Every so often a patient walks through the door who requires you to really think outside the box. Over the past year I have been seeing two clients on a regular basis at the private musculoskeletal clinic where I am a physiotherapist. Both presented with longstanding musculoskeletal complaints that were affected by neurological conditions. To achieve the desired outcome, a combined management approach was needed. Neil and Simon were motivated and inspirational, and managing their conditions was refreshingly challenging.
Neil was 70 years old and diagnosed with Parkinson’s disease seven years ago. He is determined to stay active and let it have as little effect as possible on his lifestyle. He had had no physiotherapy for his Parkinson’s, and because of the lack of medical resources in his locality, he was not due to have any in the future. Nor had he any understanding of how physio could benefit his neurological condition. In an ideal setting he would have been referred to a specialist neurological rehabilitation clinic.
For most of his life, Neil has been a huge tennis fan and he was determined to continue playing for as long as possible. He presented complaining of intense stiffness in his lumbar spine. While he played tennis he felt his lumbar spine was quite unrestricted, but the next morning he was always very stiff. Over the following days he would then have difficulty with certain tasks and would be stiff at the start of his next tennis game. He was having difficulty with activities such as bending forward to put on his shoes and socks and going from sit to stand.
On physical assessment he had very limited lateral flexion and trunk rotation and his range of lumbar flexion/extension was about a third of what would be considered normal for his age. He was very hypomobile centrally L1 to L5 and tender on the lower lumbar unilaterally on the right. Neil was also very restricted through his hip movements. His hip flexors, glutes and hamstrings were all very tight, particularly on the right. He had no neurological signs and had not had an X-ray.
Neil demonstrated a flexed posture and gait consistent with Parkinson’s: slowness, decreased stride length, poor hip extension, reduced arm swing and a falling shuffling pattern. He was also suffering side-effects: difficulty with initiating movements, performing sequenced movements, balance and a decrease in reaction time. Neil was particularly rigid in all his movements.
It was hypothesised that his lumbar spine problem was probably the result of a degree of degeneration that was restricting joint movement. However, his increasing rigidity and lack of rotation during movement were playing a big role in his increasing stiffness. We therefore approached Neil’s problem from both the musculoskeletal angle and the neurological angle.
We began by addressing the musculoskeletal component with regular joint mobilisations to reduce hypomobility. Treatment also included trigger point releases through his lumbar spine and pelvic area. Neil’s was a chronic condition that would require both regular maintenance physiotherapy and a home exercise programme that included some joint mobility and stretches. Neil responded quite well to treatment and was feeling less stiff.
Neil was one of those patients you really wanted to go out of your way to help. My tennis coaching background allowed me to assess him as a tennis player. If I could help his tennis, it would keep him active for longer and delay the progression of his Parkinson’s. I also believe that playing tennis was good to maintain his lumbar spine movement.
Neil was quite a good tennis player. His stroke production was very good, but his movement around the court was obviously suffering. However, he seemed to move far better on the court than in daily life, possibly because of the instinctive nature of movement on the court. Neil’s movement was suffering because he was always taking two many shuffling steps and couldn’t turn and step, which you so often have to do in tennis.
He was also having problems with his serve. Parkinson’s patients often have difficulty with performing two activities simultaneously. Neil couldn’t coordinate his ball toss with taking his racquet back to the correct cocking position. To help improve his serve, we employed a coaching technique called backward chaining. We got him to start with his arm and racquet in the cocked position, concentrate on the ball toss and then the throwing motion. This simplified the serve. Although he felt uncomfortable at first, his ball toss improved and so did the consistency of his serve.
To put it all together again, we then looked at the second component of treatment for his lumbar spine: a home exercise programme that focused on combating the side-effects of his Parkinson’s, but adapted to help Neil with his on-court movement. This included exercises such as turning to the left and taking a big first step with the right foot to simulate moving to his backhand, standing and accelerating forward but having to step over markers to avoid any shuffling steps, and practising turning with only two steps to either side. The programme also concentrated on making Neil rotate his trunk, with exercises such as keeping the feet still while turning and reaching out to the side to place or pick up objects. We also incorporated balance exercises.
Neil was a happy man. His lumbar spine was feeling better, he was working away enthusiastically at his home exercises and was continuing with fortnightly physiotherapy sessions for joint mobility, soft-tissue massage and trigger point therapy to his lumbar spine and pelvic region, as well as reviewing his exercises and progressing where necessary.
It may sound like a lot of work, but Neil was retired and wanted nothing more than to work hard at staying active and to continue playing tennis. His case is a great example of combining different aspects of therapy to help a special patient manage an injury and enjoy their sport.
Simon was one of the most fascinating patients I have ever treated and an absolute pleasure to help. For 40 years he had believed he was a polio victim, until one day a specialist told him otherwise. She diagnosed Simon with mild hemiplegic cerebral palsy affecting the right side. Cerebral palsy can be defined as a ‘permanent disorder of movement, posture, or both, beginning before birth or in early infancy and characterised by hypotonia, spasticity, ataxia or involuntary movements, either single or in various combinations. The dysfunction is caused by impairment of the brain and is neither episodic nor progressive’(1). Simon was a family man, the director of his own accounting practice and loved to play golf, at which he was left-handed and quite good (handicap of 18). Golf to Simon was stress relief, a challenge and an opportunity to socialise.
Yet for the two years before he came to see us, he had been struggling with his golf. His right shoulder had become very painful. It was painful to play, but even more troublesome was the aching pain after and when trying to sleep.
Simon had a common presentation. He was complaining of pain in the deltoid region and anterior shoulder that was reproduced by impingement testing. He demonstrated incorrect patterning of his shoulder movements as a result of the cerebral palsy and not just the impingement problem. Most noticeable was that on flexion and abduction, scapular elevation was occurring far too early. Simon could not isolate glenohumeral movements, in particular any rotation. He was extremely tight through his posterior rotator cuff and capsule and this was limiting his horizontal abduction and internal rotation.
Our management of this client was not that of your average patient. We had to be realistic. Simon was not going to be able to do any normal muscle re-education exercises, because of his inability to isolate movements. So we could not hope to retrain the muscle system to correct any muscle imbalance or movement dysfunctions. Rather we had to put a plan in place that would maintain the shoulder movements. I hypothesised that this would be enough, because Simon had not had pain in his shoulder previous to the last two years and the pain had only presented because of the tightening of these structures over a long period of time. We would work intensively to try and free his shoulder from pain and then continue with fortnightly consultations as maintenance.
Not all patients like the notion of maintenance therapy and it may not be the best thing to raise it at the outset. The key is to develop a good rapport with the patient and make sure you educate them about their problem first.
Treatment went according to plan. We began by working on releasing chronic trigger points through his infraspinatus, teres minor and subscapularis, posterior capsule mobilisation in various positions, joint mobilisations to help restore normal glenohumeral joint movement and gentle passive stretches into internal rotation while maintaining joint centralisation and horizontal flexion. Simon maintained his anti-inflammatory medication and worked on gentle stretches and self-trigger points at home that had to be modified slightly for him. After two months, he was completely pain free and feeling much better when swinging the golf club. He had his full range of flexion, horizontal flexion and internal rotation back. His shoulder has been pain-free for nine months. Because Simon’s shoulder had affected his golf so much, his handicap had blown out. Now he’s back on form and knocking spots off his golfing buddies.
Simon and Neil are great examples of how sports therapists must be willing continually to adapt their management to suit the specific needs of the patient. And just as importantly, always try and think outside the box for your not-soaverage athletes.