Case of the Week 15/5/98: What people said...

Here is my clinical viewpoint about the case of the week:

1.  The lateral trunk movement decreases the moment arm for the gluteus medius
and allows it to operate more efficiently in its compromised (painful) state.

2.  The right arm goes up because so much of her body mass is going to the
left with the trunk lean, if something doesn't go up on the right side, she
will fall.

3.  The knee angle remains constant because she is not getting terminal knee
extension (my interpretation of the EMG data seems to support this
observation)....try walking without terminal swing phase... I walked with a
constant knee angle, too!  It might decrease forward momentum and thus
eliminate knee extension in terminal stance on the opposite side.

4.  As a clinician, I see her gait deviations as a very good strategy to
minimize the forces on the surgical side, and maximize her ability to get from
point A to point B without falling.  I realize this is rather simplistic, but
patients are very goal oriented....they get the job done via the path of least
resistance.....minimizing pain, muscle force,  moment arms, etc.

5.  Intervention: For strength: I would focus on lots of closed chain, forced-
use activities for her left lower extremity.  She needs to be able to deal
with her body weight, so why not use it as the resistance.  It is possible to
scale task difficulty so that she is successful with the forced use
activities.  Intervention needs to help her overcome any fears she might have
of falling when she walks more dynamically--more forward momentum vs. lateral
momentum. This can be accomplished with the task scaling and some clinical
creativity.  For ROM:  I would use soft tissue and or joint mobilization
techniques as appropriate to increase ROM and decrease pain (if needed).

6.  I would happily elaborate more on the clinical intervention if anyone
wants more detail.

Melanie Weller MPT

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