By guest blogger, Susan Bamberger
The patient is better, but symptoms are not fully resolved. In determining the next step, considerations include the following:
- Analysis of the exercise:
- Is he performing the exercises as prescribed?
- Is he reaching end range?
- Is the exercise correct?
- He is performing the exercise correctly, and he is reaching end range. It is too premature to abandon the exercise. In one visit, he is demonstrating improvement, as he can run longer and with less pain.
2) Is he doing anything between the exercises that may aggravate his symptoms?
In his detailed journal, he had stopped all the other stretches as requested, and had not really changed his regular routine. He was not doing anything in his life that might aggravate the hip.
3) Was there anything about the posture of running that might aggravate his symptoms?
In this case it made sense to assess his running posture. This was not a running gait analysis, but rather an evaluation of the hip posture in relation to the understanding that his range of motion decreases and pain is produced when running. A derangement causes a mechanical obstruction, and therefore I wanted to see what it was about his running that was causing the mechanical obstruction.
Example of the running posture he was assuming:
With the forward flexed posture, it was reasonable to conclude this may contribute to his pain presentation. He was experiencing 2/10 pain when running during this demonstration, as he had just run over for the visit. So, I asked him to stand more upright by engaging his hip extensors. With this positional modification, his pain went away.
Two days later, the patient returned, reporting he could run longer- 15 minutes, vs 10 minutes before, He reported he was learning to run upright, but was not able to maintain his upright posture, When he experienced pain, if he corrected his posture, the pain went away immediately.
Correcting posture with activities can be a process that takes a long time to correct. It is best to correct the pain before the pain comes on, but at first this may be challenging. With diligence, he should be able to permanently fix his running posture and avoid aggravation of his symptoms.
Since we were on visit three and he still could only run 15 minutes, it made sense to reassess the effects of the exercise. It was not completely clear that the stretch prescribed was enough to fully reduce his symptoms. At this point, it made sense to intentionally aggravate the symptoms through progressive mechanical loading to determine what it takes to fully reduce the symptoms.
Pt had 0/10 pain prior to the start of the start of this test. The patient performed unloaded hip flexion, or walking marches: there was no effect. I then had him perform walking marches into a full lunge, which reproduced his symptoms to a 3/10 and reduced his range of motion .I then had his perform his prescribed exercise, which reduced his pain to 2/10, but did not abolish it. I then encouraged him to hold his stretch 5-7 seconds longer, which abolished his symptoms altogether.
His instructions were to hold his stretch a little longer, and to gradually increase his running, integrating the prescribed exercise into his running, Some minor adjustments of the exercises gave him the results he wanted- a full resolution of symptoms.
He was given guidelines for getting back to running up to 30 minutes at a time. He was given the guidelines for pain production. He was instructed not to be afraid of the pain, but to respect it and be sure to move it when he feels it, so as to not aggravate it as he had during the marathon. He was instructed on what to do if his hip does truly worsen to the point that it causes constant pain; to perform the stretch regularly and take a few days off from running.
Visit 4: 2.5 weeks later
The patient was pleased that he was able to run up to 30 minutes without exacerbation of symptoms. He was so pleased with this progress that one day he tried running faster with some of his running buddies, which pushed his hip harder and further than he had been. During that run, he got the same 5/10 pain he had at the marathon. After the run, he immediately went back to the hip extension exercise. While they helped, they did not immediately abolish his pain as they had before.
An exacerbation of symptoms can be used as a learning tool for the patient; to see if they understand the principles of self management. McKenzie and May state in The Lumbar Spine: Mechanical Diagnosis and Therapy (2004) “At the first sign of recurrence, the patient should immediately commence the procedures that led to recovery”. Learning how to manage symptoms when they recur is a key to long term recovery and prevention of disability.
To determine if he understood these principles, I asked him what he did. He understood that he had run too fast and too far, and was not ready for it yet. He immediately went back to an increased frequency of hip extension in half kneeling, and stuck with them regularly for 2 days. He also stopped running altogether for a few days. Within a few days he felt much better, and was ready to start running again.
Using the last visit as a baseline, we tested the irritability of his symptoms through progressive mechanical loading. I ran him through the same litany of tests as before. Standing hip flexion had no effect. Walking marches into a full lunges had no effect. He then performed many squats, lunges, lunges with torso twists, and side lunges over the course of 25 minutes. None of these symptoms reproduced his symptoms or created any mechanical change, indicating a vast improvement from the testing we had performed during the last visit. My instructions were to continue with self treatment and gradually increase his running program.
The patient came in three more times over the course of four weeks. During these visits, we would mechanically test the hip as we had previously done. His hip remained stable, as there were no mechanical symptomatic changes with progressive loading. At this point in the program we started to work on hip strengthening exercises. He wanted to return to the exercises he was doing before, so we reviewed what he was doing and discussed how he could integrate the hip extension exercise into his exercises: If he overdid the strengthening and his left hip pain resumed, he could utilize the hip extension exercise to self manage his symptoms.
By the time he was discharged, he was running pain free up to 10 miles at a time, at his desired pace. He was contacted a few months later for permission to publish this case study He reported he was gradually increasing his running, was still painfree, and was on track for his next marathon..
In 8 visits over 6 weeks, this runner progressed from not running at all to training for a marathon again without pain. As health care changes, we have to be poised to prove our value in providing cost effective care. Ask yourself:
- How can we set ourselves apart as leaders in health care? What services can we provide that patients find valuable in this information age?
- How can we maximize health care dollars and prove to our payers that physical therapy is a valuable tool?
- What tools are you going to use to prove you are effective and necessary?
Thank you for your attention to this case study. I have enjoyed hearing from so many of you and hope you have received value through this exchange. Feel free to leave any parting comments below. Warmly, Susan.
A FINAL NOTE FROM EDUCATA:
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