 5 days post-injury. The patient’s

previous medical and surgical history were unremarkable.

The patient had been evaluated by a physical therapist and occupational therapist 2 days

post-MVA and was reevaluated 11 days post-MVA for discharge. At that time, the patient

4
required moderate assistance for bed mobility. He required moderate assistance from two people

to perform sit to supine transfers, minimal assistance to contact guarding for sit to stand

transfers, and supervision for all other transfers. His lower extremity strength was rated as below

normal limits but manual muscle tests for specific muscles were not completed at this time. His

sitting balance was rated as good with minimal challenges, and independent with arm support.

His standing balance was rated as fair with no challenges, and independent with arm support. He

was able to ambulate using a front wheeled walker 3x75 feet with supervision. His ability to use

stairs was not tested. The patient’s pain was rated as 5/10 using a pain rating scale. Stairs were

not tested at this time. Upon meeting his goals in acute care, his discharge setting

recommendation was to inpatient rehabilitation.

The patient was subsequently transferred to an inpatient rehabilitation facility 14 days

post-MVA after meeting his acute care goals. At this time the patient had to follow back

precautions, including no excessive bending, twisting, or lifting over 5 lbs, and wearing a

lumbosacral orthosis while out of bed. Since transitioning from his previous placement, the

patient’s pain medication schedule had not been established. As a result, his pain levels were

severe and unstable, as he could not tolerate any other position besides supine in bed with his

arms overhead, bracing the bedrails. This limited his participation at initial presentation. Thus the

full initial evaluation was not conducted and completed until the pain was managed. The patient

also reported right upper leg pain and tightness in his muscle that could not be relieved with his

attempts of self-massage, including stripping and rubbing the muscle with his thumb and fingers.

Clinical Impression 1

The patient was considered a good candidate for physical therapy once pain was

managed. Since the patient was only 2 weeks post-MVA, his presentation was considered an

5
acute injury. The initial evaluation was initially postponed because he could not tolerate any

movement due to severe pain. Therefore, the primary issue for this patient was pain management

secondary to the patient’s spine fractures, surgical repairs, and leg soft tissue tightness. As a

result, the patient was seen 3 days post-admission to rehab when his medication schedule had

been established. From then on, the patient’s main problems included decreased functional

mobility, endurance, strength, balance, and complaint of soft tissue pain and tightness in his right

upper leg following his injury. These impairments limited his ability to independently perform

activities of daily living and participate in normal social, leisure, and work activities.

Prior to the MVA, the patient was independent with all activities of daily living and

worked for a construction company. His goals for therapy were to return to his previous level of

independence, increase his strength and balance, and return home and resume normal work

activities. Positive factors for the patient’s prognosis included his strong social support, his age,

his prior level of function, and his level of motivation. The patient was cognitively aware of his

diagnosis and prognosis, demonstrated understanding on the rehabilitation process, and

demonstrated adherence and safety with the precautions in place.

The patient was considered a potential candidate for interventions such as bed mobility

and transfer training, gait training, progressive lower extremity strengthening, static and dynamic

balance activities, coordination, and endurance activities. The interventions would be selected

based on whether they abided by the back precautions that were in place and whether they were

appropriate for his level of functioning. The plan for examination to determine whether the

patient was a good candidate for these interventions included the following: range of motion

measurements, manual muscle tests, bed mobility and transfers, palpation and soft tissue

extensibility, functional mobility, and static and dynamic balance during sitting and standing.

6
Examination

Communication, cognition, and affect. The patient’s communication, cognition, and affect were

all considered to be within normal limits. The patient was alert and oriented to himself, place,

time, and situation. He was able to follow all commands and answer all questions and

demonstrated appropriate social behaviors and emotional responses during interactions with the

physical therapist.

Pain. The patient’s pain levels were measured primarily by subjective report. The patient

reported that his back pain was “much better” after taking medication. Despite this, the patient

still reported unstable pain at night, stating “it woke me up every couple of hours and I couldn’t

get comfortable.” Additionally, he stated he “felt pressure in his back” following prolonged

inactivity, such as lying in bed or sitting in his wheelchair and that “it usually feels better after I

walk around a little bit.” The patient was observed to be occasionally grimacing during

movements requiring increased exertion, such as during manual muscle testing or during

functional movement such as performing sit to stand transfers. The patient explained that his

right upper leg felt “very tight and uncomfortable” and that “it actually wakes me up more than

the back pain.” He also mentioned that he experienced pain on occasion in his sternum secondary

to a fracture.

Range of motion. Active range of motion (ROM) of the lower extremities was assessed with the

patient seated at the edge of the mat. The patient was able to flex his hips to 90 degrees, but per

the back precautions, anything past 90 degrees was not tested. The patient was asked to

“straighten his leg,” “bend his knee toward his butt,” “point his toes up to the ceiling, then down

to the floor,” and “point the sole of your foot outward, then inward” to examine the remaining

7
joints. The patient’s active ROM in his lower extremities was considered to be within functional

limits.

Strength. Manual Muscle Testing (MMT) of the lower extremities was performed according to

many of the procedures described by Reese.9 Some positions, such as testing for knee flexion,

were modified secondary avoiding provoking pain or potentially violating the patient’s back

precautions. Most MMTs were performed with the patient seated at the edge of the mat. The

patient’s proximal hip musculature was not assessed at this time in order to avoid provoking pain

secondary to the patient’s healing spinal fractures. The patient was instructed “don’t let me push

your leg down” and “don’t let me pull your leg out” to test knee extension and flexion. The

patient was instructed “don’t let me move your foot” to test ankle musculature in all directions

except ankle plantarflexion, in which the patient was instructed to perform as many single leg

heel raises as possible in standing. Strength grades were assigned to each muscle based on a 5-

point numeric scale, with 0 indicating no voluntary contraction and 5 indication normal strength.

Interrater reliability is strong, ranging from .82-.97, and is also high for test-retest reliability at

.96-.98.10 The concurrent validity is good at .768 when compared to a hand-held dynamometer.10

See Table 1 for specific MMTs performed for the lower extremity. The patient’s gross strength

was rated as decreased, but within functional limits. The patient’s strength in his left ankle

musculature was decreased relative to his right.

Balance. The patient’s balance was initially screened via observation. He demonstrated normal

sitting balance unsupported, and normal static standing balance. The patient’s dynamic balance

was screened, with instructions to the patient to reach for targets out of his base of support. His

balance was considered good but decreased.

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 The Berg Balance Scale (BBS) was performed to objectively measure the patient’s

balance during functional tasks. The BBS contains 14 items, each with a 5 point scale ranging

from 0-4, with 0 indicating lowest function and 4 indicating highest function for a total of 56

possible points. The relative intrarater and interrater reliability of the BBS are excellent at .98

and .97 respectively.11 Another study that involved physical therapists examining with patients

with spinal cord injuries (SCI) further supports the reliability for single items on the BBS, with

interobserver reliability between .84-.98 and for the overall score with ICC = .95.12 The BBS

also has good construct validity, with the correlation between admission BBS and admission

Function Independence Measure at .76 in patients with stroke.13 Although the patient did not

have a stroke or a SCI, the measure has an acceptable level of reliability and validity to measure

the patient’s balance and gait impairments and risk for falls. Steps were taken to reduce as much

measurement error as possible, as the scale was administered by the same therapist each time,

performed at roughly the same time of day, and performed with the same set of instructions of

the measurement tool to reduce sources of measurement error. The patient scored 51/52,

demonstrating most difficulty with the forward reach which was limited by pain. One item was

omitted rather than counted against the patient because the task involved picking up an object

from the floor, which would potentially involve excessive bending of the spine and hip. The

patient’s score indicated he was at low risk for falls.

The Tinetti Balance and Gait Assessment was used to further test the patient’s balance.

The Tinetti consists of 17 balance and gait items, each with a 2 or 3 point scale, with 0 indicating

lowest function and 1 or 2 indicating impaired ability to function or normal function depending

on the item. For conditions such as stroke, the test-retest reliability is good at ICC = .84, and

criterion validity when compared to the motor domain of the Functional Independence Measure

9
is adequate at .55.14 Although the patient did not have a stroke, the measure has an acceptable

level of reliability to measure the patient’s balance and gait impairments. Steps were taken to

reduce as much measurement error as possible, as the scale was administered by the same

therapist each time, performed at roughly the same time of day, and performed with the same set

of instructions of the measurement tool to reduce sources of measurement error. The patient

scored 24/28 on the assessment as whole. The patient demonstrated need for an assistive device

to ambulate, and demonstrated decreased foot clearance bilaterally. This put the patient at low

risk for falls.

Palpation. Per the patient’s complaint of muscle tightness and discomfort, the patient’s

quadriceps in the right lower extremity was palpated with three distal finger pads. The muscle

texture was tight, fibrous, and spanned the length of the upper one third of the patient’s anterior

thigh. With light pressure applied to the area, the tissue was unyielding and provoked increased

pain.

Bed mobility. The patient’s bed mobility status was modified independent. The patient required

use of the bedrails to assist with bed mobility, including logrolling to prevent excessive twisting

of the spine using the log rolling method.

Transfers. The patient required supervision on almost all transfers secondary to proper handling

of his Foley catheter bag. The patient required minimal assist with performing a supine to sit

transfer secondary to increased pain.

Gait and locomotion. The patient primarily used a manual wheelchair for locomotion throughout

the facility, where he was able to propel over 1000 feet a time without requiring breaks. The

patient was able to propel the wheelchair by himself but was given supervision status for safety

and handling concerns regarding his Foley catheter bag. The patient was able to walk 100 feet on

10
tiled surfaces with a standard walker with supervision before requiring a rest break secondary to

discomfort in his lower back and leg.

Gait Analysis. The patient’s gait was observed as he walked in a straight line using a standard

rolling walker. The patient’s trunk, and upper and lower extremities were examined during

walking in a straight line. Minimal deviations were noted, including decreased gait velocity,

decreased step length, and decreased stride length and decreased foot clearance during step phase

of gait.

Functional Mobility. The Functional Independence Measure (FIM) was performed to assess how

much assistance the patient required with functional mobility and activities of daily living. The

FIM consists of 18 items, each scored with a 7-point ordinal scale, with 0 indicating the item was

not tested or it did not occur, 1 indicating total assistance, and 7 indicating complete

independence. The median interrater reliability and median test-retest reliability are strong at .95

for the total FIM.15 The equivalence reliability is also strong at .92.15 The internal consistency is

also strong for the total FIM at .95.16 Only the gross motor items were assessed in physical

therapy. See Table 5 for a summary of the patient’s scores at initial evaluation. The patient

scored a 4 on transfers, walking, and stair use, indicating that he required minimal assistance to

perform each task. The patient scored a 5 on wheelchair use, indicating he required supervision

and was otherwise independent with his wheelchair. This put the patient in the “helper” level

category, requiring modified independence for functional mobility.

Clinical Impression 2

The examination performed was considered moderate complexity, given that the patient

had unstable pain and multiple systems affected by his acute injuries. The patient demonstrated

functional but decreased balance and strength in his lower extremities. The patient also

11
demonstrated decreased endurance, and decreased walking performance such as decreased gait

velocity, decreased step length, and decreased foot clearance. With the absence of a neurological

injury, the patient was considered to have a high level of functioning and was expected to

progress quickly.

The plan was to see the patient for physical therapy 5 times per week during the course of

his inpatient stay. The target interventions would address the patient’s impairments in endurance,

strength, balance, and coordination. Given the patient’s intact cognitive status and current level

of functioning, he was a good candidate for more advanced interventions that could be easily

modified according to his performance. The interventions would decrease his level of disability

and increase his independence and participation in normal life activities.

Interventions

Manual therapy. Soft tissue mobilization can be beneficial for patients post-fusion surgery.17 At

initial evaluation, the patient was recommended as a candidate for massage therapy secondary to

the large palpable fibrous knot in the patient’s right upper quadriceps muscle, and the patient’s

subjective complaints of pain and discomfort limiting his participation and mobility. However,

the patient’s referral for this service was delayed early on due to not having an assigned physical

medicine and rehabilitation physician to prescribe it. Until the patient could get a prescription for

massage therapy, manual therapy was included during physical therapy sessions to temporarily

alleviate the patient’s pain and discomfort. Functional massage has been shown to be effective in

decreasing musculoskeletal pain and increase range of motion.18 Functional massage was trialed

during 2 physical therapy sessions prior to therapeutic exercise. The patient responded positively

to this intervention, reporting decreased pain and improved sleep in the nights that followed. The

patient and his wife were educated on positioning, body mechanics, and performing the

12
technique so that the patient could attain pain relief as needed until massage therapy services

could be initiated.

Treadmill training. See Table 2 for a detailed description of treadmill training interventions

completed as an adjunct to gait training. Treadmill training has been shown to have beneficial

outcomes in walking and decreasing fall risk in other groups. Patients who were post-stroke and

who underwent a high intensity treadmill training regime had greater 6 Minute Walk Test

distances and peak treadmill speed than those who underwent low intensity treadmill training.19

Geriatric patients with fall risk showed improved walking performance, with parameters such as

step length and width, after treadmill training and progressive dual tasking.20 Thus, treadmill

training was selected to improve the patient’s endurance, strength, and coordination during gait.

At the time of initiating this intervention, the patient had been cleared to walk independently

with a rolling walker around the facility at his leisure. Thus, more advanced gait training was

needed to appropriately challenge the patient. Using the treadmill would promote walking above

the patient’s self-selected speed, increase his endurance by taking fewer rest breaks, and

maximize repetitions for stepping and muscle actions. Early treadmill training consisted of

walking at higher speeds and walking in different directions, and progressed to walking without

upper extremity support, walking with directional changes, marching, and dual tasking.

Strengthening. See Table 3 for a detailed description of strengthening exercises completed.

Strengthening has been commonly recommended for patients post-fusion surgery.6,17

Strengthening exercises were selected to increase the patient’s lower extremity and core strength

and endurance in order to improve his independence with functional mobility and his activities of

daily living. The patient was able to complete strengthening exercises that did not infringe on his

back precautions. Strengthening of the lower extremity musculature was initially limited to using

13
resistance bands (Theraband Professional Latex Resistance Bands 2021-C Theraband, Akron,

Ohio) and functional squats performed to the patient’s tolerance. Light core strengthening and

stabilization occurred with standing static and dynamic balance exercises requiring upper

extremity movement, requiring activation of core musculature. All exercises were progressed or

regressed according to the patient’s performance or tolerance.

Balance training. See Table 3 for a detailed description of balance training exercises completed.

Interventions to increase motor control are recommended for patients post-fusion surgery

(Madera 2017).17 Exercises to improve the patient’s gross balance and coordination began with

standing static and dynamic activities, involving single and double leg support, uneven surfaces

such as the Bosu Ball (Bosu® Pro Balance Trainer 72-10850-P, Ashland, Ohio) and balance

cushion (Air Stability Wobble Balance Rehab Cushion AB305107, Lancashire, England),

advanced walking, and using weighted medicine balls (Ideal Products Weighted Medicine Balls

MBS5, red 2.2 lbs and yellow 4.4 lbs, Broseley, Montana). All exercises were progressed or

regressed according to the patient’s performance or tolerance.

Outcomes

See Tables 4 and 5 for outcomes measured at initial evaluation and at discharge. The

patient was seen for a total of 11 physical therapy treatments. The Berg Balance Scale and

Tinetti Balance and Gait Assessment were used to measure the patient’s balance deficits. At

initial evaluation, the patient scored 51/52 on the BBS and 24/28 on the Tinetti, indicating the

patient had low fall risk. Additionally, the Functional Independence Measure was used to

evaluate the patient’s independence with basic activities of daily living and functional mobility.

At the time of initial evaluation, the patient required supervision with wheelchair use, and

minimum assistance with transfers, walking, and stair use.

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 The patient demonstrated improvement in all standardized outcomes at the time of

discharge, indicating no fall risk and improved independence. At the time of discharge, the

patient’s pain was stable enough to tolerate a squat to pick up an item off the floor instead of

bending forward for the BBS, so the item was included. This resulted in an improved score of

56/56. The patient’s score on the Tinetti also increased to 28/28, with improved walking

performance without use of assistive device and resolved gait abnormalities. His performance on

the Functional Independence Measure improved to 6 in all areas of mobility. This indicated that

he was modified independent, requiring modified transfers and bed mobility techniques such as

using a handrail, using the rail for stairs, and using an assistive device for locomotion.

Discussion

The purpose of this case report was to implement physical therapy interventions in the

treatment of a middle-aged patient who had undergone recent decompressive and fusion surgery

to a traumatic spinal burst fracture to assess outcomes related to strength, balance, gait, and

functional independence. On admission to inpatient rehabilitation, the patient demonstrated

deficits in functional mobility, endurance, strength, and balance. Interventions were implemented

to address these deficits, address his goals, decrease his fall risk, ensure safe functional mobility,

and increase his independence for discharge.

The outcomes used in this case report, including subjective pain reports, Berg Balance

Scale, Tinetti Balance and Gait, and Functional Independence Measure, found that the patient

demonstrated improvements in his impaired balance, gait performance, and functional mobility.

These outcomes were supported by previous literature review. Goals of rehabilitation primarily

include reducing pain and disability and restoring function and fitness.6 Physical therapists play

important roles in providing care for individuals who undergo this type of surgery by using

15
skilled therapy interventions to address deficits in these areas, as well as other areas such as

decreased strength, balance, and endurance. In a systematic review performed by Madera, Brady,

and Deily et al, it was suggested that soft tissue mobilization may be beneficial for addressing

postsurgical pain and reducing anxiety and tension.17 While soft tissue mobilization was not

performed specifically on the patient’s back musculature or around the incision site, this

intervention was found to be effective in addressing his pain and tightness in the patient’s upper

leg, per his subjective report, that manifested after his injury and surgery. Additionally, Madera,

Brady, and Deily et al suggested that neuromuscular re-education and strengthening may be

beneficial for facilitating healing and decreasing muscle atrophy in core musculature.17 In

particular, upright exercises that are functional and loadbearing were typically recommended.17

As such, strengthening exercises in static and dynamic standing were focused on the lower

extremity early on in the patient’s rehabilitation, with the addition of many exercises

incorporating upper extremity movement to involve a degree of core stabilization. More

advanced core strengthening and stabilization exercises may be the emphasis further in this

patient’s rehabilitation as the healing process continues. Additionally, previous studies

incorporating treadmill training regimes have shown benefits in walking parameters, such as

distance and walking performance, in other populations.19,20 While the patient did not undergo a

specific treadmill training protocol, different aspects of treadmill training incorporated into his

treatment plan may have positively impacted his gait as demonstrated by his improved

endurance, and performance during walking.

This case report contributes to existing literature by supporting conservative management

and physical therapy interventions in the treatment of a patient with spinal fusion surgery,

especially after a traumatic injury. The patient’s response to these interventions both objectively

16
and subjectively add to the supporting literature regarding postoperative treatment that can be

implemented safely during the first 3 months post-fusion.21 While exercise is crucial to the

rehabilitation of patients who undergo spinal fusion, there is no consensus on the content of these

exercise rehabilitation programs following spinal fusion.6 Recovery through active exercise is an

important aspect of rehabilitation in order to decrease pain and prevent long-term disability from

occurring for patients post spinal fusion. The physical therapy interventions that were

implemented to address pain and impairments in strength, balance, and endurance were safely

performed with regard to the patient’s pain levels and back precautions that were in place.

One limitation to this case report was delayed treatment. The management of the patient’s

pain with medications had an impact on his participation in physical therapy early on. As a new

admit, the patient’s medication schedule had not been established at the time of initial evaluation.

This delayed his physical therapy examination and evaluation, and treatment by 3 days. Had the

patient been able to tolerate this evaluation and subsequent treatment earlier, it is possible that he

would have been able to return earlier to home, which has further implications on decreased cost

of inpatient stay.

Another limitation to this case report was the lack of objective scales to measure the

patient’s pain levels as well as his quality of life. The patient was asked during examination and

during each treatment session whether his pain level had or had not changed. Additionally,

nonverbal cues such as facial grimacing were observed to subjectively monitor changing pain

levels. The patient was asked how he was feeling day-to-day, during which subjective

information about his sleep, pain tolerance, ease of movement, and performing basic activities of

living was collected. While this information was crucial to treatment planning with modifications

or progressions to physical therapy interventions, using more objective measures in these key

17
aspects of care would provide a more detailed illustration of the patient’s progress and response

to treatment.

The plan was for the patient to be discharged from inpatient rehabilitation to his home.

His need for 3 or more hours of therapy services had decreased during his inpatient stay, which

meant that he no longer met criteria to be in inpatient rehabilitation. From a physical therapy

perspective, he demonstrated improvement on all functional impairments, demonstrated safety

awareness, and was adherent to all precautions. The patient was recommended to continue

outpatient physical therapy 3 times per week to continue making gains in his functional mobility,

strength, balance, and endurance. Potential future participation in a specialized work-hardening

or work-conditioning program was suggested upon proper clearance with his surgeon once back

precautions are lifted.

18
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