Retrospective Comparison of Patients Undergoing Formal Physical Therapy Versus No Physical Therapy Following Bunion Correction

Retrospective Comparison of Patients Undergoing Formal Physical Therapy

Versus No Physical Therapy Following Bunion Correction

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM

Anthony Borrelli, DPM, Wendy Benton-Weil, DPM


WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

Physical therapy (PT), following bunion correction, is theorized to recover range of motion of the first metatarso-phalangeal joint (MTP). PT can also aid in decreasing the recovery period from hallux valgus surgery, which is particularly advantageous to the active patient.1 Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function.2

Few investigations include both subjective and objective measurements of the effectiveness of physical therapy treatments in reconstructive foot surgery, particularly following hallux valgus correction.

We hypothesize that patients receiving formal physical therapy will yield functional benefits and an improved return of 1st MTP range of motion, as well as an increased patient satisfaction as compared to those who did not receive a formal physical therapy program, post operatively. This study evaluates the effectiveness and differentiates whether a regimented course of physical therapy following bunion correction enhances the results of the surgical correction.

Methods

Study Design

Patients with a history of receiving Scarf bunionectomies by three surgeons at the Weil Foot & Ankle Institute were identified using retrospective chart review and (N=55) recruited to participate in this retrospective, post-operative follow-up study. All three surgeons used virtually the same technique in performing the Scarf Bunion Procedure.

Two of the surgeons used a standard, formal physical therapy program beginning at one week post-operative. The third surgeon did not use physical therapy post operatively.

Data Collection

Patients were administered five subjective instruments during their follow-up clinical office visit. Instruments were completed before any clinical assessment to avoid biasing patient’s responses. Several instruments include objective clinician rating, which were completed during the course of the office visit. Retrospective chart review was used to obtain pre-operative pain ratings as well as the number of post operative physical therapy sessions attended.

Instrumentation

1. The 8-item American Orthopedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale: a patient-reported measure of pain combined with a clinician rating of function and alignment.
2. The 3-item AOFAS Hallux MPJ Scale: a patient-reported measure of pain and function.
3. The 10-item Weil Satisfaction Survey: a newly developed patient-reported measure of function, pain, patient satisfaction, level of improvement and time necessary to resume regular activities.
4. The 5-item American College of Foot and Ankle Surgery First Metatarsophalangeal Joint and First Ray: a patient-reported measure of pain, cosmesis, and functional capacities with clinician ratings of radiography and function.
5. The 23-item Foot Function Index: a patient-reported visual analog scale (VAS) of pain severity, activity difficulty, and limitation frequency.

Statistical Analysis

Descriptive statistics were used to examine the distribution for all key variables. For categorical variables (i.e., level of satisfaction, level of function, and etc..), frequency counts were calculated. For continuous variables (i.e., level of improvement, level of pain), measures of central tendency and dispersion were calculated. Change in level of pain was assessed using a paired samples t-test. The sub-analyses by physical therapy participation was assessed using Independent Samples t-test. Additional analyses included cross tabulation and correlations of key variables to further understand the data. SAS version 9.1 was used for all analyses.

Overall Results

Patient Demographics

The study included 55 patients (79 feet; average age 57, range 16-78 years) with right (n=16), left (n=15), or bilateral (n=24) Scarf Bunionectomies. 44 patients (80.0%; 65 feet) participated in a formal, regimented physical therapy program and 11 (20%; 14 feet) were not given a post operative, PT program.

Patient Satisfaction

48 out of 55 patients (87.3%) were moderately to extremely satisfied with the results of the Scarf Bunionectomy procedure.

Function and Daily Activities

49 out of 55 patients (89.1%) were able to return to their routine daily activities at an average of 11.6 weeks (SD=10.2, range=1-48 weeks). 48 out of 55 patients (87.3%) reported similar or improved post-operative functioning. On the AOFAS Hallux MPJ, 89.4% of patients indicated “no limitations” in daily activities.

Pain

Patients reported a 87.1% (SD=21.8) improvement in pain post-operatively. There was a significant reduction in patient reported pain rating (t=6.280, df=30, p= < 0.0001). The average change in pain rating (0-10) was a 3.2 point decline (FIGURE 1: SD=2.9). Pre-operatively, patients reported an average pain score (0-10) of 5.3 (SD=2.3, range=2-10). Post-operatively, patients reported an average pain score (0-10) of 2.1 (SD=2.1, range 0-4). On the patient report AOFAS Hallux MPJ, 75% of patients indicated “none” to “mild, occasional” pain.

Physical Therapy Results

Results indicate that patients who participated in physical therapy reported significantly higher foot function and fewer activity limitations as measured by the Foot Function Index (see Table 1: Foot Function Index), than the patients who had no physical therapy program. These results were confirmed by the patient reported measure of functional capacity as well as the clinical (objective) rating of foot function on the ACFAS (SEE TABLE 1: ACFAS).

Dorsiflexion was categorically measured on the ACFAS as well as clinically rated during the office visit. For 65.0% of patients who participated in physical therapy, the range of motion was 60 degrees or greater (39 feet, mean=66.4, SD=20.2). Only 45.5% of patients who did not participate in physical therapy had a similar range of motion (5 feet, mean=60.7, SD=25.8).

Plantarflexion was categorically measured on the ACFAS. For 98.4% of patients who participated in physical therapy, the range of motion was 0 degrees or greater (63 feet). The same was true for 91.7% of patients who did not participate in physical therapy (11 feet).

Conclusions

The application of continuous passive motion to joints immediately after joint surgery stimulates the regeneration of articular tissue, eliminates adhesions, prevents joint stiffness, reduces pain, and is well tolerated by patients.³
Although the idea of post-operative physical therapy is supported and recommended by podiatric and orthopedic surgeons, the literature is weak in identifying the benefit of physical therapy after reconstructive bunion correction.

Patients who underwent regimented physical therapy post-Scarf Bunionectomies at the Weil Foot & Ankle Institute presented higher satisfaction rates, and scored better in the Foot Function Index and ACFAS total scores, versus those patients who did not complete physical therapy. These patients were also shown to function better and at a higher level of capacity with less limitation (TABLE 1). It is imperative to note that the correlation, while positive, between AOFAS and ACFAS scores is considered marginally moderate (r=0.409). Similarly, it was expected that the correlation between the Foot Function Index and ACFAS and AOFAS would be low, but the direction negative, given that one is patient-reported while the other two are clinically rated. This assumption was true for the ACFAS (r=-0.072); however, for the AOFAS, the correlation was positive (r=0.007). This indicates that the ACFAS may be more sensitive for discriminating between patient groups in observational studies.

Formal physical therapy following bunion correction yields favorable clinical and functional results, including an increased level of patient satisfaction, and is shown to provide continual long-term benefits after the post-operative course.

References

1. Saxena, A., O’Brien, T. Postoperative Physical Therapy for Podiatric Surgery. JAPMA. 1992, Aug. 8. 2(8): 417-23.
2. Deyle, Gail D., MPT et al. Effectiveness of Manual Physical Therapy and Exercise of the Knee:
   A Randomized, Controlled Trial. Annals of Internal Medicine. Vol. 132 (3), 1 Feb. 2000. 173-8.
3. The Podiatric Application of Continuous Passive Motion: A Preliminary Report. JAPMA
   Dec. 1991; 81(12): 631-7.

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