Case Study: Patient cannot negotiate stairs

I stress in my class to focus on what the patient cannot do functionally to guide your evaluation and treatment by asking “What activity or activities do you have difficulty performing”.

This is beneficial for the following reasons:

1. We now have functional goals which are vital for insurance reimbursement

2. We now can break the activity down into its components and determine where the dysfunction is and what type of dysfunction exists.

3. As a result we will be able to provide the appropriate treatment to restore function.

I was recently given such a case study and asked to evaluate and treat the following functional limitations.

1. Patient is unable to negotiate stairs
2. Patient is unable to balance on one foot to don clothes

Significant patient history is the following:

1. Total toe replacement over 5 years ago on the R.
2. Trendelenberg gait on the right

When we observe this patient we notice the following:

1. Bilateral pronated feet
2. Right hallux extension, approximately 3 degrees in neutral
3. Diminished push off phase of gait.

My evaluation will be as follows: There are u-tube links next to the various evaluations

1. For negotiating stairs I will evaluate:

1. ROM of dorsiflexion with the knee bent in stepping (going up and going down). The knee should come forward over the toes. Going up: http://www.youtube.com/watch?v=-3JxExXQKM0&feature=relmfu Going down: http://www.youtube.com/watch?v=KMCieNrpwfo
2. Pelvic Depression with the leading leg on descending stairs, it should drop 2 inches:http://www.youtube.com/watch?v=047nRKXzBpw&feature=relmfu
3. Hamstring Contraction. You should feel a contraction with your hand. http://www.youtube.com/watch?v=JEyM4as3YRQ&feature=relmfu

2. For Single leg Balance I will evaluate:

4. PROM of the hallux to neutral
5. AROM of the hallux in flexion
6. Observing where motion occurs (motion = instability) Single leg balance

Pelvic stabilization with lower extremity hip/pelvic extension

One of the most challenging movements to achieve is stabilization of the lumbar spine with hip extension. The reason is that virtually every human being lacks efficient hip extension. The compensation for a lack of hip extension results in excessive extension in the spine in younger people and flexion of the spine in older people. This is, in my opinion, one of the major reasons that lower back pathology is a pandemic in society.

Various authors state that normal hip extension is as little as 10 degrees and as much as 50 degrees. (Note that these authors do not state whether the lumbar spine was stabilized when the range of motion measurements were taken.) I believe it to be 30 degrees without compensation of the lumbar spine as this is the amount of hip extension needed to ambulate with a efficient gait pattern.

The following is an awesome activity to do with your clients to disassociate stabilization of the lumbar spine with hip extension. My class and I came up with it in our Balance and Gait Class.

As see in the photo to the left, have your client stand behind a chair and wrap a towel or a strap around the lumbar spine or at the particular segment or vertebrae that you are trying to stabilize. Apply a forward force with the towel so the patient engages their abdominal core stabilizers and the patient can resist without straining. The patient may hold onto the back or the chair for support or on the therapist's shoulders.

In the photo in the right, ask the patient to hold their trunk stationary maintaining the pressure of their back on the towel as they move one leg posterior so that the toes of that leg are parallel with the heel of the leg that is not moving (this is the equivalent of 30 degrees of hip extension). Have the patient repeat or alternate legs moving posterior.

To see a video of this activity, click the link: http://www.youtube.com/watch?v=OPwJaiiuRqI&feature=youtu.be

Just a footnote, if your client is not able to perform the activity without compensation, there is either a structural or non structural dysfunction of the thigh, pelvis, sacrum or a non-structural dysfunction in the lumbar spine that needs to be addressed first.