OUTPATIENT REHABILITATION FOR A PATIENT FOLLOWING A

SURGICALLY STABILIZED TRIMALLEOLAR FRACTURE

A Doctoral Project A Comprehensive Case Analysis

Presented to the faculty of the Department of Physical Therapy

California State University, Sacramento

Submitted in partial satisfaction of the requirements for the degree of

DOCTOR OF PHYSICAL THERAPY

by

Julie Hammond

FALL 2017

© 2017

Julie Hammond

ALL RIGHTS RESERVED

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OUTPATIENT REHABILITATION FOR A PATIENT FOLLOWING A

SURGICALLY STABILIZED TRIMALLEOLAR FRACTURE

A Doctoral Project

by

Julie Hammond

Approved by:

______, Committee Chair Edward Barakatt, PT, PhD

______, First Reader William Garcia, PT, DPT, OCS, FAAOMPT

______, Second Reader Rafael Escamilla, PhD, PT, CSCS

______Date

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Student: Julie Hammond

I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project.

______, Department Chair ______Michael McKeough, PT, EdD Date

Department of Physical Therapy

iv

Abstract

of

OUTPATIENT REHABILITATION FOR A PATIENT FOLLOWING A

SURGICALLY STABILIZED TRIMALLEOLAR FRACTURE

by

Julie Hammond

A 46 year old woman with a right surgically stabilized trimalleolar fracture was seen for physical therapy treatment for 13 sessions from 06/17/2016 to 09/16/2106 at an outpatient pro bono physical therapy clinic. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist.

The patient was evaluated at the initial encounter with manual muscle test, goniometric measurements, single leg balance test, Timed Up and Go test, and a self- report questionnaire ( and Ability Measure). Following the evaluation a plan of care was established. The main goals for the patient were to improve her strength, increase her range of motion, normalize her gait pattern, improve her static standing balance, and regain her functional independence. The main interventions used were therapeutic exercise, joint mobilization, soft tissue mobilization, over-ground gait training, and functional activity training.

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The patient improved her strength, increased her range of motion, improved her balance, normalized her gait pattern, regained her functional independence in all activities of daily living, and was able to resume participation in a few recreational activities. The patient was discharged from outpatient physical therapy with a home exercise program.

______, Committee Chair Edward Barakatt, PT, PhD

______Date

vi

ACKNOWLEDGEMENTS

I acknowledge California State University, Sacramento Physical Therapy Pro Bono clinic for allowing me to learn about and treat a patient with an orthopedic disorder.

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TABLE OF CONTENTS Page

Acknowledgements ...... vii

List of Tables ...... ix

Chapter

1. GENERAL BACKGROUND ...... 1

2. CASE BACKGROUND DATA ...... 3

3. EXAMINATION – TESTS AND MEASURES ...... 6

4. EVALUATION...... 11

5. PLAN OF CARE – GOALS AND INTERVENTIONS...... 13

6. OUTCOMES...... 20

7. DISCUSSION ...... 22

References ...... 24

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LIST OF TABLES Tables Page

1. Medication Table………………… ...... ……………………………….5

2. Examination Table……………………………….……………………………10

3. Evaluation and Plan of Care… ... ………….………………………………….13

4. Outcomes……………………………….……… .... ………………………….20

ix 1

Chapter 1

General Background

Ankle fractures are common injuries of the lower extremities, occurring at an incidence rate of approximately 187 fractures per 100,000 people each year.1 Studies have shown that one third to one half of these fractures are due to sports-related injuries.1,2 Similar fracture rates were found overall between women and men, although women have higher rates in the 50 to 70 year age group.3 The large majority of ankle fractures are malleolar fractures: 60-70% occur as unimalleolar fractures, 15-20% as bimalleolar fractures, and 7-12% as trimalleolar fractures.1,3 In trimalleolar fractures, the medial of the , the lateral malleolus of the fibula, and posterior aspect of the distal tibia (considered the posterior malleolus), are all fractured.

Medical management of ankle fractures can entail conservative treatment without surgery, or the fracture may be surgically stabilized. Stable fractures in which the are not displaced are likely to improve with conservative care.4 Surgical treatment of unstable ankle fractures typically consists of an open reduction internal fixation of the fractured malleoli and/or a syndesmotic stabilization.4-6 After surgery, the orthopedic surgeon may opt to immobilize patients for up to 6-8 weeks by means of an external support with the aims of protecting the surgical wound, limiting postoperative pain, and minimizing the mechanical stress on the joint during the initial phases of healing.7

Studies that have investigated the possible risk factors for fractures in perimenopausal women found that cigarette smoking, a high body mass index, polypharmacy and a positive fracture history have been associated with an elevated risk

2 of ankle fractures.8,9 Long term work disability was also a notable risk factor with all fractures in perimenopausal women.9

The clinical impairments associated with operatively managed ankle fractures are pain, swelling, decreased strength, decreased joint range of motion (ROM), and impaired balance. These impairments can have a large effect on patients’ functional status by reducing their ability to perform activities of daily living. These limitations can lead to restrictions in patients’ participation in community events, social gatherings and sports.

Rehabilitation efforts are aimed at managing pain, increasing ROM and strength, reducing edema, maximizing function, and teaching self-management skills.

Ankle fractures can have long lasting effects on a patient’s physical, social, and psychological health.10 Some of these effects can be limited function, decline in leisure activities, fatigue, and persistent ankle symptoms.5,10 An unfavorable prognosis has been associated with multimalleolar fractures, higher levels of pain, reduced function, swelling, and decreased ROM.6,11-13 Broos and Bisschop found that 39% of patients with trimalleolar fractures and only 13% of subjects with unimalleolar fractures had unfavorable outcomes.13

Return to sports is a common rehabilitation goal for athletes sustaining ankle fractures. Colvin et al. found that at one year after surgery, 88% of recreational athletes had resumed participation in sports.14 Younger age, male gender, lack of a syndesmotic injury, and no systemic disease were positive predictors of returning to sport.14 The negative predictors that were found were older age, female gender, and several comorbidities.14

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Chapter 2

Case Background Data

Examination – History

The patient was a 46-year-old, active female who self-referred to physical therapy

(PT) due to weakness, stiffness and limited function of her right (R) ankle secondary to a trimalleolar fracture sustained during a skiing incident. The fracture was surgically stabilized approximately 3 months prior to her PT examination. The patient had three PT treatments at an outpatient facility for her present condition; she had discontinued care at the other outpatient PT facility. The patient had returned to her surgeon for follow up three weeks prior to her initial PT evaluation at which time radiographs revealed her bones were healed and she was permitted to weight bear as tolerated (WBAT). She had sprained her R ankle ten years ago resulting in a residual instability that did not interfere with her daily function or recreational activities. Her past medical history was unremarkable except for controlled asthma and occasional migraines, both of which her primary care physician was aware. She lived with a supportive partner in a two story house with multiple stairs.

The patient’s chief complaints were weakness in R quadriceps and plantar flexor muscles, an occasional aching pain and stiffness in R medial and anterior ankle region, stiffness in the R foot, and an aching pain in R anterior knee. She reported past episodes of numbness and tingling in R lateral ankle/foot which resolved about 1 week prior to her examination. The patient’s aching pain was intermittent, ranging from 0-3/10 on the numerical pain rating scale (NPRS) and only present when ambulating without boot. Her

4 symptoms of weakness and stiffness were reported to be constant and variable. She reported increased swelling after periods of activity. The patient’s symptoms recently worsened with her increased activity since given WBAT orders. She temporarily relieved her symptoms with Naproxen, elevation of her R lower extremity (LE), and ice.

The patient stated that her symptoms interfered with daily activities such as walking, stair climbing, and sitting or standing for prolonged periods of time. Her pain disturbed her sleep about six times per night, but she was able to return to sleep within a few minutes after a change in position. The patient reported increased stiffness in the morning for 15-

20 minutes. She was ambulating with one crutch and was wearing the post-operative boot most of the day. The patient noted that she was unable to drive, go grocery shopping, or participate in any recreational activity that she previously enjoyed. Her goals were to improve her R ankle ROM and strength, return to her previous level of activity which included multiple sports, and to resume driving.

Systems Review

The patient’s musculoskeletal system was impaired as demonstrated by decreased muscular performance and limited ROM of the R ankle. The neuromuscular system was impaired as demonstrated by impairments in her gait pattern and balance, and her elevated levels of pain. The integumentary system was unimpaired based on the patient’s self-report and observation of healed incision sites on the R ankle. The patient’s cardiovascular system was unimpaired based on the values of vital signs taken. The patient’s respiratory system was mildly impaired with a self-reported diagnosis of asthma. The patient’s communication was unimpaired based on observation. Her

5 cognition was unimpaired as she was oriented to person, place, time, and situation. The patient’s affect was unimpaired based on her appropriate emotional and behavioral responses. Her language was unimpaired based on observation of fluent verbal and reading comprehension.

Examination - Medications

Table 1

Medications

MEDICATION DOSAGE REASON SIDE EFFECTS Naproxen 500 Used to relieve Constipation, diarrhea, gas, excessive thirst, milligrams, pain, 1 oral tablet tenderness, headache, dizziness, lightheadedness, every 4-6 swelling, and drowsiness, difficulty falling asleep or staying hours as stiffness asleep, burning or tingling in the or legs, needed cold symptoms, ringing in the ears, hearing problems, changes in vision, unexplained weight gain, shortness of breath or difficulty breathing, swelling in the abdomen, , feet, or legs, sore throat, fever, chills, and other signs of infection, blisters, rash, skin reddening, itching, hives, swelling of the eyes, face, lips, tongue, throat, arms, or , difficulty breathing or swallowing, hoarseness, excessive tiredness, pain in the upper right part of the stomach, nausea, yellowing of the skin or eyes, flu-like symptoms, bruises or purple blotches under the skin, fast heartbeat, cloudy, discolored, or bloody urine, back pain, difficult or painful urination, decreased urination, loss of appetite, confusion

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Chapter 3

Examination – Tests and Measures

The patient’s deficits were categorized using the International Classification of

Functioning, Disability and Health (ICF) model’s three categories: body functions and structures, activity, and participation. Multiple measure were taking to identify impairments in the category of body functions and structures: goniometry was used to measure ROM, manual muscle testing (MMT) was used to measure strength, and single leg standing was used to measure static balance. The Activities of Daily Living (ADL) subscale of the Foot and Ankle Ability Measure (FAAM), and the Timed Up and Go

(TUG) test were used to identify activity limitations. The patient’s report of her ability to perform in recreational activities and the sports subscale of the FAAM were used to measure changes in her participation restrictions.

The standard universal goniometer is a common and valid tool utilized by clinicians to measure joint range of motion. A reliability study of ankle plantar flexion and dorsiflexion in individuals with cerebral palsy provided information that allowed the computation of a minimal detectable change based on a 95% confidence level (MDC95) of 14 degrees for both ankle positions.15 Another reliability study of ankle dorsiflexion and plantarflexion in patients with orthopedic provided information that, conservatively, allowed computations of a MDC95 for dorsiflexion of 11 degrees and plantar flexion of

14 degrees.16 The standard universal goniometer has been shown to have good intrarater reliability with ankle measurements with an Intraclass Correlation Coefficient (ICC) of

0.76-0.90.17,18 However, the interrater reliability of the goniometer with ankle

7 measurement is poor with an ICC of less than 0.50, except for plantarflexion, which was

0.71.17,18

Manual muscle testing is the most commonly used clinical method for evaluating impairments in muscular strength.19 Grading the strength of a muscle ranges on a six point ordinal scale with 0 of 5 (0/5) indicating no contraction, and 5 of 5 (5/5) indicating normal strength of the tested muscle. The results of multiple studies indicate that in order to be confident that a true change in muscle strength occurred, MMT scores must change more than one full grade.19

The Single Leg Stance measurement is recommended upon examination of ankle injuries by the American Physical Therapy Association’s (APTA) Clinical Practice

Guidelines (CPG) to assess static balance.20 There is limited evidence on this test and, therefore, it does not have established psychometrics to use in order to show a true change has occurred.

The FAAM is a self-report measure that assesses physical function of individuals with musculoskeletal disorders of the lower leg, foot, and/or ankle. This instrument has two subscales: an ADLs subscale which contains 21 items, and a Sports subscale which contains 8 items. The FAAM has excellent test-retest reliability (r=0.89 for the ADL subscale and r=0.87 for the Sports subscale) for persons with various ankle/foot musculoskeletal disorders. The MDC95 is 5.7 points for the ADL subscale and 8 points for the Sports subscale. The minimal clinically important difference (MCID) is 12.3 points for the ADL subscale and 9 points for the Sports subscale. The MDC95 and the

MCID are used to establish appropriate goals for improvement. It is necessary to have a

8 change in the ADL and Sports subscales of at least 5.7 and 8 points, their respective

MDC95, to indicate that there has been an actual change in function and that the change was not due to an error in measurement. In order for the change in function to be clinically important to the patient, the ADL subscale score must change by more than

12.3 points (MCID) and the Sports subscale score must change by more than 9 points

(MCID).

Screening for a deep vein thrombosis (DVT) during the initial patient interview and examination is strongly recommended by the APTA’s CPG based upon a high level evidence.21 The clinical decision rule (CDR) established by Wells and colleagues is now commonly used to assess the probability of a patient having a DVT. In the current CDR there are seven clinical features that are used to provide a total score, which can then be used to classify the patient into two categories of probability: likely and unlikely.21 A previous version of the Wells CDR categorized patients into three categories of probability: low, moderate, and high. One study using this older categorization method had found that patients categorized into the low, moderate, and high probability categories had a 3%, 17%, and 75% frequency rate of the presence of a DVT upon venography testing.22 Using the two category CPR, a study of 1082 participants found that the frequency of venous thromboembolism in patients categorized as likely and unlikely was 27.9% and 5.5%, respectively. The results of the Wells criteria guide the physical therapist in decisions in regards to the necessity for further medical testing or to continue with rehabilitation efforts without such a referral.21

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The Timed Up and Go (TUG) test is a prognostic measure that is used to determine fall risk. The ICC for the TUG is 0.94, which indicates a very high test-retest reliability.23 The normative mean for a sample of healthy older adults was found to be

23 8.36 seconds with a standard deviation (SD) of 1.63. The MDC95 was computed to be

1.11 seconds using the previously stated ICC and SD. Studies have shown that a score of higher than 24 seconds is predictive of falls in the six months post surgery.24

In this study, 95% of subjects who fell had TUG scores of >24 seconds.24 This cutoff score of 24 seconds results in a sensitivity of 95%, a negative predictive value of 93% and a negative likelihood ratio of 0.1.24

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Table 2

Examination Table

BODY FUNCTION OR STRUCTURE Measurement Test/Measure Test/Measure Results Category Used Range of Goniometry R ankle: L ankle: Motion DF: DF: Weight bearing = 0-5° Weight bearing = 0-14° Non-weight bearing = 0- Non-weight bearing = 0-35° 18° Plantarflexion: 0-65° Plantarflexion: 0-45° Inversion: 0-39° Inversion: 0-24° Eversion: 0-19° Eversion: 0-11° Strength Manual Muscle R ankle: L ankle: Test DF = 4/5 DF = 5/5 PF = 2/5 PF = 5/5 Inv = 4/5 Inv = 5/5 Ever = 3/5 Ever = 5/5 Balance Single Leg Stance R ankle: L ankle: 0.5 seconds 45 seconds FUNCTIONAL ACTIVITY Measurement Test/Measure Test/Measure Results Category Used Level of FAAM – ADL Score = 20/84 = 0.2381 x 100 = 23.81% of maximal function function Subscale Fall Risk Timed Up and Go 11.67 seconds test PARTICIPATION RESTRICTIONS Measurement Test/Measure Test/Measure Results Category Used Participation in Patient report Patient is unable to drive in order to go grocery shopping. social outings and errands Participation in FAAM – Sports Patient score = 0/32 = 0.0 x 100 = 0% of maximal function sports Subscale indicates she is unable to participate in sports Abbreviations: ADL=activities of daily living, DF=dorsiflexion, Ever=eversion, FAAM=Foot and Ankle Ability Measure, Inv=inversion, L=left, LE=lower extremity, MCID=minimally clinically important difference, MMT=manual muscle test, NWB=non-weight bearing, PA=posterior to anterior, PF=plantarflexion, PWB=partial weight bearing, R=right, Reps=repetitions, Sec=seconds, Tib-fib: tibia and fibula joint, w/= with, WB=weight bearing,

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Chapter 4

Evaluation

Evaluation Summary

The patient presented with decreased ROM, decreased strength, and impaired balance in the R ankle that led to limitations in her daily activities of driving, walking, climbing stairs, squatting. She was also unable to perform athletic activities such as jumps, hops, and jogging; which has led to a restriction in her participation in recreational activities and sports. The patient was a low risk for falls.

Diagnostic Impression

The patient developed body structure and function impairments in her R ankle including: pain, limited ROM, decreased strength, and balance deficits. These impairments contributed to activity limitations including her limited ability to: walk, balance, negotiate stairs, jump, and jog. Her activity limitations ultimately restricted her participation in social and recreational activities including: grocery shopping, cycling, stand up paddle boarding, and jogging.

Prognostic Statement

The patient’s positive prognostic indicators included: a high level of education, socioeconomic status (healthcare access not limited), no adverse lifestyle or behavioral factors (such as smoking or high body mass index), intact cognitive functioning, and a supportive family. The patient’s clinical features that have been associated with a good outcome following ORIF were: attaining DF ROM of at least 10° and low levels of pain.

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Negative prognostic indicators included: female gender, age, and having a multimalleolar fracture.

G-Codes

Current with modifier: G8978CL, G8990CM

Goal with modifier: G8979CI, G8991CJ

Discharge Plan

The patient was expected to be discharged home with a home exercise program after 8 weeks of physical therapy intervention. The expectation was that the patient would be instructed to continue with her HEP and encouraged to resume her previous gym routine.

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Chapter 5

Plan of Care-Goals and Interventions

Table 3

Evaluation and Plan of Care

PROBLEM PLAN OF CARE Short Term Goals Long Term Goals Planned Interventions (Anticipated Goals) (Expected Outcomes) Interventions are Direct or (4 weeks) (8 weeks) Procedural unless they are marked: (C) = Coordination of care intervention (E) = Educational intervention BODY FUNCTION OR STRUCTURE IMPAIRMENTS Limited R ankle Patient will Patient will Interventions will include a AROM as measured demonstrate an demonstrate an variety of manual therapy in standard testing increase in R ankle increase in R ankle techniques including joint positions with AROM to the values AROM to the values mobilizations, manual universal stated below as stated below as stretching, flexibility goniometer: measured in standard measured in standard exercises, and a HEP. testing positions with testing positions with a Mobilizations will be a universal universal goniometer progressed (higher grade, goniometer within 4 within 8 weeks. performed at larger ROM) weeks. as pain allows per patient report. DF: WB 0-9° 0-14°  Talocrural joint distraction, DF: NWB 0-28° 0-35° grade IV, 3x30 sec  Posterior glide of talus, grade IV, 3x30 sec  Anterior glide of distal tibia in WB, grade IV, 3x30 sec  Standing DF stretch, 3x30 sec with R knee straight, 3x30 sec with R knee bent  Longsit DF towel stretch, 3x30 sec  AROM: alphabet drawing in air while in longsitting, 3x, 2-4x/day  STM to gastrocnemius muscle to address tightness that may limit DF  Manual stretching of gastrocnemius/soleus complex, 3x30 sec and

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hold-relax 5x15 sec to help increase DF ROM. Plantarflexion 0-55° 0-60°  Proximal and distal AP/PA tib-fib glides, grade III-IV, 3x30 sec  AROM: alphabet drawing in air while in longsitting, 3x, 2-4x/day

Inversion 0-35° 0-40°  Lateral glide - subtalar joint, grade III-IV, 3x30 sec  Distal tib-fib AP, grade IV, 3x30 sec  Inversion towel stretch towel, 3x30 sec  AROM: alphabet drawing in air while in longsitting, 3x, 2-4x/day Eversion 0-15° 0-20°  Eversion towel stretch, 3 x 30 sec  AROM: alphabet drawing in air while in longsitting, 3x, 2-4x/day Decreased strength Patient will Patient will Interventions will include in R ankle demonstrate an demonstrate an instruction in a variety of musculature as increase in R ankle increase in R ankle therapeutic strengthening measured in strength to the values strength to the values exercise and (E) HEP. standard testing stated below as stated below as position with MMT: measured with MMT measured with MMT in standard testing in standard testing positions within 4 positions within 8 weeks. weeks. DF 4+/5 5/5  Longsit DF w/ resistance band, yellow, 3 sets of 10 reps, progress w/ higher level resistance  Heel walk, 2 x 15 feet, progress w/ increased distance PF 3/5 4+/5  Longsit PF w/ resistance band, yellow, 3 sets of 10 reps, progress w/ higher level resistance  Sitting heel raises, 3 sets of 10 reps, progress to using weighted objects on thigh  Standing heel raises, 3 sets of 10 reps, begin in PWB and progress to single heel raise on R

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 Skipping, 2x5 feet, start with modified speed and height, progress in distance, speed and height of jump. Inversion 4+/5 5/5  Longsit inversion w/ resistance band, yellow, 3 sets of 10 reps, progress w/ higher level resistance Eversion 3+/5 4+/5  Longsit eversion w/ resistance band, yellow, 3 sets of 10 reps, progress w/ higher level resistance

Impaired static Patient will be able to Patient will be able to  Single leg stance, stable balance on R LE as stand on R LE only stand on R LE only for surface, 3 x 5 seconds, measured by for 15 seconds on an 30 seconds on an even, progress w/ increase in standing single leg even, stable surface stable surface within 8 time, change to compliant balance test. within 4 weeks. weeks. surface, addition of movements of arms/leg/trunk, then eyes closed  Bridge, stability ball supporting head and neck, hold 30 sec x 3 sets, begin w/ wide double leg, progress to narrow, then to single leg ACTIVITY LIMITATIONS Limited functional No short term goal Patient will improve All above treatment ability to perform ability to perform interventions will indirectly ADLs: ADLs as measured by increase ability to perform an increase in 13 points functional activities. (MCID) in the FAAM Additional interventions will ADL subscale score. include instruction in a variety of task-specific therapeutic activities and (E) HEP.

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Ambulation  Manual resistance of R hip flexors for tactile cueing during swing phase.  Verbal cues during ambulation for proper mechanics throughout phases: mainly R knee flexion during swing and extension during initial contact; great toe extension during push off and ankle DF during swing and initial contact.  Rocker step to focus on advancement of R hip during swing phase, R knee flexion during swing phase, and R great toe extension and R ankle PF during push off phase.

Stair Climbing  Step down, lead w/ L LE, 3 x 5 reps, 2 inch step, progress with reps and height of step  Clamshells in L sidelying, 3 sets of 10 reps, progress w/ addition of resistance or change to quadruped position to strengthen hip stabilizers for proper technique with stair climbing  SLR exercises on table in all directions, 3 sets of 10 reps, progress w/ addition of resistance to strengthen hip musculature for proper technique with stair climbing Squatting  Double leg squats, 3 sets of 10 reps on even stable surface, progressing to weight shifting towards R and then eventually single leg squat.  (E) Instructed to resume previously performed leg press exercise at gym, 3 sets of 10 reps at 50% of previous load.

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PARTICIPATION RESTRICTIONS Limited ability to No short term goal Patient will improve All the above treatment will perform sports: ability to perform be indirectly working sports as measured by towards improved tolerance an increase in 9 points to sports performance. (MCID) in the FAAM Also included in Sport subscale score intervention will be (E) within 8 weeks patient education and advice with self-management as sports activities are resumed. Jumping/Hopping (E) Instructed in jumping exercises in pool at local gym: chest deep water, double leg jumps in place, progress to higher jumps and change in directions Jogging (E) Instructed patient in progression to jogging: pool walking, pool jogging in deep end and progress to shallow water, then transition to performance on land. Abbreviations: AP=anterior to posterior, AROM=active range of motion, DF=dorsiflexion, Ever=eversion, FAAM=Foot and Ankle Ability Measure, HEP= home exercise program, Inv=inversion, L=left, LE=lower extremity, MCID=minimally clinically important difference, MMT=manual muscle test, NWB=non-weight bearing, PA=posterior to anterior, PF=plantarflexion, PWB=partial weight bearing, R=right, Reps=repetitions, Sec=seconds, Tib-fib: tibia and fibula joint, w/= with, WB=weight bearing,

Plan of Care – Interventions

See Table 3.

Overall Approach

The treatment approach for this patient was partially guided by the CPG established by the APTA for ankle sprains. The interventions recommended in the CPG are based on moderate to strong evidence to support their effectiveness in patients with ankle sprains and chronic instability. There are no current CPG by the APTA for ankle fractures. Research on the best training program and rehabilitation protocol for operatively managed ankle fractures is widely variable and inconclusive at this time. The

18 plan of care was a multimodal approach that consisted of: manual therapy interventions including joint mobilization, soft tissue mobilization, and manual stretching; therapeutic exercise addressing both flexibility and strength; task specific therapeutic activities; gait training; balance training; patient education; and home exercise instruction. Due to the minimal irritability and low severity level of the patient’s symptoms, initial interventions consisted of both manual therapy techniques and therapeutic exercises. These interventions focused on improving joint range of motion, muscle flexibility, and muscle strength. The interventions were gradually progressed when it was appropriate. The treatment sessions were 60 minutes in duration and varied in frequency as follows: 1 time per week for a total of 4 weeks; then 2 times per week for 4 weeks; and then one follow up visit 3 weeks after resumption of patient’s work schedule. The patient was monitored throughout the sessions for pain, performance of techniques properly, and overall response to the interventions. The home exercise program and plan of care were adjusted as needed.

PICO question

In patients with ankle fractures (P), is a supervised exercise program and advice more effective (I) than advice alone (C) for increasing functional abilities (O)?

A randomized clinical trial (evidence level Ib) by Moseley et al. compared a treatment approach of a supervised exercise program and advise about self-management with advise alone25. The participants of the study had: an isolated treated with immobilization (with or without surgical fixation), approval to WBAT or partial weight bear, reduced ankle DF ROM, ankle pain at least 2 of 10 when 50% of body

19 weight was borne through the affected leg, completed skeletal growth, and no concurrent pathologies that would affect the ability to perform everyday tasks or the measurement procedures used in the trial. The patient in this case study would meet the criteria to be a candidate for the research study reviewed for this PICO question.

The participants were randomized into two groups: supervised exercise program and advice with self-management (rehabilitation group) and advice alone (advice group).

The primary outcome measures that were assessed were two self-report questionnaires, the Lower Extremity Functional Scale and Assessment of Quality of Life instrument.

The results showed there was no statistical difference in the primary outcomes between the groups. However, it was noted in the study that 39 of the 108 advice group participants received out-of-trial physical therapy and 15 of the 106 rehabilitation group participants also sought out-of-trial physical therapy. The authors conducted a series of sensitivity analyses that demonstrated similar results with the primary outcomes, concluding that the out-of-trial physical therapy did not affect the overall conclusion.

However, since 25% of the participants in this study sought out additional physical therapy treatment on their own may demonstrate the patients’ desire for extensive follow up care after cessation of ankle immobilization following an ankle fracture. Therefore, it was the decision of the student physical therapist to incorporate both supervised exercises and advice with self-management throughout the episode of care in order to provide quality care.

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Chapter 6

Outcomes

Table 4

Outcomes

OUTCOMES BODY FUNCTION OR STRUCTURE IMPAIRMENTS Outcome Initial Follow-up (DC) Change Goal Met? Measure (Yes/No) Goniometry DF: WB = 0-5° DF: WB = 0-11° + 6° No DF: NWB = 0-18° DF: NWB = 0-30° +12° No PF: 0-45° PF: 0-57° +12° No Inv: 0-24° Inv: 0-44° +20° Yes Ever: 0-11° Ever: 0-28° +17° Yes MDC=14° Manual DF = 4/5 DF = 5/5 +1 grade Yes Muscle Test PF = 2/5 PF = 4/5 + 2 grades Yes Inv = 4/5 Inv = 4-/5 - ½ grade No Ever = 3/5 Ever = 5/5 + 2 grades Yes MDC≥1 grade Single Leg 0.5 seconds on 42 seconds on even, Increase in 41.5 seconds. Yes Stance even, stable stable surface surface

Unable to perform 36 seconds on Increase in 36 seconds. Yes on unstable unstable surface surface ACTIVITY LIMITATIONS Outcome Initial Follow-up (DC) Change Goal Met? Measure (Yes/No) FAAM ADL Score = 20/84 = Score = 77/84 = +57 points Yes Subscale 0.2381 x 100 = 0.9167 x 100 = MCID=12.3 points 23.81% 91.67%

Timed Up 11.67 seconds 5.15 seconds Improved by 6.52 seconds Yes and Go MDC=1.6 seconds PARTICIPATION RESTRICTIONS Outcome Initial Follow-up (DC) Change Goal Met? Measure (Yes/No) FAAM Score = 0/32 = 0.0 Score = 12/32 = +12 points Yes Sports x 100 = 0% 0.375 x 100 = 37.5% MCID=9 points Subscale Abbreviations: ADL = activities of daily living, DC = discharge, DF = dorsiflexion, Ever = eversion, FAAM = Foot and Ankle Ability Measure, Inv = inversion, MCD=minimal detectable change, MCID=minimally clinically important difference, NWB = non-weight bearing, PF = plantarflexion, R = right, WB = weight bearing.

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Discharge Statement:

The patient attended outpatient physical therapy for treatment of a surgically stabilized trimalleolar fracture of her R ankle. The patient was seen 1x/week for 4 weeks, then 2x/week for an additional 4 weeks. Interventions included joint and soft tissue mobilization, ROM, strengthening, balance exercises, functional activity training, gait training, patient education and home exercise instruction. A follow up visit one month after the end of the 8 weeks of treatment was added to reassess ROM, strength, and functional status. Upon initial examination, the patient was limited in ADLs due to impaired ROM, strength, and balance deficits. Throughout the course of care, the patient achieved goals associated with ROM, strength (except inversion), balance, functional activities, walking, and was able to resume a few recreational activities. The patient had significant self-reported improvements in ADLs and sports performance ability. The patient was discharged to a home exercise program consisting of flexibility and strengthening exercises, and sports specific activities. The patient was advised to contact the treating student physical therapist if any questions or concerns arose in the near future.

DC G-Code with modifier

G8979CI, G8991CJ

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Chapter 7

Discussion

Throughout the management of this patient case, the responses of the patient to the examination and treatments were as expected. The examination findings were typical for those of individuals having undergone surgical stabilization of a trimalleolar fracture.

A good rapport was established with the patient and I was able to earn her trust and confidence in my ability to handle her care. I was able to answer her questions and provide her with education of the rehabilitation process ahead. During the examination, the patient had a complaint of anterior knee pain that was briefly discussed, but I did not address it until visit three. In the future, I will try and address areas associated with the primary region of the patient’s complaint sooner than I did in this case.

In the course of the examination and first treatment session, the patient expressed her dissatisfaction and frustration with the level of compassionate care she received upon her initial injury and follow up care prior to her arrival to this clinic. Therefore, I made it a priority to show her empathy, compassion, and my understanding of her current condition. I made the decision to continue with manual techniques for a period of time longer than typically warranted due to the patient’s positive response to, and preference for hands on techniques. In the future, this approach will be decided upon on a case-by- case basis depending upon a patient’s needs, preferences, and circumstances. All of the interventions used in this episode of care will be suitable for future patients with a surgically stabilized ankle fracture. The degree of rigor and speed of treatment progression will always need to be individualized based upon the patient’s response.

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The outcomes measures used in this patient case are appropriate for patients with similar pathologic conditions. Since the patient was not regularly bearing full weight on her involved LE at the time of the initial examination, a very basic static balance test was performed. In the future, in cases similar to this, I will administer a more challenging and validated dynamic balance test such as the Balance Error Scoring System, Single Limb

Stance Touch, or the Star Excursion test once the patient is able to tolerate it.

The evidence established for management of surgically treated ankle fractures is minimal. There are a limited number of studies that investigate the best rehabilitation interventions for fractured ankles. Research studies assessing the effectiveness of stretching and joint mobilizations in this patient population were found to have conflicting results.26-28 Therefore, additional research in the area of post-fracture ankle rehabilitation would be beneficial. It would also be helpful in the management of ankle fractures if there was a CPG established by the APTA based upon the most recent and best evidence to help guide physical therapists.

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