Grandpa Treamtn Day 6

This day was all about function and functional exercises. I took advantage of the good weather and treated on the deck. It is an optimal location as there are many places to hold on while walking. What I observed was that when my grandfather walked with the cane in his right hand and held on with his left hand, he was able to assume a normal gait pattern. This was not the case while walking with the cane in the left hand and hand rail on the right. Therefore, I had him walk holding on with the left and cane in the right walking forward, backward and side stepping.

I also had him perform his home exercises of hip abduction and extension having his back to the railing of the deck and holding on to his side and rear rather than forward so that he would not compensate with flexion.

I also incorporated another exercise that was recommended to me by a student in my class to reinforce pelvic motion in sitting and it is to perform seated pelvic clocks on a commode and drop a small object ( I choose cereal ) into the bucket. The benefit to doing this on a commodes is that you can obtain the appropriate seat height to maximize range of motion. I had him work on moving his pelvis into anterior rotation.

Finally, I decided to have him try walking with 2 canes. He walked better than I have seen him walk in years and he comment on how his walking felt normal. We practiced taking a few steps with the wheelchair behind him and called it a day.

Grandpa: Enviornmental Impact on Recovery

On Friday afternoon post treatment and after dinner, my grandfather complained about dizziness. This is not a new problem for him as episodes have occurred for years now and the doctor's that he has visited have said that nothing is wrong. (I too have evaluated him in the past to find no evidence of a vestibular cause).

What I did observe was that just prior to our afternoon treatment, he was eating quite a few M & M's, during dinner he had a Sangria and after dinner he had chocolate chip cookies and ice cream.

The next morning, yesterday, I heard him get up in the early morning to go to the bathroom (something that hasn't happened since he has been here) and woke up feeling poorly and observably sluggish. I discovered after it was too late that he choose to have Trix cereal for breakfast.

Our treatment Saturday was productive in gaining range of motion to pelvic extension, his mechanics at the hip and pelvis are normal with the exception of left hip extension. His gait markedly improved post treatment and he walked about 15 steps without and assistive device.

The remainder of the day, he did not indulge in alcohol or sweets and there were no episodes of dizziness.

I hope that today will be more productive.

Treatment Day 5

For today's session I have made sure that the mechanics at his hip pelvis and sacrum are working as they should and we are reinforcing glut medius and minimus strengthening in supine with hip abduction. To reinforce hip extension we are performing bilateral bridging.

To work on proper use of the rolling walker, I have bound his arms so that the walker is within a forearms distance to reinforce advancing the walker with his legs and not his arms. I have also used Mc Connell tape to his right quad to reinforce extension.

I positioned him at the corner of our deck at home and had him hold onto each side rail with the walker in front of him to reinforce an upright rather than forward flexed posture. With my facilitating left knee extension and resisting at the outer left heel maintain a neutral foot we worked on taking a step with the right foot.

We are all able to notice progress in my grandfather's level of independence. He is walking further, 1/4 of a city block independently. He is able to go up and down stairs with supervision and even tried taking a few steps with a straight cane.

Tomorrow, I hope to work in prone and continue to get him weight bearing with proper mechanics on his left leg.

Grandpa treatment Day 1

When I got him in supine for treatment, I noticed again a leg length discrepency of about 1.5 inches and attributed it to the prolonged sitting in the car. I also summized that it is a major contributor to his left knee flexion and his shaking. I suspect that he is flexing his left knee to compensate for the difference in his leg's length since his pelvis is unable to drop on the right to compensate. I also observed and palpated a restriction in his left hamstring and sciatic nerve that prevented him from obtaining knee extension in sitting with out leaning back.

With treatment of the tissues around the pelvis and legs the leg length discrepancy resolved. I also treated the left hamstring/sciatic nerved via functional mobilization with stabilization to his pelvis and left lower extremity. His gait improved and his home program the same, stand every 15 minutes getting both knees straight and weight shift.

I also worked on depressing of the right lower extremity in sitting so that he would not need to bend his left knee in order to properly heel strike.

We also worked step ups on the stairs using 1 handrail and cane (to mimic his home environment) 5 times each.

Throughout the day, I assess the leg length in supine and it manged to be okay, in spite of his sitting most of the day.

Grandpa s/p 4 hour car ride

In spite of hourly stops on the road for a standing session, my grandfather arrived at my home physically compromised.

At the house we opted to keep him outdoors, and practice standing and walking until he literally stabilized and would be safe to perform stairs.

During his first few initial standing and walking bouts he was shaking quite a bit. The shaking subsided with subsequent tries and was gone after about 1 hour and 4 bouts of walking.

My manual treatment consisted of work to his left foot to increase dorsiflexion with the foot in a neutral position. He tendency in walking is to externally rotate it and ambulate with a very narrow base of support (his heels almost touching).

We later worked on step ups on the steps 5 times leading with each leg and after a rest went up the 5 steps using handrails on both sides. He made with a min assist and facilitation to his stepping foot's buttock to elicit depression of the pelvis.

I was not optimistic about his recovery and independence after today.

Grandpa coming home

Upon our return from the rehab facility, we were faced with 5 steps from the outside of his house in. It wasn't pretty but we managed.

Based upon observation and subjective history/complaints our goals for the week as follows:

1. Able to obtain 0 degrees knee extension with standing ADL's, walking, and right lower extremity heel strike.

2. Able to go up and down stairs using both legs for ascending and descending.

3. Progress from rolling walker to straight leg cane.

4. Increase walking distance to 1 city block.

Day 1

I decided to start treatment and when I got him supine noticed that there was about 1.5 inch leg length discrepancy.

Upon functional mobilization with stability to the L. LE and pelvis, they became even. We worked on L. pelvis abduction and extension.

Treatment lasted about 45 minutes and home program was to stand every 15 minutes, with both knees straight and weight shift side to side.

Note that we had adapted his recliner chair to be about 3 inches higher on blocks and provided support behind the his back to get him over his pelvic floor.

Patient tolerated treatment well.

Grandpa

After almost 2 months of rehab status post hip replacement, my family has decided, against the advice of the facility, to discharge my grandfather. We will all be traveling to my home so that I can provide services with home health to try to restore his functioning.

His status has deteriorated slowly with him choosing to use a cane last fall and then came the fall on ice at his home in Vermont which led to his hip replacement surgery 4/29/2010. His recovery has been slow, but he is now walking 100 to 120 feet using a rolling walker, stairs are a min to mod assist with 1 handrail and cane. Sit to stand transfers are independent, bed mobility and transfers, not pretty but independent as well. Medically he is in good health for his 82 years, he had a right THR about 12 years ago and has a 30 year history of Low Back pathology including stenosis.

His chief complaints are as follows:

1. Shaking occasionally with standing, walking and stairs.

2. Decreased ability to ambulate distances.

3. Decreased ability to negotiate stairs.

4

I hope to post video of his treatment and progress, so stay tuned.

Wish me good luck!!

Exciting new Foot and Ankle treatment class

As a result of the positive feedback on the foot section from my Balance class, I have created a 1 day class dedicated to the evaluation and treatment of foot and ankle injuries. The class will focus on how to identify dysfunctional structures associated with certain diagnosis and deformities of the foot and ankle and how to choose the appropriate treatment techniques based upon the structure of your patient's foot.

The functional gains that I have made using these techniques both personally and professionally cause me to consider these techniques the most powerful treatment tools that I know how to perform. Provided that I address the dysfunctional structures and choose the appropriate treatment technique, I have restored 85-100% of range of motion and eradication of symptoms in a couple of minutes. These techniques work on all patients from infants to people in their 90's.

The foot and ankle respond particularly well to these techniques. There is excellent carry over provided that the patient is ambulatory and inexpensive, prefabricated orthosis and taping can be used to reinforce gains. . These techniques can be taught to most patients to so that they can treat themselves.

Several of my patients have avoided surgery and have resolved or halted the progression of deformities including; flat feet, hammar toes, hallux valgus, and talar bunions.

Because the foot is the ultimate base of support for every joint above it, treatment of the foot and ankle profoundly effect the functioning of knee, hip, lower back and everything above.

As stated in my balance class, to be at a decreased risk of falls one must have 8 degrees of ankle dorsiflexion with the knee straight and 10 degrees of dorsiflexion with the knee bent. In order to have a normal push off 90 degress of hallux extension is required.

In the thousands of patients that I have treated, even those without pain, I have never encountered a person with 2 optimally functioning feet. There is not a person who would not benefit from this type of treatment.

Breaking Down the Axle

The men's short program for Figure Skating was the focus of the Olympics last night.

A beautiful skater representing France, Stephane Lambiel performed a planned double axle in his program. This is an unheard of element in Men's figure skating where a triple axle is accepted as the norm. It is not that Mr. Lambiel is a bad jumper, he completed a quadruple toe loop in the same program, it was said by the commentators that he has difficulty performing the axle which involves a forward take off. This not only requires different edging with the skate, but what makes this jump unique is that it is the only jump which requires hip flexion.

When considering that a person's center of gravity is at sacral level 2. It could be that Mr. Lambiel is lacking the appropriate sequencing of range of motion in his take off leg which in turn, alters his center of gravity in the air and prevents him from landing the jump.

Just a thought.

Million Dollar Exercise. What is it worth?

A recent participant of my comprehensive Treatment and Assessment Strategies for Balance Enhancement and Fall Prevention asked the purpose of the Million Dollar Exercise that I teach.

Here was my response.

The reason that I refer to that exercise as a Million Dollar exercise is because it targets so many areas in one activity and it can be broken down into parts to accommodate various levels of patients. Also it can be used as an evaluation and treatment tool

When you have your arms are in contact with your torso, with elbows bent at a 90 degree angle, pushing into the wall and up to the ceiling will elicit a abdominal core contraction. Alignment is important in the rib cage and pelvis for this to happen, so if it doesn't it tells you that you need to address those areas. For treatment you can apply further stabilization challenge to the pelvis, abs, Lower extremities or torso.

While in the before mentioned position, when you take a step forward with one foot and peel the heel off of the floor with the back foot, the patient is able to practice weight acceptance of the front foot and push off with the back foot. Maintaining the hand contact with the wall and allowing the elbows to bend as you weight accept and push off elicits challenge through the system into the weight bearing legs and feet while providing the patient with security by having hand contact into the wall. At this point you can evaluate, dorsiflexion on the weight acceptance foot, hallux extension to 90 degrees on the push off foot and calcaneal position on the push off foot. Treatment can include the stabilization mentioned before or functional mobilizations to the foot, ankle, pelvis.

With the hand contact the same as the previous step we add a lifting the push off foot up toward our chest and a coming up into the tip toe of the previous steps weight acceptance leg. This increases the challenge of balance in the weight bearing leg, accentuates pelvic depression on the weight bearing leg and, pelvic elevation on the lifted lower extremity that is off of the floor. In this position it is very easy to note compensations through the torso that may be revealed, similar to what we would see in the pelvic dropping test off of the book and leg swing test. You can evaluate the ability of the pelvis to elevate and depress as well as pelvic extension on the push off leg and pelvic flexion of the lifted leg that should be independent of spine. Compensations that you may see are side bend, rotation, trunk flexion or extension. Treatment would include all of the above plus stability challenge to pelvic depression or elevation, and/or weight bearing lower extremity.

Another exercise that I like to do and demonstrated in class is attached to this email. It is similar to the million dollar exercise except you will not get as much of the abdominal core contraction because your hand contact is at your side and not in front. I usually perform it using a step stool or on a stair case.

New Years Resolution

January 3, 2010

My new year’s resolution is to get my thoughts on the web.

I was watching The Biggest Loser Finally the other night. The final 3 contestants lost on average of about 45% of their body weight. I was obviously moved by their physical transformation but what struck me was the obvious change in their persona. To my knowledge they did not receive any psychological counseling during their stay on the ranch yet they now exhibited confidence, joy and peace with their bodies and their minds.

America watches as these people are put through grueling workouts. We watch as these people want to quit, even beg to quit. Although I realize that show is edited and the participants are closely monitored, these workouts even scare me a little. It is at these moments that I believe that these psychological transformations take place. It is the doing, even when we don’t want to and not quitting even when we want to that elicits change.

In many of the course evaluations for my Fall Prevention class students have requested that I demonstrate the treatment techniques on an appropriate patient. This week I choose to film my treatment a family member who was visiting for the holiday weekend. This is not the first time that I have treated this individual and there were many a year when I have swore never to treat him again. He is the type of patient who hurts all over, he is vague with the triggers of his pain and I believe a symptom magnifier.

In the past I have treated him as any manual therapist would, patient lying down, me palpating and utilizing various release techniques. This would elicit the usual moans and groans, oohhs and ahhs that would drive me crazy and truth be told would not yield the results that I had hoped for. All of the before mentioned factors along with my personal relationship with this person made my treating him a nightmare, but for the sake of my students, inspiration from the biggest loser, and renewed confidence as a therapist from teaching my class I decided to try again.

I kept my evaluation and treatment functional for several reasons. I was able to keep the patient focused on what he was doing and not his pain. I would critique and correct his technique and a keep my hands on him to mobilize, evaluate and facilitate. By doing this I was able to note that he was significantly more stable and strong than he appeared to be. Because he needed to focus on the functional tasks at hand he was less able to focus on his pain and if he experienced symptoms, I was able to immediately note when they occurred to identify triggers as well as area that required treatment.

I was able to perform 3 sessions which included his evaluation. At our post treatment filming he choose to walk without his cane, was able to perform sit to stand and stand to sit transfers without holding on and with control, and was able to get out of bed unassisted and using proper form. During his entire stay I required him to sit on a foam wedge to keep him in good alignment. I caught him not doing so only once when I returned from snow shoeing. Incidentally, when he got up after not sitting on the wedge he experienced pain to his left buttock.

I sent him home with the following instructions:

DAILY TO DO:

MAKE SURE THAT IF YOU ARE IN ANY CHAIR FOR LONGER THAN 15 MINUTES THAT YOU ARE SITTING ON A WEDGE. PERIODICALLY WHEN YOU ARE SITTING ON THE WEDGE PUSH BOTH FEET INTO THE FLOOR TO FEEL YOUR BELLY GET HARD.

1. GETTING UP AND SITTING DOWN FROM A CHAIR, 15 TIMES A DAY.
Remember to:
A. Focus on a point on the floor about 3 feet in front of your feet.
B. Place your hand or hands on the front of your thighs, bow and let your hands drop to your knees. When your hands touch your knees then bend them to sit with control.
C. When you go to get up push into the floor with both feet, find a point on the floor 3 feet in front of your feet, bend at your hips and stand.

2. PRACTICE GETTING UP FORM THE BED, 10 TIMES.
Remember to:
A. Reach with your arm across your body to the edge of the bed and
B. Turn and nod your head at the same time
C. Bend your knees up toward your chest
D. Slightly straighten your knees so that your feet and lower legs are off of the bed.
E. Push your elbow into the bed and
F. Push your ass down to the bed as you move into a sitting position at the same time.

If you choose not to do any of the above you are harming your body! No matter what medication you take or what surgery you may have you will still be harming your body if you choose not to do these things above.

From this experience I had learned several valuable pieces of information:

1. This person was at a significantly less risk for falling that I had thought based upon his gait pattern and subjective complaints/vocalizations.

2. I was able to target the appropriate dysfunctional areas that would allow for maximal functional improvement.

3. He had dysfunction and instability around his left pelvic region which concurred with his subjective report of pain to the left buttock.

4. He lacked appropriate motion to perform certain functional activities which needed to be treated.

5. When he was able to perform the activities with proper form he was asymptomatic. When he did not he would present with “Charley Horse” or “pain”. This allowed me to examine his form and correct as needed.

6. I was able to allow him to experience the difference in how it feels to perform an activity with appropriate form and dysfunctional technique.

7. I was able to express to him that even though his has physical challenges he is able to function with less pain by changing the way he does things and when he continues to do these activities wrong he is harming himself. Therefore, regardless of any medical or pharmaceutical intervention he will continue to harm himself.

8. Like the Biggest Loser it is not about what you have been given it is how you choose to use it.

I plan to follow up with him upon my next visit home in about 2 weeks. I plan to follow up daily to inquire about compliance, reevaluate, and hopefully work on gait and stairs.