Functional recovery following scoliosis deformity correction in a patient with Parkinson’s disease: A case report

Mohammed Shabeer N*

Neuro – Physiotherapist, Department of Physiotherapy and Rehabilitation, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu

*Correspondence

Abstract

Introduction

Patients with Parkinson’s disease undergoing major spinal surgery may present complex rehabilitation challenges because of pre-existing motor impairment, gait dysfunction, postural instability and the potential for postoperative medical complications. This case describes the rehabilitation course of a patient with Parkinson’s disease who underwent complex lumbar deformity correction and subsequently developed life-threatening postoperative complications, including massive pulmonary thromboembolism, cardiac arrest, prolonged mechanical ventilation and intensive care unit-acquired weakness.

Case Presentation

A 54-year-old man with Parkinson’s disease diagnosed in 2010 and treated with regular antiparkinsonian medication presented with progressive low back pain, left lower-limb numbness and paresthesia, gait difficulty, freezing during turning and obstacle crossing, foot drag and left knee buckling. Imaging demonstrated lumbar degenerative scoliosis with canal compromise at L3–L4 and L4–L5. Preoperatively, he had left lower-limb weakness, sensory impairment in the L3–L5 dermatomes, impaired standing balance and a short-stepping, freezing gait requiring minimal support. Following spinal deformity correction, the patient initially commenced bed exercises and chair mobilization. He subsequently developed respiratory symptoms followed by cardiac arrest. A second cardiac arrest occurred the following day, and echocardiography demonstrated massive pulmonary thromboembolism. Thrombolytic/life-saving intervention and Thrombectomy were performed. He required prolonged mechanical ventilation and developed severe weakness consistent with intensive care unit-acquired weakness.

On postoperative day 9, reassessment demonstrated Medical Research Council grades of 2/5 in both upper limbs and 1/5 in lower limbs, poor static and dynamic sitting balance, and maximum assistance requirements for functional mobility. A structured rehabilitation programme was subsequently implemented, including respiratory physiotherapy, range-of-motion exercises, limb facilitation, trunk control training, progressive mobility, tilt-table standing, motorized cycling and ankle continuous passive motion. Functional Independence Measure scores improved from 49 on postoperative day 9 to 61 at discharge and subsequently to 98 and 124 during follow-up, with the latter representing independence according to the presentation data.

Conclusion

This case highlights the importance of early reassessment, cardiopulmonary monitoring, progressive rehabilitation and multidisciplinary management following severe postoperative complications in a patient with Parkinson’s disease. Despite cardiac arrest, massive pulmonary embolism, prolonged ventilation and intensive care unit-acquired weakness, structured rehabilitation was associated with substantial improvement in functional independence.

Keywords: Parkinson’s disease; Spinal deformity; Pulmonary embolism; ICU-acquired weakness; Neurorehabilitation; Case report

Introduction

Parkinson’s disease is a progressive neurological disorder associated with motor impairments including bradykinesia, rigidity, tremor, postural instability and gait dysfunction. These impairments can substantially affect mobility and functional independence and may complicate recovery following major orthopedic or spinal procedures. Spinal deformity correction in a patient with established Parkinson’s disease may present additional rehabilitation challenges because pre-existing gait dysfunction, freezing, postural impairment and muscle weakness may interact with postoperative pain, surgical restrictions, cardiopulmonary complications and deconditioning.

The present case describes the rehabilitation course of a patient with long-standing Parkinson’s disease who underwent complex lumbar deformity correction and subsequently experienced two episodes of cardiac arrest, massive pulmonary thromboembolism requiring thrombectomy, prolonged mechanical ventilation and severe intensive care unit-acquired weakness. The patient subsequently underwent structured multidisciplinary rehabilitation with progressive improvement in functional independence. The case is clinically relevant because it illustrates the changing rehabilitation priorities across the perioperative and post-intensive-care phases and demonstrates the potential importance of progressive, goal-oriented rehabilitation following severe postoperative complications.

Case Presentation

A 54-year-old man with a known history of Parkinson’s disease since 2010 was evaluated for progressive lumbar symptoms and functional difficulty. The patient had been receiving regular medication for Parkinson’s disease. His past surgical history included left hernioplasty approximately two years before the current episode.

Presenting complaints

The major complaints presented were

Severe low back pain
Left lower-limb numbness and paresthesia, greater on the left than the right
Difficulty walking
Freezing episodes during turning and obstacle crossing
Foot drags during walking
Left knee buckling
Bowel and bladder incontinence

The pain was reported in the lower back and left lower limb, aggravated by sitting and standing and relieved by lying down. The pain was described as tingling in nature.

Clinical Findings

Preoperative assessment

The preoperative physiotherapy assessment demonstrated:

Pain – VAS 8/10
Upper – limb ROM| Full and free
Lower – limb ROM| Full and free
Upper – limb strength| 5/5 bilaterally
Right lower limb – 4+/5
Left hip – 3/5
Left knee – 4/5
Left ankle dorsiflexion – 4/5
Left EHL – 3+/5
Sensation| Pain and touch reduced by approximately 50% in left L3–L5 dermatomes
Sitting balance – Good
Static standing balance – Fair
Dynamic standing balance – Poor
Gait – Short stepping, freezing positive, minimal support required.

Diagnostic Assessment

The patient had a history of Parkinson’s disease and progressive low back symptoms. MRI demonstrated degenerative scoliosis with a right-sided curve and compression of the thecal structures at L3–L4 and L4–L5. The patient was planned for deformity correction with L2–L5 pedicle screw and rod fixation, L3–L5 laminectomy/posterior decompression and transforaminal lumbar interbody fusion.

Timeline of Clinical Course

POD 1 – Initially conscious and oriented; surgical drain in situ; left UL tremor. Bed exercises initiated; mobilization to chair

POD 1 – Cough and breathing difficulty followed by witnessed cardiac arrest, CPR performed; spontaneous breathing returned

POD 2 – Second witnessed cardiac arrest; patient on anticoagulation/vasopressors, ACLS-based resuscitation; subsequent investigation

POD 2 – Massive pulmonary thromboembolism identified, Life-saving lysis/thrombectomy performed

POD 3–8 – Mechanical ventilation; OFF-state dystonia and rigidity, Medical/ICU management

POD 9 – Tracheostomy documented; patient on room air thermoset| Severe ICU-acquired weakness identified

POD 9 – MRC: UL 2/5, LL 1/5; poor sitting balance, Maximum assistance required

POD 9 onward – Progressive rehabilitation| Respiratory therapy, ROM, facilitation, trunk control and mobility training

Discharge/POD 37 – Functional improvement, FIM 61

Follow-up – Home-based rehabilitation| Progressive mobility and functional training

3 months – Further functional recovery, FIM reported as 124; independent standing and walking for 50 m documented.

Therapeutic Intervention

Surgical and medical management

The patient underwent complex spinal deformity correction for lumbar degenerative scoliosis and associated canal stenosis.

The documented postoperative surgical plan included:

L2–L5 pedicle screw and rod fixation
L3–L5 laminectomy
Posterior decompression
TLIF

Postoperatively, the patient developed severe cardiopulmonary complications, including two witnessed cardiac arrests and massive pulmonary thromboembolism. Thrombectomy was performed as a life-saving intervention. The patient subsequently required prolonged mechanical ventilation from approximately POD 3 to POD 8.During this period, OFF-state dystonia and rigidity were also documented and managed medically with propofol, sustained-release Syndopa and clobazam according to the presentation.

Physiotherapy intervention

The initial postoperative physiotherapy aims were to:

Improve respiratory function.
Protect the surgical correction.
Manage pain and symptoms.
Restore mobility and functional independence.

Intervention| Dose/frequency documented in PPT

Chest physiotherapy and suctioning – 15 min, 6 times/day
PROM to upper and lower limbs – 10 repetitions each side × 3 sets, 2 times/day
Facilitation to upper and lower limbs – 10 repetitions each side × 3 sets, 2 times/day
Turning to either side – 10 repetitions each side, moderate support and verbal cues, 2 times/day
Trunk control training – 10 repetitions each side, 2 times/day
Out-of-bed mobilization – Minimum 2 hours, 2 times/day
Tilt-table standing – 30 min, once/day
Motorized cycling – 20 min, once/day
Ankle CPM – 30 min, twice/day

These interventions were progressed according to the patient’s clinical status and functional tolerance. Because of the occurrence of massive pulmonary thromboembolism and cardiac arrest, cardiopulmonary status required close monitoring during rehabilitation.

ICF-Based Rehabilitation Assessment

The rehabilitation assessment was organized using the International Classification of Functioning, Disability and Health framework.

Health condition

Parkinson’s disease
Lumbar degenerative scoliosis
Lumbar canal stenosis
Postoperative pulmonary embolism
Intensive care unit-acquired weakness

Body functions and structures

Low back pain
Left lower-limb weakness
L3–L5 sensory impairment
Bradykinesia
Freezing of gait
Poor standing balance
Respiratory impairment following pulmonary embolism
Severe generalized weakness following prolonged ICU stay

Activity limitations

Difficulty with bed mobility
Assisted sit-to-stand
Inability to walk independently
Difficulty with transfers
Dependence in activities of daily living

Participation restrictions

Inability to return to normal daily activities
Reduced community mobility
Increased caregiver dependence

Environmental factors

Multidisciplinary rehabilitation team
Family support
Walker
ICU facilities

Personal factors

Long-standing Parkinson’s disease
Patient motivation
Good family support

Rehabilitation Goals

Short-term goals

Improve chest hygiene.
Improve muscle strength from grade 2 to grade 4 within two weeks.
Maintain joint ROM.
Improve functional mobility from maximum assistance toward minimal assistance.
Improve sitting balance from poor to good within two weeks.

Long-term goal

The primary long-term goal was to achieve independence in:

Bed mobility
Sitting
Transfers

These goals were subsequently extended through progressive standing and walking training according to functional recovery.

Follow-Up and Outcomes

Functional Independence Measure

Functional recovery was monitored using the Functional Independence Measure (FIM).

FIM domain	POD 9	POD 37/ Discharge	Follow up 1	Follow up 2
Self-care	6	18	33	42
Sphincter control	2	2	10	12
Transfers	3	5	14	21
Locomotion	2	5	6	14
Communication	14	14	14	14
Social cognition	21	21	21	21
Total FIM	49	61	98	124

The presentation categorized the total scores as maximum assistance at POD 9, moderate assistance at discharge, minimal assistance during subsequent follow-up and independent at the final reported assessment.

Home-based rehabilitation

Following discharge, home-based rehabilitation was continued.

The patient-oriented goals included:

Independent bed mobility within two weeks
Sit-to-stand using walker support within two weeks
Independent sitting within two weeks
Independent standing using walker support within four weeks

Family members were also trained in car-transfer techniques.

At follow-up, the patient achieved independent standing and walking for approximately 50 metres.

Discussion

This case demonstrates the complexity of rehabilitation following major spinal deformity correction in a patient with long-standing Parkinson’s disease when recovery is complicated by severe cardiopulmonary and critical-care events. The patient’s preoperative presentation already included several factors likely to influence postoperative mobility, including Parkinson’s disease, short-stepping gait, freezing, impaired dynamic balance, left lower-limb weakness and sensory impairment. These findings established a relatively complex baseline from which postoperative recovery had to occur. The postoperative course substantially changed the rehabilitation priorities. Initially, the focus was on respiratory function, protection of the surgical correction, symptom management and graded mobilization. However, the development of respiratory symptoms followed by cardiac arrest and subsequently identified massive pulmonary thromboembolism resulted in a major interruption to the expected rehabilitation trajectory. The patient subsequently required prolonged mechanical ventilation. By POD 9, severe generalized weakness was documented, with MRC grades of 2/5 in both upper limbs and 1/5 in both lower limbs, poor sitting balance and maximum assistance requirements for functional mobility.

At this stage, rehabilitation had to shift from the patient’s original neurological and postoperative mobility limitations toward management of severe weakness, impaired postural control, respiratory needs and dependence in basic activities. The intervention therefore progressed through a combination of respiratory physiotherapy, maintenance of joint mobility, neuromuscular facilitation, trunk control, bed mobility, progressive mobilisation, tilt-table standing and cycling. The program was subsequently extended to task-specific functional activities and home-based rehabilitation. The FIM trajectory provides an objective description of functional change. The total FIM score increased from 49 on POD 9 to 61 at discharge, followed by further improvement to 98 and eventually 124 in the reported follow-up data. This progression is clinically important because the patient was initially severely dependent after the ICU course but subsequently achieved independent standing and 50-metre walking according to the follow-up presentation.

The case also demonstrates the importance of multidisciplinary management. The clinical course required coordination between surgical, medical, critical-care and rehabilitation teams. In addition, family education became an important component of discharge preparation and continued home-based rehabilitation. From a physiotherapy perspective, one important lesson is that rehabilitation planning must remain dynamic. A patient who begins with a primarily neurological and musculoskeletal rehabilitation profile may develop acute cardiopulmonary and critical-care complications that completely alter the immediate rehabilitation priorities. The case supports the principle of repeated functional reassessment and progression from impairment-focused interventions toward task-specific functional training as the patient’s medical condition permits.

Clinical Implications

Reassess functional status after major ICU events – Preoperative functional status should not be assumed to represent the patient’s post-ICU rehabilitation needs.
Monitor cardiopulmonary status closely – Major postoperative cardiopulmonary complications can substantially alter rehabilitation safety and progression.
Progress rehabilitation according to medical stability – Rehabilitation should transition from positioning, respiratory management and maintenance interventions toward active functional training as tolerated.
Use objective outcome measures – Serial FIM assessment provided a measurable description of functional progression in this case.
Use task-specific rehabilitation – Bed mobility, transfers, standing, walking and car-transfer training directly addressed the patient’s functional goals.
Include caregivers in rehabilitation – Family education supported discharge readiness and continuation of rehabilitation at home.

Functional recovery following scoliosis deformity correction in a patient with Parkinson’s disease: A case report

Functional recovery following scoliosis deformity correction in a patient with Parkinson’s disease: A case report

Mohammed Shabeer N*

Nightingale Journals