Where do you start with a treatment ?

How many times are we as therapists confronted with a client with multiple injuries and we just do not know where to begin ?

In todays post I would like to share a case that my students and I worked on in class this week.

Peter had a very bad car accident two years ago, he shattered his right hip and ankle . He bashed his head badly and sustained various other injuries. He now uses one cane to help his walking and puts a lot of weight on his left uninjured leg.

His main complaint is upper back pain T8 T10  and lower back pain especially on his injured side. Hip pain and ankle pain. He cannot tolerate sitting for very long before his back becomes painful.

We know that human movement is made up of a couple of fundamental qualities.

1. Diapragmatic breathing

2 . Flexibility

3. Stability

4. Strength

If we follow human growth babies are born very flexible. They develop stability and then strength which leads to walking and eventually running and climbing.

Normally we restore flexibilty first then stability and lastly strength. We carried out a standard proceedure for testing Peter.

1. Standing posture, were his back muscles turned on or nice and soft ?

2. Was he a belly breather or stress breather ?

3. Standing against a wall could he maintain a neutral spine, neck , arms and belly breath ?

Normally we would test flexibilty next but because of his injuries and movement we decided to test what we thought was his biggest challenge at present . BALANCE !!

When we asked Peter to stand on one leg he stood on his good left leg, his balance was ok but not great.

When he stood on his right leg his entire torso swayed over his left leg in a compensation pattern and he was very uncomfortable.

TREATMENT PLAN

Correct standing posture so backlines become soft and take pressure off the back

Work on breathing patterns and release the apical breathing muscles

Work on balance to improve right side stability and stop left compensation

Work on hip hinging to stop excessive lumbar flexion and increase hip strength

HOMEWORK

Backbends as often as possible

Breathing over a brace, engaging the core and keeping the ribs down.

Bird dogs

Single leg half kneeling

Hip hinging

Rolling his hips and back  on a baseball

 

CONCLUSION

There were so many places to work on, the hips and ankle flexibility, the pokey chin and T spine mobility , the chest breathing and stability . We had to start at his basic movement restrictions which were breathing and balance. I am not saying that starting with hip flexibility or the neck would have been wrong but I believe that a lot of his tightness was comming from the stress of his accident and after being bed ridden for two years he had lost a lot of stability and balance which caused his nervouse system to increase the tension in his muscles to try to make up for his lack of stability.

If Peter can improve his core with a better  breathing  pattern and improve the balance on his right side then possibly his nervouse system will allow his muscles to relax and his flexibilty will improve.