Let’s kick off a regular installment here on the blog.  Periodically, we’ll discuss case studies and case conceptualizations based on a functional rehab approach.  Case studies were always one of my favorite ways to learn in school.  Some of these will be straight up cases that we see in the clinic, some will be composites of several commonly presenting complaints somewhat like the vignettes we all knew and loved from board exams.  It’s my hope that this will help those of us with a bit more familiarity with these methods provide a more direct path for learning to the newer adoptees of functional rehab.  There are of course, many “Roads to Rome”, so some of the therapies applied don’t matter as much as how they are applied in the big picture.  Let’s start with Mike, a recent patient in our with shoulder pain.

SUBJECTIVE

Mike, a 38 y.o. carpenter, presented on referral from his wife, with complaint of chronic left anterior shoulder pain of 4 months duration after lifting a heavy door by himself.  He said he bent down with left arm straight under the bottom side of the door, right hand grasping the top of the door and stood up.  He walked for a ways and had difficulty turning a corner. He thinks he might have felt a pulling sensation in the shoulder at that time.  He continued his work day and noticed pain at rest in the shoulder the next day, and marked pain on left arm flexion, abduction and extension when putting his shirt on the in morning.  After a week of pain, he saw his PCP, who prescribed OTC NSAIDs.  PCP also offered steroid injection which patient says he denied because of fear of needles.  Pain at rest improved over the subsequent weeks but movement related pain remained at a slightly lower level.  He also found it impossible to lay down on either side and was not sleeping well as a result.

OBJECTIVE-STRUCTURAL

Exam revealed a sitting and standing posture with head and shoulders forward, with inwardly rotated arms.  Ortho eval revealed painful arc in the left arm between 90-120 degrees.  Neer’s, Yocum’s and Hawkins-Kennedy were all positive for external, anterosuperior rotator cuff impingement.  Supine external rotation was limited with report of anterior tightness over the shoulder, relocation of the humerus anteriorly did not affect the pain with external rotation, making internal impingement unlikely.  Active internal rotation and abduction were primary painful movement vectors.  Motion palpation of the thoracic and cervical spine revealed restricted motion in extension and rotation in both areas.

OBJECTIVE-FUNCTIONAL

• Janda Key Movement Patterns: Scapulohumeral dyskinesis with early hiking of the left shoulder on abduction.  Supine neck raise revealed chin jutting and head shaking after 12/30 seconds.

• Stecco Movement verification screen implicated following Centers of Coordination:  ante-scapula, ante-humerus, ante-cubitus; retro-scapula, retro-thoracic; lateral-scapula, lateral-humerus, lateral-cubitus; intra-scapula, intra-humerus; extra-humerus.

Shoulder abduction movement pattern assessment, from Assessment and Treatment of Muscle Imbalance, Page, Frank and Lardner, 2010

Antonio and Carla Stecco demonstrate IR-HU movement verification screen, from Fascial Manipulation, Stecco and Stecco, 2009

• Selective Functional Movement Assessment (SFMA): DN for MS rotation and extension. DP for squat, UE MRE/LRF bilateral, C-sp rotation and extension.

• Dynamic Neuromuscular Stabilization (DNS): Apical breathing pattern observed and patient showed insufficient activation of diaphragm/core with Diaphragm Test and Intra-Abdominal Pressure test.

Pavel Kolar assesses IAP in Naples, FL, Jan, 2010

Gray Cook shows SFMA multisegmental extension assessment

ASSESSMENT/DX

Structural diagnosis of external impingement syndrome was rendered, with a functional dx of Upper Crossed Syndrome per Janda.  Presumed pre-existing postural habitus contributed to the poor healing of the acute injury and resultant impingement syndrome.

PROCEDURES/PLAN

Initial treatment consisted of Stecco Fascial Manipulation over AN-SC, RE-SC, IR-HU.  Mid-treatment re-assessment after manual therapy revealed improved painful active abduction of the left arm to near 120 degrees before pain and perhaps 30-40% improvement in internal rotation.  Thoracic extension was improved but still painful.  HVLA manipulation to the T4, T6 and R1 segments allowed for painless thoracic extension.

Exercise instruction consisted of neck ups, home self mobilization using lacrosse ball with focus on mid-scap area and pecs, and Sidelying Thoracic Extension and Rotation peeled back to painless abduction to around 110-115 degrees.  After the latter exercise, Mike reported a big sense of opening in his chest and upper back.  He was emailed tutorial videos of the 3 exercises from MyRehabExercise.com for reference with HEP.

Shoulder self mobs @ MyRehabExercise.com. Members may click and view the video.

Sidelying Thoracic Extension + Rotation @ MyRehabExercise.com. Members may click and see the video.

Neck ups @ MyRehabExercise.com. Members may click and view the video.

In subsequent follow up treatments, we worked on the areas implicated in the Stecco movement verification screen with Fascial Manipulation and continued exercise prescription, progressing from kettlebell armbars and screwdrivers, to TGU to the high hip position.  Breathing/stabilization faults were addressed with Dead Bug variations incorporating diaphragmatic breathing and “sternal crunch”.  He was then progressed to full TGU and early soft rolling patterns.  Patient was released after having met his treatment goals after 6 treatments in 6 weeks.

Armbar + Screwdrivers @ MyRehabExercise.com. Members may click and view video.

TGU 1-4, High Pelvis Position @ MyRehabExercise.com. Members may click and view video.

Dead Bug + Sternal Crunch @ MyRehabExercise.com. Members may click and view the exercise.

Dr. Craig Liebenson discusses cryotherapy with Stu McGill, Phd.

COMMENT:  This treatment method of assessing movement quality to determine functional deficits, applying manual therapy and re-assessing after treatment, and finding painfree multisegmental movement pattern-based exercises to build on is what marks the functional rehab approach.  With every manual therapy applied in the clinic, patient was shown ways to try to accomplish similar results at home to reduce dependency on the caregiver.  Exercise played a role in the treatment from Day 1.  An excellent overview of this approach from one of the pioneers in functional rehab is at http://www.craigliebenson.com/?p=1595.

These multi-joint functional exercises are a bit more difficult to teach patients how to do, and having the video tutorial back up at MyRehabExercise.com helped groove those movements and allow the patient to make more headway at home.  The methods of manual therapy are interchangeable, all will have some benefit.  The particular exercises may differ dependent on the ability of the patient to perform them painlessly.  This offers a way out of the sterotypical boxes of our respective professions.  Gone are the endless chiropractic visits consisting of heat/stim and manipulation.  Gone are the endless physical therapy visits of ASTYM/Graston, iontophoresis and ultrasound.  Gone are the weekly spa massage treatments that help for a few days.  Gone are the single joint bicep curls and leg extensions in the corporate gym environments that push unbalanced clients to injury and one of the aforementioned treatment scenarios.  So let’s all of us look around our communities and find the experts in our respective fields and work together for the benefit of our patients and clients.  Folks need us out there.

I would be interested to hear your respective comments and experiences, so chime in.

Also, if you’d like to see what the functional rehab video tutorial library looks like at MyRehabExercise.com, you can trial it for $1 for 30 days risk free.  After that, the cost is only $9.99 per month.  Click on the link below to start the trial!

Click Here to See the Videos, Trial the Service for $1 for 30 days!