Carryover 2 years after treatment for repetitive falling

Last entry I spoke about carry over. I recently saw a patient who I treated 2 years ago for repeated falling. I tell her story in almost all of my classes as it was one of the first experiences that I had using Diagnostic Motion Evaluation that amazed me, here it is:

An older woman, who is an avid tennis player, had been falling on the tennis court. Her multiple falls resulted in an ankle fracture and pelvis fracture on her left side. As a result she was fearful that she would have to quit her favorite sport.

When I had seen her, I decided to perform the foot clock evaluation in the directions of 3-9 o’clock. My rationale was this; she had been falling only on the tennis court, not during her normal community ambulation. The motion in tennis that is distinctly different than walking are the lateral motion. When I had her do this action, I observed that her Right medial foot came almost completely off of the floor very soon after she began to shift her weight toward her right side. Bear in mind her injuries were on her Left and I assumed that her dysfunction would be on the Left side as well.

Based on the principle of Diagnostic Motion Evaluation, this was a closed chain activity,  therefore, my beginning observation point was just above the knee. Base on her compensation being with the first few degrees of motion, I realized that her dysfunction was somewhere at the proximal tibia. I brought her into sitting and moved her passively to determine if this was a structural or a non structural dysfunction. The dysfunction was the same and therefore was determined to be structural.

When I palpated, I found the structural dysfunction to be at the superior/medial tibia and I treated with ARMS. I re educated by facilitating her medial foot to stay on the floor as she shifted to the Right and her home program was foot clocks 3-9 with progression to side stepping and karaokes.

As I had mentioned earlier, until a few weeks ago, I had not seen her in over 2 years. I am thrilled to report that since our treatment she has not fallen on the tennis court and she continues to play consistently.

She did however, mention tripping over a step that she had not seen, so I decided to evaluate open chain Dorsiflexion and this is what I saw.

http://www.youtube.com/watch?v=ZZlWMNXOPhw

Her initial walking pattern revealed external rotation of the right foot, narrow base of support, widened arm swing and mild trendelenberg to the right.

http://www.youtube.com/watch?v=c0jS6EXihe4

I will post her treatment for her gait and dorsiflexion next post.

2 week follow up of Neuro pt's AROM Dorsiflexion

Here is a video of my patient’s AROM Dorsiflexion 2 weeks post treatment:

http://www.youtube.com/watch?v=rIk0YLXysT4

To see her original videos copy and paste the following link or go to www.sigproed.com, resources: www.sigproed.com/res_before_after.html#neuropatient_dorsifexion

 A frequently asked question during my classes is how to maintain the gains that we make in the clinic. Like my students, I find carry over to be the most challenging aspect of therapy. It is easy to gain range and function when the patient is in therapy, but when the patient is independent and at home we often see our gains disappear in as quickly as a day’s time.

My experience has been that carry over is impacted by the following:

1. Age: A younger patient will tend to have greater carry over.
2. Compliance to home program: Individuals who are vigilant with their home program have better carry over.
3. Duration of dysfunction: The less time that a problem has been going on the easier it is to rectify.
4. Patient Choices: Some individuals will make unwise choices in their activities and overdo leading to the undoing many of the gains made in clinic.
5. Patient’s level of activity: If I am working on the foot or gait in the clinic, I find significant carry over with patients who ambulate, as walking is their home program.
6. Treating the correct dysfunction that is inhibiting the function.

Since we cannot change a patient’s age or the duration of their dysfunction, we really need to focus on the factors that we can change.

Treating the correct dysfunction: Lets use our patient mentioned in the previous entry as an example: her dysfunction was a gait dysfunction associated with heel strike. This occurred secondary to decrease AROM in dorsiflexion in the open chain, lacking 24 degrees. At this point we do not know why she lacks open chain dorsiflexion, it could be due to any of the following reasons:

1. Structural dysfunction in the calf muscles
2. Structural dysfunction in bone, fascia or nerve of the calf and foot
3. Joint restrictions in the ankle joint
4. Non structural dysfunction due to her Upper Motor Neuron Injury of CP. 

I could have legitimately treated any of the above dysfunctions and gained range in clinic but my gains would not have lasted as I was not treating the dysfunction that was causing her to lack AROM dorsiflexion in the open chain.

Only by using Diagnostic Motion Evaluation was I able to determine that the reason she lacked AROM was due to structural dysfunction in her hallux. When that was restored we gained and maintained AROM, at this point 2 weeks post treatment.

Compliance: I have been told that Diane Lee tells her patients “I am not your aspirin, do your exercises”.  Everyone’s amount of time and level of compliance will be different. Find out what works best for your patients. A 5 minute routine 1 time a day, 1 minute of exercise 5 times a day or exercises that can be incorporated into their other ADL’s. In addition to modifying your home program to tailor patient’s lifestyles it is vital that the patient’s understand the importance of doing their home programs. Saying something like, “97% of my patient’s who perform their home programs have success in their rehab”.

Patient Choices: Educating the patient’s on what activities are appropriate to perform and what activities they should avoid or modify will impact carryover and healing. For the some patients it is difficult for them to give up, albeit temporary an activity or sport that they love, for others, it may be difficult to get them out of their favorite chair.

Providing a specific timeframe and guidelines to activities will be crucial in their not committing harm to themselves when they are on their own.   

Amazing increase in AROM on a Patient with Neurological Tone

As most of you know I have found great success in my practice using Diagnostic Motion Evaluation (DME) and the ARMS technique, there are occasion where I am amazed by what I find and the result in my patient's range of motion when I apply both techniques. I was particularly surprised by this result as the patient has neurological tone secondary to Cerebral Palsy.  

The following is an example of the power of (DME), I can say with certainty that I would not have fathomed that restriction in the big toe would have such an impact on open chain dorsiflexion as it did with this patient.

I had been working with a woman who was born with a mild case of Cerebral Palsy. Upon my most recent evaluation of her walking, I determined that we need to work on Open Chain Dorsiflexion on her affected side. Her primary therapist and I filmed her performing Bilateral AROM Dorsiflexion in the open chain. The film can be found at:

http://www.youtube.com/watch?v=hmXLNzvoEMM.

We also measured goniometrically, AROM to be lacking 24 degrees Dorsiflexion on her R. ankle. 

Because of the tone in her foot and ankle, her primary therapist and I were dubious about what if any AROM we could achieve. Keeping with the principles of Diagnostic Motion Evaluation I tested PROM going from Distal to Proximal beginning with the distal hallux (big toe). I found that there were structural restrictions there and treated with ARMS, I continued to evaluate and treat the hallux for a few minutes, no longer than 3, this was the result.

http://www.youtube.com/watch?v=50ZTO5VKRsw 

To see before and after side by side copy and paste this link www.sigproed.com/res_before_after.html#neuropatient_dorsifexion

FULL ACTIVE DORSIFLEXION RIGHT EQUAL TO LEFT WITH MOBILIZATION ONLY TO THE HALLUX!!

This caused me to ponder how to differentiate between palpating tone and structural dysfunction. I came up with the following differences:

1. Structural Restrictions will be point tender, tone will not
2. Tone may elicit clonus, structural restrictions will not

 Home program for this patient is ankle pumps.

Her next goal is to be able to achieve open chain ankle circles. Stay tuned, I will be posting her 2 week follow up next week.

Importance of Walking Speed

Recently walking speed has been termed the “Sixth Vital Sign” as it appears to be a strong indicator of health status, a predictor of future events, and is used to help determine outcomes such as; functional status, discharge location and the need for rehabilitation. 

A longitudinal study of 11 years found that people with a slower walking speed in middle age were one and a half times more likely to develop dementia compared to people with faster walking speed.  Other research supports walking speed as a predictor of the post hospital discharge location 78% percent of the time.

In 2009 walking speed was chosen by a panel of experts as the standardized assessment to measure locomotion for the Motor Function Domain category of the NIH Toolbox. The reason for this included the following: walking speed is safe, requires no special equipment, can be administered in less than 2 minutes, is easy to calculate, is highly reliable and has published norms.

While walking speed varies by age, gender and anthropometrics, the range for normal walking speed is 1.2-1.4 meters/second (m/s) or 2.64-3.08 mph.. Small changes in walking speed can greatly affect the functional status patients. In a 2006 study using a diverse group of older participants with varying diagnosis, only 0.05 m/s (0.11 mph) was calculated as the needed change for a meaningful improvement in walking speed. For patients without normal walking speed an improvement of at least 0.1 m/s or 0.2 mph has been shown to be a predictor of future well-being, while a decrease in the same amount is linked with poorer health status, more disability, longer hospital stays, and increased medial costs.

Walking is a complex functional activity with many variables that contribute to and influence walking speed. Research has demonstrated that very small improvements in walking speed are linked to function, independence and health status. Understanding, evaluating and treating the variables that affect your patient’s walking speed can mean the difference between independence and morbidity.

The Restoring Efficient Balance and Gait through Targeted Evaluation and Treatment Strategies is unique as it provides the PT with numerous functional approaches to determine exactly where a gait deficit occurs, why it is happening and whether the dysfunction a structural or neuromuscular dysfunction.  From this information appropriate treatment strategies that are quick and effective can be immediately incorporated into any practice settings with lasting results.

What makes Signature Allied Strategies class different than other Gait classes is the focus on the foot and ankle. The foot provides the primary generator of propulsive force in walking and its efficient function is vital to gait and improvements in walking speed. Additionally the foot is the base of support in walking and deficits in its function can lead to falling, neuropathy, slower walking speed, and painful conditions such as bunions and hammertoes.

To see improvements in gait which are the result of treatment performed only to the foot click the following link: http://www.sigproed.com/res_before_after.html

To view a list of upcoming classes including Restoring Efficient Balance and Gait click on: http://www.sigproed.com/live_seminars.html

To host a class or post a question or comment: http://www.sigproed.com/Contacts.html