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Physical therapy management of an older individual following symphysis resection due to osteitis pubis.

Osteitis pubis (OP) is an inflammatory disease of the pubic symphysis that can be very painful. It usually involves the pubic bone, symphysis, and surrounding structures. (1-4) Although the etiology of osteitis pubis remains unknown, several predisposing factors have been described in the literature. (1,2,4-8) These factors include pelvic surgery, specific local infections, pelvic trauma, vaginal delivery, vigorous exercise involving the lower extremities (such as in certain sports and especially ballet), and rheumatoid arthritis. In some cases of OP, none of these predisposing factors are present. Most frequently, osteitis pubis is diagnosed among male participants in vigorous sports such as football, soccer, rugby, and tennis that involve extreme forces of the pubic, lower abdominal, and hip muscles, (4) although OP incidence is increasing in female athletes. Occasionally, OP is associated with childbirth or surgery to the pubic area.l-9 Though most patients are young, it can occur in older individuals.

Individuals with OP present with a number of symptoms. The initial presentation of OP commonly includes insidious onset of adductor pain and abdominal discomfort along with pain in the pubic symphysis. (4) OP may also present as painful adductor muscle spasms, and increased pain when lying on the side, during walking, climbing stairs, and arising from a seated position. (8) Physical examination findings include tenderness to palpation of the pubic symphysis, and pain with resisted strength testing of the adductor and lower abdominal muscle groups. (9) Additional possible signs and symptoms include an audible or palpable click over the pubic symphysis, reduced hip abduction motion, a waddling antalgic gait, and pain over the pubis during the pelvic compression test (compression of the iliac wing with the patient in a side lying position), or the cross-leg test (contralateral iliac wing held down while the ipsilateral crossed extremity is stressed). (5) Typical anteroposterior radiographic findings made with the patient standing include rarefaction and erosion of the adjacent pubic bones. If the symptoms have been reported for greater than six months, sclerosis of the adjacent pubic bones and narrowing of the symphyseal joint space may also be present. A positive diagnostic corticosteroid symphyseal injection provides symptom relief within minutes after the injection. (10)

Non-operative treatment consists of rest, ultrasound, nonsteroidal anti-inflammatory drugs, oral glucocorticoids, corticosteroid injections, and various components of physical therapy. When conservative intervention fails, several surgical procedures are considered. Curettage, arthrodesis, and resection are surgical options performed depending on the nature of the condition. (4,5,8,11,12)

Pubic symphysis surgical resection is reserved for the small percentage of patients with OP who fail to improve spontaneously or after conservative measures are provided. (13-16) Surgical resection of OP involves removal of a small amount of bone with an oscillating saw on either side of the joint. The intervening portion of bone and cartilage is removed. (8) The anterior aspect of the pubic symphysis is not disturbed, preserving the attachments of the pectineus, adductor longus and brevis, and gracilis muscles. Care is taken to maintain the integrity of the superior and inferior pubic ligaments. The rectus abdominis and pyramidalis muscles are typically excised from their attachments on the pubic symphysis for two of centimeters on either side and upon completion of the resection are reattached with absorbable sutures. (5)

In addition to the usual perioperative complications associated with surgery, pubic symphysis resection procedures are complicated by a number of factors. Because of the rarity of the surgery and paucity of literature on the procedure, surgical outcome is uncertain. Although elite athletes do well with resection surgery, patients with infection or post-operative OP are more likely to experience surgical failure. (8) Non-elite athletes with non-infectious OP have a 60-80% chance of a satisfactory surgical outcome, including manageable pain and the ability to walk without the use of an assistive device. Infrequently and, many months following surgery, posterior pelvic instability can develop, requiring sacroiliac fusion. (8)

CASE DESCRIPTION

This case report describes the physical therapy examination, evaluation, diagnosis, prognosis and intervention for a patient who underwent pubic symphysis resection secondary to OP. The study was approved by the Institutional Review Board of Andrews University. Reasonable measures were taken to maintain the anonymity of the subject.

History: The patient was a 61-year-old woman employed as a school speech pathologist who reported pain in the pubic symphysis region. For 15 months she underwent several conservative medical treatments including prolotherapy injections and a cortisone injection. In addition, she participated in physical therapy using iontophoresis, electrical stimulation, core stabilization exercises, and pool therapy. However, none of these treatments provided relief. To the contrary, her pain level increased with exercise until she was unable to climb stairs, walk more than a few steps, or bend at the waist. Her responsibilities as a speech pathologist in an elementary school included servicing children from age three through the fourth grade. She was required to walk long hallways to gather children for therapy, sit in "kiddie" chairs to work with the preschoolers, and occasionally sit on the floor with the three-and four-year olds. Sitting leaning forward at a table designed for young children was necessary for her to be at eye level with her patients. Her pelvic pain progressively worsened to the point that she could no longer perform these physical requirements and she took a medical leave of absence from her work. Her past medical history was significant for chronic back problems, breast cancer for which she required chemotherapy and radiation, fibromyalgia, osteoporosis, depression and anxiety. She was taking bupropion, clonazepam, levothyroxine, pregabalin, progesterone cream, and ketoprofen cream.

Magnetic resonance imaging and radiographic findings demonstrated moderate to marked pubic symphysis proliferative arthritic change with juxtaarticular inflammatory changes. Orthopedic consultation resulted in a recommendation of resection of the pubic symphysis for treatment of severe osteitis pubis.

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To resect the pubic symphysis, an anterior approach was taken utilizing a Pfannenstiel skin incision (otherwise known as a bikini cut). The rectus abdominis was incised anteriorly longitudinally, the linea alba was split, and, though both heads of the rectus were elevated from the pubic symphysis, their attachments were maintained to the anterior aspects of the superior pubic rami. Five millimeters of bone on both sides of the pubic symphysis were resected until no bone was touching in the center region, and, on complete resection, the pubic symphysis was maintained. The patient spent three post-operative days in the orthopedic unit. Medical equipment included infusion pump, patient-controlled analgesia pump, indwelling urinary catheter, TED hose, and a continuous passive motion device. The only perioperative complication was the development of a deep vein thrombosis (DVT) in the left peroneal vein on post-operative day (POD) l. The post-operative pharmacologic regime included clindamycin for antibiotic prophylaxis, Lovenox for DVT prophylaxis, Lovenox and Coumadin for treatment of the DVT, and Dilaudid and Norco for pain control. Physical therapy was initiated on POD l. She was discharged to a subacute skilled nursing facility on POD 3 where she spent 11 days, for a total of 14 days from hospital admission to returning home.

Systems Review:

Communication: Unimpaired Cardiovascular: Venous ultrasound results indicated the patient had a DVT in the left peroneal vein. Though vital signs should have been taken, their values were not documented in the physical therapy notes.

Integumentary: Pelvic incision closed with staples, clean, dry, and mildly inflamed. Musculoskeletal: The patient had impaired lower extremity ROM and strength. Neuromuscular: The patient had minimal difficulty with bed mobility and transfers. She demonstrated fair standing dynamic balance using a rolling walker.

Tests and Measures: On POD 1, the initial physical therapy examination revealed that the patient was significantly limited in functional mobility, i.e., bed mobility, transfers, and ambulation. Functional mobility assessment is critical as it often relates to patient safety issues. (17) This patient's deficit was related, in part, to a reported 8 out of 10 pubic pain. The numeric rating scale used in this case is valid, reliable, has good sensitivity, and is appropriate for use in clinical practice. (18) Gait and Locomotion: The patient performed bed mobility with supervision and transferred from sit to stand with a rolling walker with minimum assistance. With the use of a rolling walker, she ambulated (10) feet, rested briefly in a chair, then walked another 20 feet, all with contact guard assistance and weight bearing as tolerated. Her performance was limited by reports of becoming light-headed and fatigued.

Range of Motion: The patient's ROM was within functional limits for both upper extremities and lower extremities (19) except bilateral hip ROM was approximately 75% of normal using visual estimation. Visual estimation of ROM has clinical utility in the acute care setting, (17) and has good test-retest reliability. (20,21) The patient's bilateral upper extremity strength was within functional limits. (17,22) Lower extremity strength bilaterally was within functional limits except for moderate bilateral hip strength (3-/5). Lower extremity ROM and strength deficits were speculated to be due to surgical pelvic pain, as well as pre-existing disability.

EVALUATION, DIAGNOSIS & PROGNOSIS

Evaluation

This 61-year old patient was significantly limited in her functional mobility, including ADLs, IADLs, vocation and hobbies. These limitations were due to 15 months of declining physical activity secondary to pelvic pain and to the expected temporary limitations following pubic symphysis resection surgery.

Diagnosis

This patient's primary physical therapy diagnosis is musculoskeletal practice pattern 4I: impaired joint mobility, motor function, muscle performance, and range of motion associated with bony or soft tissue surgery. (23)

Prognosis and Plan of Care

This patient should achieve functional independence and return to living independently following rigorous physical rehabilitation. She should return to community ambulation without the need of an assistive device, following rigorous strength and endurance training. Long-term limitations are expected for activities that would stress the surgical joint, such as high impact movement, excessive stair climbing, and using low chairs.

ANTICIPATED GOALS AND EXPECTED OUTCOMES

This report covers the rehabilitation of this patient at the hospital and skilled nursing facility (SNF). The anticipated and personal goals were established during her acute care stay and the expected outcomes were determined during her SNF stay (See Table l).

INTERVENTION

The patient received a total of 12 physical therapy sessions during acute care (5) and skilled nursing (7) stays. Physical therapy began on POD l at the acute care hospital and on POD 4 at the skilled nursing facility. Twice daily physical therapy sessions at the acute care hospital lasted 30 minutes and focused on functional mobility training. (17,24) To increase weight-bearing tolerance at the surgical site, the patient received supervised bed mobility and transfer training, and gait training using a rolling walker. During the daily 30-minute physical therapy sessions in the skilled nursing facility, functional mobility training was progressed to include ascending and descending stairs and exercise to help the patient achieve the ability to return home functioning safely with the highest level of independence possible. Exercises consisted of strengthening for all extremities and stretching of both lower extremities. To obtain maximal functional outcomes, the use of intervention techniques that optimize muscle performance while addressing the specific demands of the task and environment is advocated. (24)

OUTCOMES

While in the hospital, this patient progressed from requiring minimum assistance for bed mobility, transfers, and ambulating 20 feet with a rolling walker on POD 1, to supervision with all functional mobility activities and ambulating 65 feet with a rolling walker by the time of discharge on POD 3. By the time of discharge from the skilled nursing facility, she required only supervision for bed mobility, sit to stand and car transfers, and ambulating 200 feet with a rolling walker. Stair climbing was accomplished with standby assistance. The anticipated goals and expected outcomes were only partially met by the time of discharge from the SNF (Table l). Her lower extremity strength improved from 3- to 3+/5, which is clinically significant as the limbs could then be lifted through the ROM against gravity. The reliability of manual muscle testing is high for grades of 3/5 and lower because they allow for the greatest objectivity in scoring. (25) Such an improvement in strength over this short time is more likely related to motor learning rather than an increase in contractile protein in the muscle. (26) Another factor for her increased strength could have been a 20% decrease in reported pain, which would have made the patient more willing to move her legs against gravity. Her weakness could have been due to the nervous system protecting the injured site, and, with the repetition of action provided with exercise and functional mobility, normal function was beginning to return. (27) The 8/10 groin pain reported on POD 1 decreased to 6/10, and was described as a 'pulling pain' which limited her walking distance and standing tolerance.

The patient was discharged home with temporary assistance from her sister. Physical therapy treatments were continued with home health and outpatient services. Steady progress has been realized toward the achievement of her personal goals during the intervening two years since surgery including community ambulating without an assistive device. She has changed employment from speech therapy to her prior occupation of audiology. She exercises regularly including pool therapy and gentle rebounding, and has returned to her previously enjoyed outdoor activities (gardening and birding) with minimal discomfort (see Table l). Activities that aggravate groin and sacroiliac joint pain include excessive stair climbing, walking on inclines, and bending.

DISCUSSION

Research findings related to rehabilitation following surgical resection of the pubic symphysis are limited, especially for the non-athlete older adult. Although successful return to sports for the young athlete following surgical intervention has been documented, descriptions of the post-surgical rehabilitation are limited. (4,12) According to level-4 evidence, a moderate long-term success rate has been reported following wedge resection surgery for older adults to return to their prior functional activities with manageable pain. (5,7,8,28) Unfortunately, the rehabilitation following these surgical case reports was not outlined. The outcome of a 74-year-old woman following wedge resection for osteitis pubis (28) was similar to the outcome of this case report. Both individuals reported good resolution of anterior pelvic pain and returned to most functional activities they previously enjoyed.

No randomized controlled studies for treatment of osteitis pubis (surgical or non-surgical) have been reported. As described in a recently completed systematic review, only level-4 evidence for the treatment of osteitis pubis in twenty-four case reports/series could be found. (4) The authors concluded that determining which individual treatment option is best is difficult because no direct comparison of treatment modalities was made. The treatment provided to the patient in this case report included conventional methods of training in bed mobility, transfers, ambulation, and exercise. (12,24) The hospital length of stay of 4 days was in line with the 2006 national average (3.6) for osteoarthritis-related diagnoses for 45-64 year-olds. (29)

Though significant improvement in the quality of life has been realized following the resection of her pubic symphysis, this patient continues to report 1-2/10 pain in her pubic area and sacroiliac joints (personal communication with author). Late development of posterior pelvic instability presenting with sacroiliac pain has been reported in the literature, sometimes up to 20 years after wedge resection of the pubic symphysis. (4,6)

CONCLUSION

This case report describes the elements of physical therapy management for a patient with symphysis resection due to osteitis pubis. The description follows the APTA's Guide to Physical Therapy Practice in outlining the physical therapy examination, evaluation, diagnosis, prognosis, and intervention for this patient. (23)

Physical therapists may be unfamiliar with this patient population due to the infrequency of the surgery. This highly motivated patient made significant improvement in a short amount of time in the acute care and skilled nursing facility settings receiving conventional physical therapy treatment.

Acknowledgements: I am grateful for the assistance of Mary Jo Canaday and Merilyn Christian in organizing the medical history information and reviewing the manuscript.

REFERENCES

(1.) Lentz SS. Osteitis pubis: A review. Obstet Gynecol. 1995;50(4):310-315.

(2.) Johnson R. Osteitis pubis. Curr Sports Med Rep. 2003;2:98-12.

(3.) McCarthy A, Vicenzino B. Treatment of osteitis pubis via the pelvic muscles. Man Ther. 2003;8(4):257-260.

(4.) Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: A systematic review. Br J Sports Med. Published online Sept 23, 2008. Doi:10.1136/ bjsm.2008.050989.

(5.) Grace JN, Sim FH, Shives TC, Coventry MB. Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Joint Surg. 1989;71A(3):358-364.

(6.) Middleton RG, Carlile RG. The spectrum of osteitis pubis. Compr Ther. 1993;19(3):99-102.

(7.) Moore RS Jr, Stover MD, Matta JM. Late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of osteitis pubis. J Bone and Joint Surg. 1998;80A(7):1043-48.

(8.) Mehin R, Meek R, O'Brien P, Blachut P. Surgery for osteitis pubis. Can J Surg. 2006;49(3):170-76.

(9.) Vitanzo PC Jr, McShane JM. Osteitis pubis. Phys Sports Med. 2001;29(7):33-8.

(10.) Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes: Results of corticosteroid injections. Am J Sports Med. 1995;23:601.

(11.) Kats E, Venema PL, Kropman RF, Kieft GJ. Diagnosis and treatment of osteitis pubis caused by a prostate-symphysis fistula: a rare complication after transurethral resection of the prostate. Br J Urol. 1998;81:927-8.

(12.) Williams PR, Thomas DP, Downes EM. Osteitis pubis and instability of the pubic symphysis: When nonoperative measures fail. Am J Sports Med. 2000;28:350-55.

(13.) Coventry MB, Mitchell WC. Osteitis pubis: Observations based on a study of 45 patients. JAMA. 1961;178(9):898-905.

(14.) Harris NH. Lesions of the symphysis pubis in women. Br Med J. 1974;4:209-211.

(15.) Olerud S, Grevsten S. Chronic pubic symphysiolysis: A case report. J Bone and Joint Surg. 1974;56(4):799-802.

(16.) Schnute WJ. Osteitis pubis. Clin Orthop. 1961;20:187-192.

(17.) Paz JC, West MP. Acute Care Handbook for Physical Therapists. 3rd ed. St. Louis, Mo: Saunders;2009.

(18.) Williamson A, Hoggart B. Pain: A review of three commonly used pain rating scales. J Clin Nurs. 2005;14:798-804.

(19.) Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. 4th ed. Philadelphia, Pa: FA Davis Co;2009.

(20.) Watkins MA, Riddle DL, Lamb RL, Personius WJ. Reliability of goniometric measurements and visual estimates of knee range of motion obtained in a clinical setting. Phys Ther. 1991;71(2):15-21.

(21.) Palmer ML, Epler M (eds). Gross Evaluations. Clinical Assessment Procedures in Physical Therapy. Philadelphia, Pa: Lippincott, 1990;2-6.

(22.) Kendall FP, McCreary EK, Provance PG, Rodgers M, Romani W. Muscles: Testing and Function, with Posture and Pain. 5th ed. Baltimore, Md:Lippincott Williams & Wilkins;2005.

(23.) Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.

(24.) O'Sullivan SB. In: O'Sullivan SB and Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia, Pa: FA Davis Co; 2007:471-522.

(25.) Florence JM, Pandya S, King WM, et al. Intrarater reliability of manual muscle test (Medical Research Council Scale) grades in Duchenne's muscular dystrophy. Phys Ther. 1992;72(2):34-41.

(26.) Sale DG. Neural adaptation to resistance training. Med Sci Sport Exerc. 1998;20:S135-S145.

(27.) Millar AL. Action Plan for Arthritis: Your guide to pain-free movement. Champaigne, II:Human Kinetics;2003.

(28.) Webb CA, Jimenez ML. Longstanding anterior pelvic pain. JAAPA. 2008;21(12):68.

(29.) DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hosptal Discharge Survey. National health statistics reports; no 5. Hyattsville, MD: National Center for Health Statistics. 2008.

David Village, MSPT, DHSc is Associate Professor in the physical therapy program at Andrews University, Berrien Springs, MI 49104-0420 (village@andrews.edu).
Table 1. Patient goals and outcomes.

 Anticipated
 Goals
 (5 days)

No 1. Patient will
 perform bed
 mobility
 independently.
No 2. Patient will
 transfer sit to
 stand with a
 rolling walker
 independently.
 3. Patient will
 ambulate 50 feet
 with a rolling
 walker independently.

 Expected
 Outcomes
 (4 weeks)

No 1. Independent
 bed mobility.
No 2. Independent
 transfers.
 3 Supervision/
 Independent gait
 with single point
 cane 200-250 feet.

 Personal
 Goals

Yes 1. Patient will
 ambulate
 independently in
 the community
 without the use
 of an assistive
 device in 3-6 months.
Yes 2. Patient will be
 able to walk up and
 down the stairs of
 her home independently
 with manageable pain
 in 3-4 months.
 3. Patient will be able
 to return to work as
 a speech therapist
 within one year.
Yes 4. Patient will be able
 to resume personal
 hobbies and interests
 including outdoor
 recreational activities
 within one year.
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Title Annotation:CASE REPORT
Author:Village, David
Publication:Journal of Acute Care Physical Therapy
Date:Mar 22, 2011
Words:3443
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