Decreasing Adhesions and Avoiding Further Surgery in a Pediatric Patient Involved in a Severe Pedestrian Versus Motor Vehicle Accident
The patient was an 11 year old boy who had been involved in a MVA versus pedestrian accident in which a large vehicle rolled over his pelvis, resulting in an open book pelvic fracture, splitting the osseous structure of his pelvis. He sustained life-threatening injuries for which he underwent 19 surgeries over the course of one year in order to repair damage that resulted from the accident (). Because of healing from both the number of surgeries and trauma from the accident, the patient developed extensive scarring and abdominal adhesions as well as post traumatic stress disorder (PTSD). He had traditional physical therapy for three months to facilitate his ability to walk and perform daily functions. However, the patient experienced recurrent partial small bowel obstructions (SBO) that were treated non-surgically, and he required a laxative, polyethylene glycol (PEG) 3350 – oral, for maintenance of bowel function. The use of laxatives caused the patient distress and reportedly impacted his life significantly, causing rectal fecal leakage and thus furthered emotional distress in a pediatric patient medicated for PTSD.\nUpon initial physical therapy evaluation at a specialized manual therapy clinic, 19 months following the accident, the patient reported frequent constipation, pain of up to 7/10 during bowel movements, weakness and tingling in his left lower extremity and general pain that increased throughout the day. He expressed numerous goals, including the ability to participate in more athletic activities, to run a marathon, and to eliminate the requirement for pharmaceutical maintenance of bowel function. Findings from the initial evaluation, which included visual, palpatory, postural and movement exams were correlated with patient medical history, previous surgical reports, and physician diagnosis to determine adhered and dysfunctional areas requiring treatment. Restrictions, scars or adhesions were palpated by the therapists, major organs were identified, and decreased mobility of specific organs was determined. The patient was ambulatory, but exhibited a shuffling gait and a wide base of support with both hips held in external rotation. He presented with decreased range of motion in several areas that impacted his activities of daily living (), decreased strength, postural deviations, and biomechanical dysfunction, as well as myofascial, visceral and osseous restrictions due to scarring and adhesion formation after the original trauma, and from the 19 required surgical interventions. The extensive adhesions in his pelvis had also caused his left testicle to ascend into the inguinal canal where it was unable to be palpated, but was visible by diagnostic ultrasound.\nThe patient was treated with an intensive site-specific manual physical therapy called the Clear Passage Approach (CPA) or Wurn Technique for 4 hours a day for 5 consecutive days (a total of 20 hours). In accordance with the American Physical Therapy Association guidelines, detailed clinical treatment records were maintained on the patient throughout the course of therapy. These included symptomatic complaints, areas treated, duration and techniques performed. Unlike traditional physical therapy that often consists of exercise and modalities, the CPA utilizes a variety of techniques focused on creating microfailures of the adhesions by a variety of site-specific sustained pressures across restricted fascial bands of adhered tissues and organs. The amount and time of force that was applied to cause these microfailures was often significant, but varied with the tolerance of the patient and according to the location and delicacy of the tissues that were being treated. In previously published clinical trials and studies, these techniques increased range of motion, reversed infertility, prevented SBO and decreased pain in patients with histories indicating significant adhesion formation.\nTherapy focused on decreasing adhesions in order to decrease pain, and to increase function and range of motion. The patient’s response to treatment was significant and readily apparent to him, the therapists and his physicians. Following the initial 20 hours of treatment, the patient demonstrated an apparent decrease of adhesions evidenced by increased range of motion () of by at least 5 degrees for abnormal tests, and by improved myofascial, visceral and ligamentous mobility accessed via palpation. He reported decreased abdominal pain, increased frequency of normal bowel movements, and decreased use of laxatives by 50%.\nUpon urologic re-evaluation, his physician reported that the scar adhesions in his scrotum had decreased significantly. The urologist was optimistic that additional treatment would continue to decrease the scarring in his left inguinal region in order to aid in the increased mobility of the testis, possibly negating the need for surgical intervention for the ascending testicle. He recommended an additional 20 hour regime of the manual physical therapy.\nSeven months after the first CPA therapy (26 months following the trauma), the patient returned for an additional 20 hours of treatment focused on further decreasing adhesions. Following that therapeutic series, the patient again showed an apparent decrease of adhesions evidenced by improvement in range of motion (); improved myofascial, visceral and ligamentous mobility; decreases in pelvic and abdomen pain; decreases in left lower extremity pain and edema; and an improved gait. Pain and functional levels improved to the point that he reported no pain with bowel movements, increased frequency of bowel movements, and further decrease in the laxatives previously required for proper elimination. Upon further urologic examination, the physician noted that the patient demonstrated additional decreases in the scarring and adhesions in the inguinal area (, ) and the previously ascending left testicle was able to be reduced manually into the upper scrotum (, ). Ten months following the second treatment, his parents reported no surgical intervention for the ascending testicle and no further partial SBOs. Moreover, he was able to return to a normal diet, improving not only his health but also his return to normal daily activities after the accident. They reported that improvements in the patient’s physical ability to participate in normal activities also improved his mental status; he no longer required medication for PTSD associated with the MVA.