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.

Why the hallux isn't touching the floor and how to fix it

50% of weight bearing through the toes should occur in the hallux aka. big toe. It is an integral structure for balance and gait. When it is not articulating with the floor it can lead to; balance deficits,  falling and gait abnormalities/inefficiencies.

Try standing on one foot then try again while lifting your big toe off of the ground.

I have had several patients with this problem and the way to solve it is to determine if it is due to a structural dysfunction, an anatomical structure that is blocking motion, or a non structural dysfunction. To review non-structural dysfunctions can be due to:

1. Inflammation
2. Alignment
3. Severe Atrophy
4. Upper Motor Neuron Disease or Injury
5. Lower Motor Neuron Disease or Injury

If it is a structural dysfunction, there are several ways to determine what structures are causing the hallux to be stuck in extension.

1. Palpate up the kinetic chain: If a anatomical structure is malalgined it is usually due to forces acting on that structure from its base of supports. Palpating the 1st, metetarsal, medial cunniforms, navicular, talus, and calcaneus for restrictions in the tissues should reveal the cause of the hallux extension.

2. Reposition, Release, and Re educate: Meaning put the toe in the position it should be and see and feel for structural restrictions up the kinetic chain. Then release those and re educate.

3. Diagnostic Motion Evaluation: Doing foot clocks or having the patient perform other types of  movement over a stationary foot in the closed chain will revel dysfunctions at the location of compensation or disjointed motion. This can be done in standing, sitting or hook lying.

The observer must watch for the following; 
a. When and where the motion stops or is no longer sequential or evenly distributed.
b. When the patient compensates for the motion, in the case of the foot the compensation is usually the sole of the foot coming off of the floor.