Upload
dr-vinod-gupta
View
216
Download
0
Embed Size (px)
Citation preview
7/27/2019 How Physical Therapy Can Enhance...
1/16
1
HOW PHYSICAL THERAPY
CAN ENHANCE THEOUTCOMES OF THE
PODIATRIC PATIENT
LORI RUBENSTEIN, MAppSc, PT,
FAAOMPTLos Angeles, CA
Podiatry and Physical Therapy
We both recognize that
foot and ankledysfunction affects the
mechanics elsewhere in
the body.
Physical therapists areconsidered movement
specialists.
Toenail case
Case study
Patient referred for LBP
PMH: 7 years ago s/p left calcaneal ORIF
PT treatment focused on modalities for
swelling and pain management control. Present findings include -10 degrees
talocrural dorsiflexion resulting incompensatory gait pattern and
lumbosacral dysfunction.
7/27/2019 How Physical Therapy Can Enhance...
2/16
2
RESULTS
One physical therapy treatment with thetechniques well be discussing today
restored talocrural ROM to +5 degrees
dorsiflexion and eliminated compensatorygait pattern thus reducing her back pain.
Case study
There is a lot more that physical therapy
can do for your patients that may enhancetheir treatment outcomes and prevent
compensations elsewhere.
Introduction
Review of the podiatric and medical footand ankle literature usually references
physical therapy without specification as to
what types of physical therapy treatmentsare indicated. The aim of this lecture is to
discuss some of the physical therapy
interventions that are available and theirindications with relation to common foot
and ankle diagnoses.
7/27/2019 How Physical Therapy Can Enhance...
3/16
3
Outline
Modalities
Exercise
Gait
Physical Therapy evaluation
Joint mobilization
Neurodynamics: tibial and peroneal nerves
Common podiatric conditions1. Ankle inversion sprain
2. Cuboid syndrome
3. Bunionectomy
Modalities
Ultrasound
Phonophoresis
Iontophoresis
Electrical Stimulation
Contrast Baths
Light laser
Management of pain
and swelling
Reduce muscle
spasm
Reduce calcifications
within tendons
Enhance tissuehealing
EXERCISE
Stretching
Strengthening
Proprioceptive training (Podiatry Today, Denegar et al
2002, Osborne and Rizzo 2003, Verhagen et al 2004)
Balance
Neuromuscular re-education
Functional Training (Baxter 1995, Osborne and Rizzo 2003)
Sports specific training (Baxter 1995)
7/27/2019 How Physical Therapy Can Enhance...
4/16
4
GAIT
Gait training with
assistive device
Proper fitting of device
Post-op/Post-injury gait
training to avoid
compensatory patterns
(Rubenstein 1988)
PHYSICAL THERAPY EVALUATION
Observation
ROM (physiological)
Muscle testing/strength
Neurological
Palpation
Joint mobility/arthrokinematics (accessory mobility)
Gait
Function
Neurodynamics(Petty and Moore 2002)
Joint Mobilization/Arthrokinematics
Accessory mobilization to restore normalmobility to a joint.
Capsular restriction.
7/27/2019 How Physical Therapy Can Enhance...
5/16
5
Joint Mobility/Arthrokinematics
Common areas treated: Talocrural (restore talus posterior glide)
Cuboid (reduce plantarflexed cuboid)
Hallux (restore MTP glide to restore
physiological ROM)
( Hartman 1997, Petty and Moore 2002)
Joint Mobilization
Example: First MTP joint mobility
restriction Superior glide of
proximal phalanx onmetatarsal to restoredorsiflexion
Inferior glide of proximalphalanx on metatarsalto restore plantarflexion
Used in conjunctionwith physiologicalROM exercises
Mobilization
Dananberg et al 2000 reported twice thegains in dorsiflexion ROM following one
session of manipulation of the talocrural
and proximal tibiofibular joints versus 6months of calf stretching.(Dananberg et al 2000, Denegar et al 2002)
7/27/2019 How Physical Therapy Can Enhance...
6/16
6
Mobilization with Movement
MWM Brian Mulligan, New Zealand
Positional fault theory
Treatment must be pain-free!
When performed correctly MWM results in
immediate restoration of painfree ROM(Mulligan 2004)
MWM to restore dorsiflexion
In weightbearing, patient may experienceanterior impingement if the talus does not
glide posteriorly during dorsiflexion.
Therapist facilitates talar posterior glide
during active weightbearing dorsiflexion(Collins et al 2004, Denegar et al 2002, Mulligan 2004, Kavanagh 1999)
7/27/2019 How Physical Therapy Can Enhance...
7/16
7
Some causes of loss of ROM
Muscle length
Decreased accessory
mobility
Decreased nerve
mobility
Stretching
Joint mobilization
Neural mobilization
NEURODYNAMICS
Physical mobility of the nervous systemincluding spinal cord, meninges ,nerves.
Restricted mobility may result in traction orcompression and decreased blood flow to
the nerve, decreased axoplasmic flow,
decreased conductivity and symptoms oftingling or pain.
NEURODYNAMICS
Physical nervous system is a continuum.
Spinal cord must adapt to the 5-9cmchanges in spinal canal length that occurwith transition from extension to flexion.
Sciatic nerve must adapt to changes of atleast 12% its resting length during SLR.
Restriction of neural mobility can result inpain, nerve compression, neuropathy andtraction injury.
7/27/2019 How Physical Therapy Can Enhance...
8/16
8
Tests for LE neural mobility
Straight leg raise Tibial nerve bias
Peroneal nerve bias
(Butler 2000, Butler 1991, Hall et all 1998)
Straight leg raise tibial nerve bias
Patient lies supine, no pillow, with arms at sideor resting on abdomen.
Note resting symptoms.
Dorsiflex and evert foot. Note symptoms.
Maintain dorsiflexion and eversion whileapplying overpressure to knee extension.Note any change in symptoms.
Maintain dorsiflexion, eversion, and kneeextension while passively raising the leg intohip flexion. Feel for change in tension of themovement. Note any changes in symptoms.
7/27/2019 How Physical Therapy Can Enhance...
9/16
9
Straight leg raise tibial nerve bias
Normal response is to feel tension alongthe sciatic nerve.
Increase in symptoms distal to knee during
hip flexion maneuver indicates neural
tissue involvement.
Reproduction of patients symptoms
implicates neural tissue as source.
Straight leg raise peroneal nerve bias
Patient lies supine, no pillow, with arms at sideor resting on abdomen.
Note resting symptoms.
Plantarflex and invert foot. Note symptoms.Maintain plantarflexion and inversion whileapplying overpressure to knee extension. Noteany change in symptoms.
Maintain plantarflexion, inversion and kneeextension while raising leg into hip flexion. Feelfor change in tension of the movement. Notechange in symptoms.
7/27/2019 How Physical Therapy Can Enhance...
10/16
10
Straight leg raise peroneal nerve bias
Increase in symptoms distal to knee duringhip flexion component is a positive test for
neural tissue involvement.
Reproduction of patients symptoms
indicate neural tissue as source of
symptoms.
7/27/2019 How Physical Therapy Can Enhance...
11/16
11
Common LE neural restrictions
Nerve root compression from herniated disc
Sciatic nerve as it courses through piriformis muscle Common Peroneal nerve at fibular head Tibial nerve in tarsal tunnel
Deep peroneal nerve on dorsum of foot (Anterior TarsalTunnel Syndrome (Marinacci 1968, Dellon 1990)
Inferior calcaneal nerve between fascia of the abductorhallucis and quadratus plantae muscles
Interdigital compression (Mortons neuroma)
(Oh and Meyer 1999)
Example: Medial calcaneal nerve
MOTION
Dorsiflexion, eversion
Knee extension
Hip flexion 42
(Meyer et al 2002)
PATIENT RESPONSE
pull in calf
No change or mild
increase
Reproduction of
burning pain in medial
heel
Example: Peroneal nerve
MOTION
Plantarflex and invert foot
Overpressure kneeextension
Hip flexion 50 degrees
PATIENT RESPONSE
Lateral ankle pain
No change or slightincrease symptoms
Increase sharp painlateral ankle, may extend
to lateral calf
7/27/2019 How Physical Therapy Can Enhance...
12/16
12
Ankle Sprain/Neurodynamics
EMG studies and sensation testing insubjects s/p grade III ankle sprain showed:
-86% injured peroneal nerve
-83% injured tibial nerve
( Nitz et al 1985 as cited in Pahor and Toppenberg 1996)
Ankle Inversion Sprain
Re-injury rate s/p lateral ankle sprains inathletes as high as 80%
Chronic symptoms in up to 40% of patients
No correlation between mechanical andfunctional instability. 50% of functionalunstable ankles are mechanically stable.
Attributed to:-Abnormal joint mechanics
-poor proprioception
-functional instability(Baxter 1995, Denegar et al 2002, Jennings and Davies 2005, Osborneand Rizzo 2003)
Ankle Sprain Treatment
Proprioceptive and balance training
Joint mobilization to restore normal mechanics
Strengthening
Neural mobilization Functional training
Functional stability can be restored with use ofwobble board
(Baxter 1995, Osborne and Rizzo 2003, Rubenstein and Shay 1991, van Os et al 2005)
7/27/2019 How Physical Therapy Can Enhance...
13/16
13
Mulligan theory on Ankle Sprains
Theory: Ankle inversion injury may resultin anterior displacement of distal fibula
versus sprain of ATFL or CFL(Kavanagh 1999, Mulligan 2004)
MWM Ankle Sprain Test
Patient supine, foot off
edge of table
Stabilize tibia
Apply dorsal cephalad
glide of lateral malleolus
Foot will evert when force
is correctly applied
Maintain glide whileinverting foot
Glide and inversion
MUST be painfree
Positive Test:
Enables painfree
inversion/eversion ROM
7/27/2019 How Physical Therapy Can Enhance...
14/16
14
MWM Ankle Sprain Treatment
Repetitions
Taping to stabilize lateral malleolus posterior
Proprioceptive retraining
May need modalities for swelling control
Swelling usually resolves by next day
Do not immobilize
Can be performed at any time post-injury but
best immediately post-injury
Cuboid Syndrome
4% of athletes with foot pain
17% of professional ballet dancers
Cuboid manipulation effective to resolve
symptoms(Jennings and Davies 2005, Mooney and Maffey-Ward 1994)
7/27/2019 How Physical Therapy Can Enhance...
15/16
15
s/p Bunionectomy
TREATMENT:
Modalities to reduce swelling
Hallux AP and PA mobilization to restore normalarthrokinematics to the MTP joint
ROM
Gait training/ balance
Pool walking
Soft tissue mobilization
Taping
Bunion Taping
7/27/2019 How Physical Therapy Can Enhance...
16/16
16
For your consideration
Neural implications s/p bunionectomy
CASE STUDY Most treatment is performed with patient in long sit.
While working with a patient with a particularly stiff first MTP s/pbunionectomy (0-30 degrees, very stiff with pain) she reportedthat her sciatica had been acting up which she attributed to herantalgic gait. She had been receiving physical therapy for 2weeks with minimal changes in hallux ROM. Evaluationrevealed +SLR for lower back pain and stiff L4-5 spinalsegmental mobility. Treatment included 5 minutes of lumbarsegmental mobilization followed by sciatic nerve mobilization for3 minutes. We then immediately resumed hallux ROM andfound that ROM had improved to 10-0-75 degrees without pain.