Effect of Aquatic Therapy on motor function and pain rating in a 53-year-old patient with Chronic Low Back Pain: Case Study
Over the summer I completed a five week clerkship at an out-patient orthopedic physical therapy clinic. I would like to share such case-study of which I presented to my peers and faculty at Northern Arizona University. The patient signed a consent form and authorized release of information; however, I have decided to omit personal information that could be used to identify the patient. Furthermore, this is not a published case-study and therefore has not been through a peer-reviewed process. Use caution when interpreting and extrapolating case study findings.
Patient History
The patient, a fifty-three year old male IT specialist, was referred to Physical Therapy (PT) by his orthopedic surgeon following a diagnosis of knee pain, mild knee osteoarthritis and chronic pelvic and thigh osteomyelitis. Six years prior to his initial consult with PT, he had a tumor excised from the medial aspect of his left knee. Following tumor excision, he developed unrelenting osteomyelitis in his left hip and pelvis which required six months of antibiotic and antifungal intravenous infusions. The patient has a thirty-pack-year history and was being concomitantly managed for hypertension, dyslipidemia, DMII, stomach ulcers, dyspnea, arthritis, depression, and alcoholism.
Exam Findings
The patient presented to PT with an elevated fear of activity, antalgic gait, reports of extreme difficulty or inability to run on uneven ground, stand for prolonged periods, ascend or descend stairs, community ambulate, or squat to chair.
Pain was reported with initiation of straight-leg raise test and throughout range of motion. Referral symptoms to left buttock, left thigh and left knee were also reported with all planes of motion during a standing lumbar screen. Manual muscle testing indicated his left lower extremity was weak and painful throughout.
Intervention
Due to the patient's high level of reported pain with anti-gravity movements and absence of MRSA infection, he was cleared for treatment within the aquatic environment. Each treatment session included five to ten minutes of a dynamic warm-up, five to ten minutes of PROM soft tissue mobilizations (grades three and four) to his left hip flexors and left knee extensors, thirty to forty minutes of therapeutic exercise for his gait, upper and lower extremity muscular strength, and torso stability. Treatment sessions concluded with ten to fifteen minutes of lumbar spine traction.
Outcomes
Upon his four week re-evaluation, the patient did not show statistically significant improvements in his self-reported pain rating or disability measured using the Focus on Therapeutic Outcomes tool and Modified Oswestry Low Back Disability Questionnaire, respectively. Furthermore, the patient was faced with a fifty-dollar co-pay which prevented him from continuing physical therapy. At his six week follow-up examination, he indicated a significant relief from pain and increase in activity tolerance after receiving corticosteroid injections in his left hip bursae and left distal iliotibial band.
Discussion
Hall et al. (1) and Waller et al. (2) published systematic reviews both suggesting aquatic therapy is an effective treatment strategy compared to land based therapeutic exercise for managing patients with chronic low back pain. Furthermore, both authors did not find a statistical difference between the two methods of treatment. However, a majority of the treatment designs were observed three to four days per week and averaged eight weeks in duration. The current patient attended therapy once per week for four weeks, which may have influenced his reported outcomes.
The patient in the current case study did not observe a statistically significant improvement in his low back pain; however, he was able to tolerate an increased level of activity while receiving treatment in the aquatic environment. The ability to tolerate and engage in increased physical activity addresses the patients concomitant comorbidities which place him at a high risk for cardiovascular disease. The patient was educated on such risk reduction and referred to a self-pay, independent aquatic exercise program so he would be able to continue engaging in low to moderate levels of activity without exacerbating his low back symptoms.
Conclusion
Aquatic exercise is an effective therapeutic intervention for patients suffering with chronic low back pain. However, the benefits of exercising in an gravity independent environment may be dependent on frequency and duration of treatment sessions. Furthermore, the aquatic environment may offset the deleterious effects chronic low back pain may have on activity level, in particular for populations at risk for heart disease.
1. Hall J., Swinkles A., Briddon J., McCabe C. Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? a systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2008;89:873-83.
2. Waller B., Lambeck J., Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clin Rehabil. 2009;23:3-14.
Over the summer I completed a five week clerkship at an out-patient orthopedic physical therapy clinic. I would like to share such case-study of which I presented to my peers and faculty at Northern Arizona University. The patient signed a consent form and authorized release of information; however, I have decided to omit personal information that could be used to identify the patient. Furthermore, this is not a published case-study and therefore has not been through a peer-reviewed process. Use caution when interpreting and extrapolating case study findings.
Patient History
The patient, a fifty-three year old male IT specialist, was referred to Physical Therapy (PT) by his orthopedic surgeon following a diagnosis of knee pain, mild knee osteoarthritis and chronic pelvic and thigh osteomyelitis. Six years prior to his initial consult with PT, he had a tumor excised from the medial aspect of his left knee. Following tumor excision, he developed unrelenting osteomyelitis in his left hip and pelvis which required six months of antibiotic and antifungal intravenous infusions. The patient has a thirty-pack-year history and was being concomitantly managed for hypertension, dyslipidemia, DMII, stomach ulcers, dyspnea, arthritis, depression, and alcoholism.
Exam Findings
The patient presented to PT with an elevated fear of activity, antalgic gait, reports of extreme difficulty or inability to run on uneven ground, stand for prolonged periods, ascend or descend stairs, community ambulate, or squat to chair.
Pain was reported with initiation of straight-leg raise test and throughout range of motion. Referral symptoms to left buttock, left thigh and left knee were also reported with all planes of motion during a standing lumbar screen. Manual muscle testing indicated his left lower extremity was weak and painful throughout.
Intervention
Due to the patient's high level of reported pain with anti-gravity movements and absence of MRSA infection, he was cleared for treatment within the aquatic environment. Each treatment session included five to ten minutes of a dynamic warm-up, five to ten minutes of PROM soft tissue mobilizations (grades three and four) to his left hip flexors and left knee extensors, thirty to forty minutes of therapeutic exercise for his gait, upper and lower extremity muscular strength, and torso stability. Treatment sessions concluded with ten to fifteen minutes of lumbar spine traction.
Outcomes
Upon his four week re-evaluation, the patient did not show statistically significant improvements in his self-reported pain rating or disability measured using the Focus on Therapeutic Outcomes tool and Modified Oswestry Low Back Disability Questionnaire, respectively. Furthermore, the patient was faced with a fifty-dollar co-pay which prevented him from continuing physical therapy. At his six week follow-up examination, he indicated a significant relief from pain and increase in activity tolerance after receiving corticosteroid injections in his left hip bursae and left distal iliotibial band.
Discussion
Hall et al. (1) and Waller et al. (2) published systematic reviews both suggesting aquatic therapy is an effective treatment strategy compared to land based therapeutic exercise for managing patients with chronic low back pain. Furthermore, both authors did not find a statistical difference between the two methods of treatment. However, a majority of the treatment designs were observed three to four days per week and averaged eight weeks in duration. The current patient attended therapy once per week for four weeks, which may have influenced his reported outcomes.
The patient in the current case study did not observe a statistically significant improvement in his low back pain; however, he was able to tolerate an increased level of activity while receiving treatment in the aquatic environment. The ability to tolerate and engage in increased physical activity addresses the patients concomitant comorbidities which place him at a high risk for cardiovascular disease. The patient was educated on such risk reduction and referred to a self-pay, independent aquatic exercise program so he would be able to continue engaging in low to moderate levels of activity without exacerbating his low back symptoms.
Conclusion
Aquatic exercise is an effective therapeutic intervention for patients suffering with chronic low back pain. However, the benefits of exercising in an gravity independent environment may be dependent on frequency and duration of treatment sessions. Furthermore, the aquatic environment may offset the deleterious effects chronic low back pain may have on activity level, in particular for populations at risk for heart disease.
1. Hall J., Swinkles A., Briddon J., McCabe C. Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? a systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2008;89:873-83.
2. Waller B., Lambeck J., Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clin Rehabil. 2009;23:3-14.
Comments
Post a Comment