In late January I met a patient who had fallen in September, suffering the “terrible triad” at the elbow (coronoid and radial head fractures and a dislocation). After two surgeries to repair the damage, she contracted a staph infection which led to a third surgery and then a fourth when the wound didn’t close. Later she had physical therapy elsewhere which at times was extremely painful and at times disillusioning due to lack of attention.
At our first visit her elbow was stuck at a 90-degree angle, with a lack of forearm supination. Her shoulder on that side also demonstrated mild/moderate losses of motion in several planes consistent with adhesive capsulitis/frozen shoulder. Lastly, her neck was lacking motion in several planes. Subjectively, she did not report pain, but that it felt like a vice was around her elbow. Her ability to use her extremity for almost all tasks was obviously severely limited.
During our evaluation, I determined her homework would be pushing her elbow into extension and pushing her shoulder into flexion over the next few weeks, repeatedly. I asked her to push her elbow 10 times every 2 hours and her shoulder 10 times every 2 hours. The only equipment required was a surface like a table, and it would only take 2 minutes. A key ingredient to this exercise prescription was that it SHOULD produce pain when it was performed, but that the pain SHOULD NOT last outside of a mild aggravation up to about 15 minutes. An important piece of our encounter was also setting expectations. I explained that restoring motion in her extremity would take many months of her diligent work and that I was only needed very intermittently - mostly to steer the home program in the right direction.
This approach to physical therapy treatment was vastly different from what I had employed earlier as a clinician. Before, I would have prescribed a home exercise routine to be performed once or twice per day, including several motions at each joint. I would have recommended clinic visits 2-3 times per week. I likely would have used heat and then, after causing the patient pain, used ice. Now, instead, I was teaching the patient how to treat herself using one simple, quick exercise for each problem repeatedly throughout the day. I called a mentor to ask if this would really do the trick. Didn’t the patient need me? Soft tissue work? Mobilization? She advised me to give this approach time; if things didn’t improve then I would explore other options.
Our second visit was 6 weeks later. Due to having to take care of her mother, my patient related she had only done the exercises about once a day. However, the elbow had gained about 15 degrees; the shoulder was the same. I didn’t change her homework. At our third visit (in June) her elbow had opened an additional 30 degrees and gained a significant amount of supination. Her shoulder now lacked only about 5% of its total motion. She reported that the discomfort was decreasing and that she was gaining more use of her extremity, most notably with typing. During visits 4 and 5 this month I focused more on restoring neck and upper back mobility, giving her an additional exercise for homework. While I did some manual stretching of her elbow during our sessions, she was making herself better by doing a specific exercise repeatedly throughout the day.
The goal is to continue to improve motion at the elbow and spine and then reestablish strength. We’ll need to make sure there is no residual nerve tension as well. Despite the four surgeries and internal hardware, I am aiming for full restoration of motion and strength as I have learned the body has an amazing way of healing if it is consistently given the correct stimulus. This treatment approach (outlined by the McKenzie method of mechanical diagnosis and therapy) doesn’t just promote patient empowerment through self-treatment. It’s also safe, allows the patient to avoid unnecessary pain, and requires little to no bells and whistles. It’s a treatment model I wholeheartedly support. --Laura
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