Psychologically informed strategies to improve expectations for post-operative return to function in a patient following cervical total disc replacement: a case report.

Abstract

Background and Purpose: Patient expectation is associated with clinical outcomes. Patient expectations can be modified by healthcare providers. The purpose of this study is to describe the implementation of psychologically informed practice strategies targeting expectation in a patient with low expectations for return to functional activities following cervical total disc replacement. Case Description: The patient was a 44-year-old male pharmacist referred to physical therapy 10 weeks after C4/C5 cervical total disc replacement (TDR). Prior to surgery the patient had a 4 year history of neck pain and impaired balance following an injury while working out at the gym.  The patient presented with pain (3/10 on the numeric rating scale), functional limitations (38% on the neck disability index), impaired balance, posture, and upper extremity strength. Patient goals for therapy were to return to working out fully in the gym; however, he expected only a 50% improvement in his ability to function. The patient was treated for 13 visits over an 8-week episode. Treatment included standard physical therapy addressing the noted impairments. Additionally, the patient’s expectations for treatment outcomes were addressed through graded exposure to activities for which he had identified low expectations, education regarding the likelihood of successful outcomes based on a review of a randomized controlled trial of patients with similar surgery, and re-enforcement of post-surgical x-rays demonstrating appropriate healing. Outcomes: The patient’s expectations improved over the course of treatment to expecting 100% improvement in his ability to function. Improved expectations were associated with clinically meaningful improvements in both pain (0/10) and the neck disability index (20%) as well as meeting his goal of returning to working out at the gym. Conclusion and Clinical Relevance: Expectations are a modifiable psychological construct with a known association to clinical outcomes. We describe a patient in whom expectations were measured and specifically targeted as part of an overall physical therapy approach. Such an approach was associated with both improved expectations for recovery as well as clinically meaningful improvements in clinical outcomes suggesting a possible mediating effect of expectations on clinical outcomes perhaps worthy of further study.