NERVE DAMAGE HIP BURSITIS. and PILATES

Transcription

1 NERVE DAMAGE HIP BURSITIS and PILATES Jennifer Parrott May 10, 2012 CTTC 2011 Greenwood, IN

2 In reviewing the medical records and obstacles that my client has been presented with, both trochanteric bursitis and supination of the foot are difficult to deal with and even more so to treat. During my observations I saw many improvements. We saw major improvement in the movement of her toes, ability to keep her ankle straight and even more blood flow to her foot. I think that pilates will be a great success for her in the challenges she currently has. As far as the trochanteric bursitis, that might take a little longer based on her pain management. 2

3 TABLE OF CONTENTS Pg. No. 1. Description of Supination of the Feet and Hip Bursitis Background History Initial Evaluation Initial Observation Second Session Observations Cadillac Session Observation Conclusion Bibliography

4 ( Her left foot is supinated during every day activities including but not limited to pilates. ( Here is a picture of where the Bursae Sacs are located in the hip. Damaged Bursae Sacs result in the condition usually called Trochanteric Bursitis. 4

5 BACKGROUND HISTORY On October 7, 1992, Jennifer Black was in the back of a pick-up truck, going only 10 miles per hour and seconds later, she is on the road. She landed on the right side of her head and body, was taken to Wishard Memorial Hospital and found to have a right subdural hematoma and a left epidural hematoma. The treatment for both would include two craniotomies. Ms. Black was in a drug-induced coma for approximately two weeks following the craniotomies and suffered amnesia the third week. On October 27, 1992, she was transferred to Hooks Rehabilitation Center, where she underwent extensive physical therapy to strengthen her muscles from atrophy and ultimately make it possible for her to walk unassisted. On October 29, 1992, Dr. Lance Trexler found that Ms. Black had evidence[d] decreased dorsiflexion on the left, but strength in her upper extremities seemed to worse on the right upper extremity. Neuropsychological Consultation, (October 29, 1992, CNR Clinic pg. 1). Ms. Black was discharged from Hooks Rehabilitation Center on November 10, 1992, and awaited acceptance into CNR Clinic for further rehabilitation on November 13, During a physical therapy evaluation at CNR Clinic, her evaluation was noted within normal limits regarding tactile simulations, both unilateral and bilateral. During the examination of gross motor speed of the upper extremities, Ms. Black showed that she was better with her left extremities than her right. The evaluation showed that the scores fell within the normal limits and that the fine motor dexterity and coordination was mildly impaired on the left. During the evaluations, she advised the therapist that her left side felt heavier and there was not complete feeling in her leg, ankle or toes. Ms. Black had some mild tactile suppressions on the left when examining tactile sensitivity on the leg. She was noted to have bilateral weakness in the 5

6 shoulders, again worse on the left. There was also some evidence of clonus in the left ankle. Toe extension was decreased on the left, and she had impaired isolation of movements on the left lower extremity. Neurobehavioral Diagnostic Clinics Summary, (November 13-17, 1992, CNR Clinic pg. 2). Ms. Black had a mild bilateral intentional tremor on both sides of the body, but worse on the left side. Throughout the evaluation Ms. Black showed impairment in higher level activities. It was also noted that because she is ambidextrous it became difficult to interpret some of what was observed. After being fully evaluated Ms. Black started her rehabilitation at CNR Clinic on December 1, 1992, and participated in the YMCA exercise group two to three times a week. During two months of rehabilitation Ms. Black was successful in all areas of rehabilitation and continued to improve in her endurance and physical strength. Ms. Black progressed to the point that she [was] independently carrying out an exercise program at a local gym. Brain Injury Rehabilitation Discharge Summary (February 1, 1993, CNR Clinic pg. 3). On February 1, 1993, Ms. Black was released back to work on a part-time basis for one month and then released from rehabilitation all together. She was given a few exercises to continue to assist in rehabilitating her left leg and left ankle. Over the next eight years, while trying to maintain an independent workout regimen she continued to seek doctor s input regarding continued pains in her hips, shoulders and back. The outcome of these doctor visits was a diagnosis of lumbago, sacroiliac joint dysfunction and bilateral trochanteric bursitis; as well as moderate to severe degree of intervertebral disk space narrowing at L5-S1, and very mild spondylosis. After these findings, she still tried to maintain 6

7 an exercise regimen all while heeding the recommendation to not run on flat surfaces and only use an elliptical machine for her cardio regimen. In June of 2001, Ms. Black heard about a new exercise regimen called Pilates which was offered at the local YMCA; she decided to join. While Ms. Black took the class she noticed that, not only was the class challenging, but it helped her stretch and relieve the pressure and pain in the areas of her body that had been affected by the accident. It was at this time she was introduced to Classic Pilates movements. These exercises assisted in strengthening transverse abdominus flexibility in the hips, strengthening the hip extensors and hamstrings. More specifically, it assisted her in becoming more stable on her feet and in control of spinal extensions. Ms. Black started feeling much better within herself and body. She no longer was in as much pain and had more fluidity in her hips and shoulders because of taking the pilates classes. In June 2007, Ms. Black gave birth to her son via Cesarean Section and found that not only did the pregnancy create even more problems in her right hip, but her lower back started to bother her instantaneously. Ms. Black looked for a pilates studio closer to her home to try to rehabilitate herself. Ms. Black was introduced to Body Arts Science International ( BASI ) mat class and reformer. After she was introduced to BASI pilates studies and practiced on the different equipment that BASI had to offer, she made a steady path of successful therapy. Ms. Black started getting a little more sensation in her left foot and noticed how she was able to walk straighter. More specifically Ms. Black noticed that her shoes no longer had a deep depression of supinating, which she was very pleased about since she said she would save money on shoes. 7

8 The following information shows the evaluations that were conducted and how Ms. Black progressed within a three-month period. INITIAL EVALUATION To start out Ms. Black underwent a basic evaluation on the Reformer with this program: Foot Work Parallel Heels and Toes V-Position Open V-Position Heels Open V-Position Toes Calf Raises Prances Single Leg Heel Single Leg Toe * She supinates with her left foot and overcompensates with her right. We need to focus a little more on the placement of her left foot and see if she is able to put equal weight on all toes and focus on powering from the inner thigh and inner calf during footwork* Ab Work Hip Work Hundred Prep Then Hundred Frog Down Circles and Up Circles (feet in ropes) Openings *She is a little weak in her hamstrings. Instead of focusing on keeping her heels together, she needs to focus on extending her legs completely while pushing out* Spinal Articulation Stretches FB-1 Bottom Lift Standing Lunge (problems with foot and stability) Elephant Scooter *While doing the Elephant she is gripping with her toes instead of focusing on her abdominals. I had her lift her toes when she was returning and that helped her focus more on abs and not her feet* 8

9 Arms Lateral/Flexion Back Extension Chest Extension Up Circles Down Circles Triceps Biceps Mermaid Long Box Breast Stroke Prep INITIAL OBSERVATION During the instructor s observation of Ms. Black while she was doing foot work on the reformer, it was noticed that her left foot rotated out and her heel came into the body as if it felt more comfortable abducted from the body. The left leg is the extremity with extensive nerve damage and Ms. Black advised that she did not have complete sensation in her left toes. The instructor adjusted her foot and advised her to press more towards her big toe and apply pressure equally throughout the rest of her toes on the left foot. She was able to apply adequate pressure and straighten her leg without twisting out. This is something we will continue to work on in the future because she began displaying signs of fatigue in her foot and leg once the move was performed correctly. It would benefit her to continue working on footwork, but also work on strengthening the hamstrings and the inner thighs. Also noted during the basic evaluation were a few complaints about her hips hurting while doing Frog, Circles and Openings. We lowered the repetitions and reduced the amount of hip work at one time. Because of the bursitis issue in the hip, I think if we start more on Frog and Openings and slowly work our way into Circles it will cause less discomfort. Ms. Black loses her abdominal control during down Circles as the hip is rotating in the hip socket. She advised that the pain gets worse the further down her leg goes in returning up the center to the 9

10 starting position. She appears to lose focus on her abs and concentrates on her hips, instead of both. SECOND SESSION Foot Work Parallel Heels and Toes V-Position Open V-Position Heels Open V-Position Toes Calf Raises Prances Single Leg Heel Single Leg Toe Hip Work Frog Reverse Frog Openings OBSERVATIONS During the second session, Ms. Black was able to keep her foot straighter and push from the inside of her leg. She was able to straighten her legs a little more and keep her ankles from wobbling while doing Parallel Toes and Prances. Ms. Black s feedback was that her left foot felt like it was being stretched around the tendons in the bottom of her foot. There was improvement also in her hip work. She is still unable to keep her heels together while straightening her legs, but her form is looking much better. I think she should continue on the same exercises and on her next session, see how she does on the Cadillac during footwork. CADILLAC SESSION Ms. Black was introduced to the Cadillac for foot work, and it was a little more challenging at first. It was a challenging because the body is positioned in a different way than when on the Reformer doing footwork. Once she got acclimated to where her hips and legs 10

11 needed to be and how far down to bring the bar, she liked the Cadillac even better. She was able to watch her left leg and foot to make sure that it did not supinate. Ms. Black advised that sometimes it takes eye contact with the limb to guarantee it is moving in the direction she is intending. I had her do some hip work on the Cadillac, more specifically, we did Frog, Walking, Up Circles and Down Circles. She still had complaints of discomfort in her hip during Circles. I think that reducing the repetitions, or removing Circles completely may aid in her experiencing less discomfort. Also, assessing hip discomfort before, during, and after her session, as well as modifying the workouts based on her feedback should aid in a more comfortable workout for the client. OBSERVATION While observing Ms. Black in performing the BASI Block system she has great control of her left leg and foot when focusing. As long as the exercise is done with little or no distractions and she concentrates, I feel that she should be able to continue on rehabilitating her foot. Ms. Black and I realize that she may never get complete sensation back in her foot. As far as Ms. Black s hips, bursitis research has stated that if the hip is in pain, stop and take antiinflammatory until the pain subsides. Ms. Black does not want to stop moving. Therefore, I think as long as she reduces the repetitions, and assesses how she feels on the day of the exercise, we may limit the amount of hip work that she does. 11

12 CONCLUSION Ms. Black shows signs of improvement and willingness to continue to work on the issue of her body. As mentioned, I do not think that Ms. Black will ever fully get the feeling back in her foot, but I think she has made leaps and bounds toward her goals. Ms. Black says that she concentrates more and more, when walking, on keeping her foot straight and not supinating out. I do note how straight her leg, foot and ankle are looking and how much she has improved. She still shows signs of fatigue while doing foot work and at times we need to put a ball in between her ankles to keep the ankles stable, but the improvement continues. I think Ms. Black walks with more confidence and holds her head a higher while in and out of pilates class because she feels better and has noticed her success. BIBLIOGRAPHY Supination Picture. Bursitis of the hip Picture. Original Article: Neuropsychological Consultation, (October 29, 1992, CNR Clinic) Neurobehavioral Diagnostic Clinics Summary, (November 13-17, 1992, CNR Clinic) Brain Injury Rehabilitation Discharge Summary, (February 1, 1993, CNR Clinic) 12