Total sacrectomy rehabilitation: Implementation of the international classification of functioning, disability, and health model – A case report

Clinical findings and timeline

The patient experienced chronic low back pain with mechanical characteristics. A year ago, he began to feel intense pain radiating to his right lower limb, which responded well to conservative treatment. Approximately two months later, similar pain manifested in his left lower limb. Six months later, he noticed constipation and increased urination without the sensation of bladder filling. Subsequently, the patient underwent hospitalization, total sacrectomy, and colostomy, with sacrificed nerve roots during the surgery. The patient underwent evaluation at two distinct time points: Moment one (M1) occurred six weeks post-surgery and moment two (M2) occurred 12 weeks after the intervention in M1. During the initial objective assessment (M1), the International Standards for Neurological Classification of Spinal Cord Injury utilized the American Spinal Injury Association (ASIA) Impairment Scale (AIS) for classification.^[6] The activities domain assessment involved tasks such as “sit-to-stand” and “stand-to-sit,” the anterior functional reach test (AFRT), the lateral functional reach test (LFRT),^[7] and counting the number of steps taken. The Barthel Index was employed to evaluate activities of daily living (ADL) and functional independence.^[8] The patient, who presented in a wheelchair, required assistance with transfers but demonstrated good orientation and collaboration. The patient was classified as having a complete lesion AIS A (no preservation of sensory or motor function in the sacral segments S4-5). Following the physiotherapy objective examination, similarities with cauda equina syndrome were noted, including sensory changes and flaccid paralysis of muscles of the bladder and intestine. During anteroposterior and mediolateral load transfers, the patient struggled with trunk balance, weight transmission to the feet, and difficulty assuming a standing position. The most critical assessments revolved around the “sit-to-stand” and “stand-to-sit” sequences, which the patient could not perform independently, requiring significant support from the physiotherapist. On the Barthel Index, the patient displayed limitations in ADL, including transfers, bathing, dressing, and mobility. Emotionally, prolonged hospital stays left the patient feeling discouraged, influencing his social interactions and raising concerns about the future.

Application of the ICF model

The ICF framework was employed to organize examination information, make judgments on findings, and guide decision-making for the patient’s management [Figure 1].^[6,7]

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Figure 1:

Clinical judgments of the relationships and identification of the primary impairment of the patient into the International Classification of Functioning, Disability, and Health (ICF) model. Reprinted with permission from: ICF. Geneva, Switzerland: World Health Organization (Nº 318912).

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The patient’s primary limitation was identified as the inability to independently perform “sit-to-stand” and “stand-to-sit” maneuvers, termed as his primary activity constraint. In addition, he encountered significant challenges in standing alone and walking a few steps, categorized as secondary and tertiary activity limitations. The reduced function of leg and trunk muscles directly impacted the patient’s ability to stand independently and stroll a short distance. This clinical correlation led to a reorganization of the model based on these interrelationships and the primary impairment identified. For the patient, achieving home independence and engaging in ADL were crucial components of his physical and psychological well-being. Prognostically, his target was to regain the ability to walk and perform routine tasks within a year.^[3]

Diagnostic assessment

A lumbar magnetic resonance imaging scan revealed a lesion in the lumbosacral region involving the sacrum and soft tissues. A percutaneous echo-guided biopsy during hospitalization confirmed the diagnosis of chordoma. Bone scintigraphy displayed diffuse radiopharmaceutical hypofixation at the sacral level, consistent with a chordoma diagnosis, which indicated an unfavorable prognosis.

Therapeutic intervention

A comprehensive therapeutic plan was devised based on rehabilitation guidelines post-total sacrectomy.^[3] Therapy sessions were scheduled five days a week for 12 weeks, each lasting approximately 180 min [Table 1].

Table 1: International classification of functioning, disability, and health (ICF) categorical profile with intervention, intensity and scores of muscle strength, light touch, pin prick in the lower limbs according to the American spinal injury association (ASIA) scale, Barthel scale values, Anterior functional reach test (AFRT), Lateral functional reach test (LFRT) and number of steps, in M1 and M2.

Follow-up and outcomes

Positive outcomes were observed through postural and movement sequence analysis alongside assessments with specific instruments [Table 1].

Increased activation of stabilizing muscles in the abdominal core allowed for improved anteroposterior and mediolateral load transfers, as evidenced by improvements in the AFRT and the LFRT. Increased activation of lower trunk and leg muscles facilitated an improved extension pattern in the lower limbs. While the patient still required some support during “sit-to-stand” and “stand-to-sit” maneuvers, the need for assistance significantly decreased. The Barthel Scale reassessment indicated ongoing limitations in ADL, such as transfers, bathing, dressing, and mobility, although with reduced impact, leading to increased scores.

By the end of the 12-week treatment, the patient exhibited advancements in activities such as sit-to-stand and stand-tosit maneuvers, sitting posture, standing balance, and walking ten steps using a forearm walking stick.

The ICF Evaluation Display was utilized to visualize and evaluate the re-examination results, offering a comprehensive snapshot of the patient’s functional state to guide further treatment planning. ICF qualifiers were employed as a composite rating scale to assess the extent of issues related to specific ICF categories based on data gathered during assessments and patient interviews [Table 1].^[9]

Patient perspectives

The patient was aware of the seriousness of his situation and accepted his limitations. He recognized that his lower-limb muscle strength and level of independence had improved, but he would always have many limitations in his quality of life and health status.