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.