Title: CASE STUDIES (Orthopedic & Neurological Rehabilitation) 1

Clinical Case Studies

By
Apoorv Garg
(Intern AJIPT, DU)

Under the Guidance of Dr. Samta Sharma, Incharge Physiotherapy and Dr Junaid Jameel, Physiotherapist
Following cases are documented at Dr. Baba Saheb Ambedkar Hospital, New Delhi.
For academic evaluation, in the partial fulfillment of the of the degree of
Bachelors of Physiotherapy.
 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 2

ACCREDITATION BY THE HEAD OF DEPARTMENT

This is to certify that the academic project titled “CASE STUDIES (ORTHOPEDIC &
NEUROLOGICAL REHABILITATION)” is successfully completed by Apoorv Garg (Intern
AJIPT, DU) under the guidance of Dr. Samta Sharma (PT) and Dr Junaid Jameel (PT) for
evaluation in partial fulfillment for the degree of Bachelor of physiotherapy (BPT).

Submitted to Dr. Baba Saheb Ambedkar Hospital, Metro Station, Bhagwan Mahavir
Marg, New Delhi, Delhi- 110085 and AJIPT (DU), Vikas Marg, Karkardooma, Delhi-
110092.

Dr. Samta Sharma (PT) Dr. Junaid Jameel (PT)

Incharge Physiotherapy Dr. Baba Saheb Ambedkar Hospital
Dr. Baba Saheb Ambedkar Hospital

.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 3

DECLARATION BY THE CANDIDATE

I hereby declare that the project entitled “CASE STUDIES (ORTHOPEDIC &
NEUROLOGICAL REHABILITATION)” is the original work done by me at the
Department of Physiotherapy, Dr. Baba Saheb Ambedkar Hospital, Rohini Sector 6, New
Delhi. This work in part or full has not been submitted to any other hospital.

Date: Apoorv Garg

Place: New Delhi
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 4

INDEX
Sr. No. Topic
* Dx- Trimalleolar fracture (pg. 5)
Case 01. To study the effectiveness of Passive ROM
exercises & Ankle strengthening in
improving function & self-reported
confidence in ADLs, post Trimalleolar
fracture and ankle subluxation.

*Dx- ACL Reconstruction (pg.12)

Case 02. To measure the effects of Balance and
Coordination exercises along with
Quadriceps and Hamstring strengthening
on Static and Dynamic Postural Instability
in addition to Muscle strength post Anterior
Cruciate Ligament Reconstruction of the
knee joint
*Dx- Frozen Shoulder (pg.21)
Case 03. To identify the role of Shoulder
Mobilizations & Scapular musculature
strengthening exercises in management of
Frozen Shoulder.

*Dx- Low Back Pain (pg. 26)

Case 04. To find the effect of core muscle activation
training in Low Back Pain and Radicular
symptoms due to Non-specific Low back
pain

*Dx(sus.)- Secondary Parkinsonism (pg.33)

Case 05. To study the short-term effects of strength
and gait training on functional outcomes in
secondary parkinsonism.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 5

CASE STUDY-1

To study the effectiveness of Passive ROM & Ankle strengthening in improving function &
self-reported confidence in ADLs, post Trimalleolar fracture and ankle subluxation.

BACKGROUND:
Trimalleolar fractures refer to a three-part (3#) fracture of the ankle. The fractures involve the
medial malleolus, the posterior aspect of the tibial pilon (referred to as the posterior malleolus)
and the lateral malleolus.
Having three parts, this is a more unstable fracture and may be associated with ligamentous
injury (lateral (LCL), the medial (MCL) and the tibiofibular ligament complex and the
‘syndesmosis’ or the distal anterior tibiofibular ligament (ATIFL), the distal posterior tibiofibular
ligament (PTIFL), the transverse ligament and the interosseous ligament.)

Different mechanisms, ranging from low to high energy trauma, can lead to complex ankle
fractures with falls from standing heights in combination with ankle distortion presenting the
most common cause.

PURPOSE: To find the effectiveness of Passive ROM exercises & Ankle strengthening in
improving function & self-reported confidence in ADLs, post Trimalleolar fracture and
ankle subluxation.

CASE DESCRIPTION: This case study was done on a 28-Year-old Male who had suffered a
Trimalleolar ankle fracture (with subluxation) due to a road traffic accident on 29th January 2022.
He had come to Dr. RML Hospital’s physiotherapy department for physiotherapy treatment on
10th May 2022.
[10/05/22 to 08/07/22]

OUTCOME: Self-reported confidence and functional (gait and ambulation) capacity improved
within 20 days of passive ROM exercises and ankle strengthening (progressed to gait and
ambulation specific exercises) with improved independence in all activities of daily living.

CONCLUSION: passive ROM exercises and ankle strengthening helps in the management of,
pain and improving function outcome post ORIF [Trimalleolar ankle fracture & subluxation].

CASE DESCRIPTION:

A. CHIEF COMPLAINT:
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 6

This case study was done on a patient with a complain of ankle pain, swelling and stiffness
which interfered with their ambulation and work. He complained of pain in the ankle and foot
region. He did not have any complain of numbness. Pain increased on full weight bearing for
more than 20 steps or stair ascent/descent and standing for more than 10-15 minutes.

B. HISTORY

1. History of Present Illness: N/A

Pain assessment:

•Mechanism of injury: Road traffic accident (motor vehicle collision)

•Onset: Immediate
•Duration: 4 months
•Site: Anterior & Postero-medial ankle
•Any radiation: N/A
•Type of pain: Diffused bone pain
•Nature of pain: Constant
•Aggravating factors: Full weight bearing for more than 20 steps, stair ascent/descent
& standing for more than 10-15 minutes.
•Relieving factor: Rest
•Diurnal variation: Not present
•Severity of pain: level 7
•Intensity of pain: VAS(NPRS) score at rest-3/10, VAS(NPRS) score while
walking/standing for long- 7/10
•Stiffness: present (ankle and foot)
•Paraesthesia/ heaviness: absent
•Associated problems: Difficulty commuting to work and community ambulation

2. Medical or Surgical History:

Below Knee Cast- 23+ days

ORIF (Plating and CCS)- [13-02-2022]:
*4-hole titanium anatomic plate for fibula (lateral malleoli).
*3-hole titanium distal radius plate for posterior malleoli in buttress mode.
*2 (45mm + 50 mm) CCS for medial malleoli.

3. Personal/ Family/ Occupational History: none (presently)

CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 7

4. Socioeconomic status: lower middle class

C. OBJECTIVE ASSESSMENT

1. ON OBSERVATION:

Posture:

• Forward head posture with protracted shoulders

• Lumbar lordosis increased
• Pelvic anteriorly tilted
• Affected knee flexed and in valgus
• Affected ankle plantarflexed

Gait: Asymmetrical
* Longer step on the affected side
* Shorter stance on the affected side
* Longer stance on the unaffected side
* Overall longer stride and increased cadence

2. ON PALPATION:

Tenderness:
Over medial ankle, midfoot and posterolateral ankle
Grade- 1

D. ON EXAMINATION:

1. MOTOR EXAMINATION:

Range of Motion:

Universal goniometer was used for ankle ROM

Inversion & Eversion were measured by visual comparison with unaffected side.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 8

Movement Active Passive End Feel

Dorsiflexion 5 DEGREES 5 DEGREES* Firm

Plantarflexion 20 DEGREES 30 DEGREES* Firm

Inversion < ½ ROM ≈ ½ ROM Firm
Eversion ≈ ½ ROM ≈ ½ ROM* Firm
*Apprehension

Hip range of motion was complete & symmetrical for both limbs.

Manual Muscle Testing:

Affected Movement Unaffected

3+ Plantarflexion 5
(Gastro-soleus)
3 Plantarflexion 4-
(soleus Iso.)
3 Dorsiflexion 4+
2+ Inversion 4
3- Eversion 4

Muscle length Testing:

• Tightness in hamstrings and piriformis present

• Plantarflexor tightness present

Special Test:
• Anterior Drawer Test: negative
• Talar Tilt Test: negative

Functional outcome –
•FAAM (Foot and Ankle Ability Measure) Score (Initial eval.): 25% (21/84)

•Self-reported Confidence in ADL & Ambulation (unvalidated) (rated out of 100%): 30%

PHYSIOTHERAPEUTIC INTERVENTION:

Started from 10th may till 7th July, one session was given on alternate days.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 9

Physiotherapy focus:
• Pain Relief
• Range of Motion Improvements
• Ambulation (range, tolerance and economics) Improvements
• Balance and Stability (for community ambulation and work-related commute)

Intervention (protocol)
• Paraffin wax bath (12-20 layers) on ankle and foot for 15 minutes.

• Passive ROM (mobilizations) (talocrural joint and midfoot glides): 10 glides, 10 sets

• Stretching: Hamstring, Calf and Tibialis anterior: 30 seconds hold, 3 repetitions

• Calf muscle, evertors and dorsiflexor strengthening program started, which included (average
12 repetition,3 sets each):

1. Calf raises (Gastro-soleus & Soleus Iso: 2x 24*2)

2. Tibialis anterior with resistance band (red) (2x 10*3)
3. Ankle Rock-backs (2x 12*3)
4. Squat holds (half squats 2x 8*3*30sec)
5. Staggered Squats (affected limb backwards) (progressed with same sets/10 reps)
6. Gluteus Bridging (level) (10*3sets)
7. Gluteus Bridging (progressed to Inclined leg base) (progressed with same sets/10 reps)
8. Inversion & Eversion stance (narrow BOS) (30sec*4 sets)
9. Inversion & Eversion pacing (progressed with same sets/30 sec reps for distance)
10. Passive stretching (self) Calf + Hams + Tibialis anterior

OUTCOMES:

Range of Motion:

Movement Active Passive End Feel

Dorsiflexion 20 DEGREES 22 DEGREES Hard

Plantarflexion 52 DEGREES 52 DEGREES Firm

Inversion < ½ ROM < ½ ROM Firm
Eversion <½ ROM Full ROM Firm
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 10

Manual Muscle Testing:

Affected Movement Unaffected

4+ Plantarflexion 5
(Gastro-soleus)
4 Plantarflexion 4+
(soleus Iso.)
4+ Dorsiflexion 5
4 Inversion 4
4 Eversion 4

VAS at rest: 1/10

VAS while standing 30+ minutes: 3/10

VAS while walking 1Km+: 3/10

FAAM Score (latest follow-up): 73.8(≈74) %

Self-reported Confidence in ADL & Ambulation: 85%+

DISCUSSION: Passive Rom and ankle strengthening exercises had significant positive impact
on functional performance and ADL independence for the patient. By week 3 Self-reported
strength gains and improvement in functional capacity had already reached a significant
improvement and later it attained next to normal functional status.

CONCLUSION: with this study we can safely conclude that passive range of motion and ankle
strengthening exercises are viable in the management of Trimalleolar ankle fracture (repaired:
ORIF), with significant functional improvements even at week 4.
Exercises were also associated with better load tolerance, balance, community ambulation and
pain relief.

REFERENCES:

• Musculoskeletal Rehabilitation Series, Sixth Edition, Orthopedic Physical

Assessment, David J. Magee, Published by Elsevier.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 11

• Essential Orthopedics, Maheshwari & Mhaskar, Fourth Edition, Published by JAYPEE.

• Carolyn Kisner. Lynn Allen Colby. Therapeutic Exercise, Foundation and
Techniques, Sixth Edition, Published by JAYPEE.
• Cynthia C. Norkin, D. Joyce White, Measurement of Joint Motion, A Guide to
Goniometry, 3rd Edition, Published by Jaypee.
• Hoppenfeld Stanley and Vasantha L Murthy. Treatment and Rehabilitation of Fractures.
Lippincott Williams & Wilkins 2000.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 12

CASE STUDY-2

To measure the effects of Balance exercises along with Quadriceps and Hamstring
strengthening on Muscle strength along with balance and coordination post Anterior
Cruciate Ligament Reconstruction of the knee joint.

BACKGROUND:
Anterior Cruciate Ligament Injury is one of the common knee injuries usually post direct
traumas to the knee joint. In Indian Scenario most common mechanism of injury to Anterior
Cruciate Ligament is through Road Traffic Accidents. Two-thirds of cases are in males.

The occurrence of injury to the Anterior Cruciate Ligament (ACL) is reported to be as high
as 46% of all knee ligament injuries. Injury to ACL results in antero-lateral instability of the
knee which manifests itself as a feeling of instability and repeated episodes of “giving
away”, where the knee fails under conditions of rotary stress.
In the ACL reconstructed (ACLR) knee, movement occurs in a non-physiological axis,
creating alterations in gait and movement. The sensation of instability and giving way even
after 6-8 weeks of rehabilitation of ACL that the patient describes has been attributed to poor
proprioception in addition to the actual functional instability. ACL injury has been
associated with a resultant decrease in proprioceptive performance, with this relationship
between ACL injury and decreased proprioception being reported to be due to damage to the
mechanoreceptors in the articular structures and the ACL
The Tests used in the study for Balance and Coordination testing are
1) Sharpened Romberg Test
2) Star Excursion Balance Test (SEBT)
The SEBT test was performed with the subject standing in the middle of a grid on the leg to be tested. The
grid consisted of eight lines extending out at 45° from each other.
The subject under took the test barefoot, foot position controlled by aligning the heel with the centre of the
grid and great toe with the anteriorly projected line. The subject was instructed to reach as far as possible
along each of the eight lines (this position was then marked by an examiner) and return the reaching leg
back to the start position;
The subject repeated this process three times for each of the lines, the average score being recorded, during
the test. Individual distances along the eight lines were measured.
Prior to testing each individual practiced the maneuvering around the grid four times then had a five minute
recovery before testing took place

PURPOSE:
To measure the effects of Balance and Coordination exercises along with Quadriceps and
Hamstring strengthening on Static and Dynamic Postural Instability in addition to Muscle
strength post Anterior Cruciate Ligament Reconstruction of the knee joint.

.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 13

CASE DESCRIPTION: This case study was done on a 24-Year-old Male who had suffered a
Right side ACL Tear due to a road traffic accident on 10th September 2022. He had a successful
ACL Reconstruction surgery in Dr. Baba Saheb Ambedkar Hospital on 20th October, 2022. The
patient arrived in physiotherapy department for physiotherapy treatment on 16th January, 2023
[16/01/23 to 17/04/23]

OUTCOME: Static and Dynamic Postural Instability along with Strength in Lower Limb
Muscles steadily improved within 45 sessions of Balance and Coordination exercises in
addition to Quadriceps and Hamstrings strengthening with improved independence in
ambulation, ADL and recreational activities.

CONCLUSION: Balance and Coordination exercises along with Quadriceps and Hamstring
strengthening program helps in the management of Knee pain along with improvement in
static and dynamic postural instability in the knee joint post ACL Reconstruction, thus
improving overall movement patterns and functions outcome post ACL Reconstruction.

CASE DESCRIPTION:

A. CHIEF COMPLAINT:

This case study was done on a patient with a complaint of ‘front-of-knee’ pain and instability
while walking which interfered with their ability to walk properly and climb up and down stairs.
He complained of pain in front of the knee cap, which increased on active bending, prolonged
standing, stair descent and relieved on rest along with instability in knee while walking and
during stair ascent and descent.

B. HISTORY

1. History of Present Illness: N/A

Pain assessment:

•Mechanism of injury: Road traffic accident (hit & falls on pavement)

•Onset: Immediate
•Duration: 1 month
•Site: Antero-lateral and Antero-medial aspect of knee joint.
•Any radiation: N/A
•Type of pain: Sharp stabbing pain medially and laterally
•Nature of pain: Episodic medially and laterally (on stair ascent and descent and with prolonged walking)
•Aggravating factors: Prolonged Walking, stair ascent and descent
•Relieving factor: Rest
•Diurnal variation: None
•Severity of pain: level 6
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 14

•Intensity of pain: VAS (NPRS) score at rest-2/10,

VAS (NPRS) score while stair ascent and descent- 7/10
VAS while walking 30+ minutes: 6/10
•Stiffness: present (knee joint complex)
•Paraesthesia/ heaviness: Absent
•Associated problems: none

2. Medical or Surgical History:

ACL Reconstruction Surgery- [20-10-2022]

3. Personal/ Family/ Occupational History: none

4. Socioeconomic status: upper middle class

C. OBJECTIVE ASSESSMENT

1. ON OBSERVATION:

Posture:

• Neutral sagittal spinal posture

• Protracted shoulders
• Pelvic neutral
• Affected side: Hip-knee flexed slightly
• Affected ankle neutral

Gait: Asymmetrical
* Short step on the both sides
* Shorter stance on the affected side
* Longer stance on the unaffected side
* Overall shorter stride and increased step count

Scar:
Vascularity- 1(pink)
Pigmentation- 1(hypopigmentation)

2. ON PALPATION:

Tenderness:
Over antero-medial aspect and antero-lateral aspect of knee joint.
Grade- 2
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 15

D. ON EXAMINATION:

1. MOTOR EXAMINATION:

Range of Motion:

Universal goniometer was used for knee ROM

Movement Active Passive End Feel

Hip Flexion 0°-110° 0°-115° Firm

Knee Flexion 0°-120° 0°-125° Soft

Knee Extension 120°-0° 125°-0° Firm

Other Hip ranges and Ankle range of motion was complete & symmetrical for both limbs.

Manual Muscle Testing:

Affected Movement Unaffected

4 Hip Flexion 5
4 Hip Extension 5
4 Hip Abduction 5
4 Hip Adduction 5
4- Internal rotation 4
4 External rotation 4+
(4) Knee Flexion 4
(3+) Knee Extension 4
4+ Plantarflexion 5
(Gastro-soleus)
4 Plantarflexion 4
(soleus Iso.)
4 Dorsiflexion 5
4 Inversion 5
4 Eversion 4
 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 16

Scar:
Pliability- 2(yielding)
Height- 0(flat)

Balance and Coordination Test:

1) Sharpened Romberg Test
With Eyes Open- 18 sec
With Eyes Closed- 10 sec

2) Star Excursion Balance Test (In cm)

Leg Anterior Ant- lat Ant med Lateral Medial Posterior Post-lat Post-
med
ACLR 35±3.0 33±2.6 38±1.8 22±1.2 45±3.5 55±4.5 53±5.0 56±4.3
Non-Injured 38±3.2 36±3.7 41±2.2 26±2.2 50±4.2 58±3.3 57±2.5 60±2.4

Functional outcome –
•KOS-ADL: (initial evaluation.): 57.14% (40 points)

•Self-reported Confidence ambulation (un-validated) (rated out of 100%): 40%

PHYSIOTHERAPEUTIC INTERVENTION:

Started from 16th January 2023 to 17th April 2023, one session was given on alternate days

Physiotherapy focus:
• Pain Relief
• Range of Motion Improvement
• Strengthening; Quadriceps and Hamstrings
• Ambulation (range, tolerance and economics) Improvements
• Balance and Stability (for community ambulation and work-related commute)

Intervention (protocol)
• Cycling for knee conditioning for 15 minutes

•Hot Pack for 15 min on anterior aspect of both knees

CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 17

• Quadriceps muscle & Hamstring muscle strengthening program ,which included

(average 8 repetition, 4 sets each, 3x/week):

1. Dynamic Quadriceps: Knee Extension with Quadriceps table (progressed with adding weight &
velocity): (8*4*5sec hold*3sec eccentric)
2. Hamstring strengthening: Bridging(level) with <90 knee flexion (progressed by elevation & single
limb reps): (8*4*10 sec hold)
3. Nordic Curls (8*4*10 sec hold)
4. Leg ball curl with Swiss ball(8*4*10 sec hold)
5. Squat holds (full squats) (8*4*10 sec hold)
6. Squat holds with kettle-bell (8*4*10 sec hold)
7. One leg Swiss ball wall squats (8*4*10 sec hold)

• Balance and Coordination Exercises. (average 8 repetition, 2 sets each, 3x/week)

1. Modified Romberg exercise (standing in balance with eyes closed)
a) On hard ground
b) On soft ground (on a mat)
2. Walking on Toes (25 m) (8*2*5 sec rest after every rep)
3. Single Leg standing with Medicine Ball (initial 1 kg progressed to 3 kg) (8*2*10 sec hold)
4. Single leg standing on Balance board (8*2*10 sec hold)
5. Tandem walking with eyes open (25 m)
6. Forward barrier hops (8*2)

OUTCOMES:

Manual Muscle testing:

Affected Movement Unaffected
5 Hip Flexion 5
5 Hip Extension 5
5 Hip Abduction 5
4 Hip Adduction 4
4 Internal rotation 4
4 External rotation 4+
5 Knee Flexion 5
4+ Knee Extension 5
5 Plantar-flexion 5
(Gastro-soleus)
4 Plantar-flexion 4
(soleus Iso.)
5 Dorsiflexion 5
5 Inversion 5
5 Eversion 4
 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 18

Range of Motion:
Movement Active Passive End Feel
Hip Flexion 0°-120° 0°-125° Firm

Knee Flexion 0°-125° 0°-130° Soft

Knee Extension 125°-0° 130°-0° firm

Balance and Coordination

1) Sharpened Romberg Test
With Eyes Open- 35 sec
With Eyes Closed- 25 sec

2) Star Excursion Balance Test

Leg Anterior Ant-Lat Ant-med Lateral Medial Posterior Post-Lat Post-Med

ACL R 40±2.5 39±3.0 44±2.9 28±2.0 53±2.7 68±3.3 66±4.2 67 ±3.6
Non-Injured 44±2.3 42.6±3.7 50.6±2.7 33.5±3.4 59±1.4 72±2.8 71±3.5 73 ±1.9

VAS at rest: 0/10

VAS while walking 30+ minutes: 3/10

VAS while stair ascent and descent: 2/10

KOS-ADL Score (latest follow-up): 82.8% (58 points)

Self-reported improvement in ADL & Ambulation: 90%

DISCUSSION: Patient experienced a significant enhancement in static and dynamic balance and
a decrease in pain following 3 months of balance and coordination exercises in addition to
quadriceps and hamstring strengthening protocol, thus providing an effective treatment option
for the frustrating instability problem in knee joint post ACL Reconstruction

CONCLUSION: In conclusion, exercises for balance and coordination, in combination with

quadriceps and hamstrings strengthening program aid in the management of knee pain after ACL
reconstruction, as well as an produce significant improvement in static and dynamic postural
instability in the knee joint and thus a great focus should be considered placed on these during
ACL Rehabilitation program, even if a small amount of discomfort is noted.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 19

REFERENCES:

• Herrington, L., Hatcher, J., Hatcher, A., & McNicholas, M. (2009). A comparison of Star Excursion
Balance Test reach distances between ACL deficient patients and asymptomatic controls. The Knee,
16(2), 149–152. doi:10.1016/j.knee.2008.10.004 
• Llurda-Almuzara, L.; Labata-Lezaun, N.; López-de-Celis, C.; Aiguadé-Aiguadé, R.; Romaní-
Sánchez, S.; Rodríguez-Sanz, J.; Fernández-de-las-Peñas, C.; Pérez-Bellmunt, A. Biceps Femoris
Activation during Hamstring Strength Exercises: A Systematic Review. Int. J. Environ. Res. Public
Health 2021, 18, 8733. https:// doi.org/10.3390/ijerph18168733
•MYER, GREGORY D.1; FORD, KEVIN R.1; PALUMBO, OSEPH P.1; HEWETT, TIMOTHY E.2.
NEUROMUSCULAR TRAINING IMPROVES PERFORMANCE AND LOWER-EXTREMITY
BIOMECHANICS IN FEMALE ATHLETES. Journal of Strength and Conditioning Research
19(1):p 51-60, February 2005.
•Cynthia C. Norkin, D. Joyce White, Measurement of Joint Motion, A Guide to Goniometry, 3rd
Edition, Published by Jaypee
• Essential Orthopedics, Maheshwari & Mhaskar, Fourth Edition, Published by JAYPEE.
• Carolyn Kisner. Lynn Allen Colby. Therapeutic Exercise, Foundation and Techniques,
Sixth Edition, Published by JAYPEE.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 20
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 21

CASE STUDY-3

To identify the role of Shoulder Mobilizations & Scapular Musculature activation exercises
in management of Adhesive Capsulitis.

BACKGROUND:
Adhesive capsulitis (AC) often referred to as Frozen Shoulder or PA shoulder, is characterized
by painful and progressively restricting active and passive Gleno-humeral joint range of motion
with spontaneous complete or nearly-complete recovery over a varied period of time.
There is a restriction in the active and passive range of motions of external rotation followed
by abduction and relatively less for the internal rotation (capsular-pattern of restriction)
.
Reduction of anterior joint capsule space indicates tightness of anterior capsule limiting shoulder
external rotation most
The etiology of the adhesive capsulitis is unclear however there is a long-held hypothesis based
on arthroscopic and pathological observation, that there is an inflammatory component within
the axillary fold, which is followed by stiffness, adhesions and which further leads to fibrosis of
the synovial lining.
The common etiology can be
1. Idiopathic
2. Post Traumatic
3. Post-Operative
4. Due to Diabetes Mellitus
Prevalence is more in women (70% cases are women) and is seen in individuals of age range 35-
65 years.

PURPOSE: To study and examine the role of Shoulder Mobilizations & Scapular
Musculature activation exercises in management of Frozen Shoulder.

CASE DESCRIPTION: This case study was done on a 45-year-old male patient who
presented with chief complaint of pain and stiffness in the right shoulder, while performing
certain over-head movements like: dressing, combing hair and lifting objects over the
shoulder height along with difficulty in reaching the upper back since past 2 ½ month.
Patient had a history of fall (uneventful) on the right flank & shoulder 4 months ago.
[16/01/23 to 17/03/23]

OUTCOME: There was a significant increase in the range of motion and strength of the
muscles following 15 sessions of shoulder mobilizations, scapular PNF Patterns and Scapular
Musculature muscle strengthening. There was a positive reduction in the pain intensity as well
significant increase in the activities of daily living.

CONCLUSION: Shoulder passive mobilization paired with Scapular Musculature activation

exercises helps in the management of, pain and improving functional outcome in frozen shoulder
cases.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 22

CASE DESCRIPTION:

A. CHIEF COMPLAINT:

This case study was done on a patient with complain of pain and stiffness in the right shoulder
which interfered with their ADLs & work. He complained of pain in the shoulder and arm
region and did not have any complain of numbness, tingling or paraesthesia. Pain increased on
trying to lift the arm above shoulder level, sleeping on the right shoulder and trying to cook, it
relieves with hot showers and rest (besides sleep)

B. -HISTORY

1. History of Present Illness: No Diabetes Mellitus, Hypertension and Thyroid issues

Pain assessment:

•Mechanism of injury: (gradual onset) following a fall on right shoulder & flank.
• Onset: Gradual
• Duration: 4 months
• Site: Anterolateral shoulder and lateral arm (till deltoid insertion)
• Any radiation: Lateral arm (till deltoid insertion)
• Type of pain: Dull aching pain
•Nature of pain: Constant
• Aggravating factors: Overhead activities, sleeping on right shoulder
•Relieving factor: Rest & Hot showers
• Diurnal variation: More at night (disturbs sleep)
• Severity of pain: level 7
• Intensity of pain: VAS(NPRS) score at rest-6/10,
VAS (NPRS) score while sleeping on right shoulder- 8/10(disturbs sleep),
VAS (NPRS) score while overhead activities- 7/10
•Stiffness: present (upper trapezius)
• Paraesthesia/ heaviness: absent
• Associated problems: none

2. Medical or Surgical History:

None

3. Personal/ Family/ Occupational History: Is a primary school teacher (required to

reach overhead quite frequently)
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 23

4. Socioeconomic status: middle class

C. OBJECTIVE ASSESSMENT

1. ON OBSERVATION:

Posture:
• Forward head posture with protracted shoulders
• Lumbar lordosis increased
• Pelvic anteriorly tilted

Gait: Symmetrical + Reduced arm swing on the right side

2. ON PALPATION:

Tenderness:
Over antero-lateral to acromion
Grade: 2

D. ON EXAMINATION:

1. MOTOR EXAMINATION:

Range of Motion:

Universal goniometer was used for shoulder ROM.

Movement Active Passive End Feel

Flexion 0°-120° 0°-135° Firm
Abduction 0°-100° 0°-120° Firm
Extension 0°-30° 0°-40° Firm
Internal Rotation 0°-50° 0°-55° Firm
External Rotation 0°-40° 0°-45° Firm
 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 24

Muscle length Testing:

Left Movement Right
• Tightness in 5 Shoulder Flexors (3+) pectorals and
upper trapezius
5 Shoulder Extensors 4
present
4+ Shoulder Abductors (3+)
4 Internal Rotators (3+) Special Test:
4 External Rotators (3+) None
4- Scapular Retractors 3
Functional
outcome –
• Shoulder Pain and Disability Index (SPADI) Score (Initial eval.): 55.38% (72 points)

PHYSIOTHERAPEUTIC INTERVENTION:

Started from 16th January till 17th March, three sessions were given per week for 27 sessions (9 weeks)

Physiotherapy focus:
• Pain Relief
• Range of Motion Improvements

Intervention (protocol)

• Long Wave Diathermy (SWD) (continuous) for 10 minutes applied on the right shoulder joint.

Passive mobilization of Gleno-humeral Joint: (10 glides, 10 sets)

 Posterior Glide
 Inferior Glide
 Superior Glide
 Anterior Glide
 ER/IR rotation with distraction.

• Stretching (Capsular stretching exercises) (2x 3*30 seconds hold)

 Upper Trapezius
 Levator Scapulae
 Anterior, Inferior & Posterior capsule stretch
 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 25

Scapular Strengthening Exercises:

Exercise Material Description
Prone Shoulder Dumbbells Subject prone with the shoulder in neutral
abduction position; subject performs shoulder
abduction to 90° with external rotation in a
horizontal plane
Forward Flexion in Dumbbells Subject in side-lying position, shoulder in
side-lying neutral position; subject performs forward
flexion in a horizontal plane to 135°
Prone Extension Dumbbells Subject prone with the shoulders resting in
90° forward flexion; subject performs
extension to neutral position with the
shoulder in neutral rotational position
High row Vertical Pulley Subject standing in front of vertical pulley
apparatus apparatus with the shoulders in 135°
forward flexion; subject performs an
extension with the shoulders until neutral
position
Scaption with external Dumbbells Subject sitting with the arms at the side;
rotation subject performs maximal elevation of the
arms in the plane of the scapula (30°
anterior of the frontal plane)
Rowing in sitting Pulley apparatus with 2 Subject sitting in front of pulley apparatus
position handles with the shoulders in 90° forward flexion;
subject performs an extension movement
with the elbows flexed and in the
horizontal plane
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 26

OUTCOMES:

Range of Motion:

Range of Motion Active Passive End Feel

Flexion 0-173° 0-180° Firm
Abduction 0-170° 0-175° Firm
Extension 0-50° 0-55° Firm
Internal Rotation 0-65° 0-70° Firm
External Rotation 0-75° 0-80° Firm

Manual Muscle Testing:

Left Movement Right

5 Shoulder Flexors 4+
5 Shoulder Extensors 4+
4+ Shoulder Abductors 4+
4 Internal Rotators 4
4 External Rotators 4
4+ Scapular Retractors 4

VAS (NPRS) score at rest-2/10

VAS (NPRS) score while sleeping on right shoulder- 2/10

VAS (NPRS) score while overhead activities- 3/10

Shoulder Pain and Disability Index (SPADI) Score (Latest follow-up): 31.53% (41 points)
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 27

DISCUSSION:
Shoulder Mobilizations along with active scapular activation exercises are a great means to
preserve and advance the ROM deficit seen in frozen shoulder, especially if paired with deep
breathing activity during the mobilization and adequate assist-resist programming of
strengthening exercises.

Significant improvements are also seen in shoulder pain and function outcomes.

CONCLUSION:
We can conclude with this case study, that shoulder mobilization with active scapular activation
exercises and strengthening could be an effective method to preserve and increase the range of
motion, promote activity tolerance, proper shoulder mechanics and pain-relief (when paired
with deep heating modalities) in patients with Frozen Shoulder (adhesive capsulitis).

REFERENCE:

 Carolyn kisner. lynn allen colby. therapeutic exercise, foundation and

techniques, sixth edition, published by jaypee.
 J maheshwari. essential orthopaedics, 4th edition
 S, brent brotzman, kevin e. wilk, clinical orthopedic rehabilitation, second
edition, published by mosby
 Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of Scapular Muscle
Balance: Which Exercises to Prescribe? The American Journal of Sports
Medicine. 2007;35(10):1744-1751. doi:10.1177/0363546507303560
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 28

CASE STUDY 4

To find the effect of Core muscle activation training on Low Back Pain and Radicular
symptoms due to Non-specific Low back pain

BACKGROUND:
Low back pain (LBP) is usually defined as pain and discomfort, localized below the costal
margin and above the inferior gluteal fold, with or without referred leg pain.
Non-specific low back pain is defined as low back pain not attributable to a recognizable,
known specific pathology (eg, infection, tumor, osteoporosis, fracture, structural deformity,
inflammatory disorder, radicular syndrome, or cauda equina syndrome).
The symptoms of back pain varies, the most common symptom is lower back pain. This pain may:
 Feel similar to a muscle strain
 Radiate to the buttocks and back of the thighs
 Worsen with activity and improve with rest
In patients with Non-specific low back pain, muscle spasms may lead to additional signs and
symptoms, including:
 Back stiffness
 Tight hamstrings (the muscles in the back of the thigh)
 Difficulty standing and walking

LBP presents on a spectrum between primarily neuropathic pain and primarily nociceptive pain.
Various structures in the spine could constitute the origin of pain in accordance with their
innervation, but the clinical interpretation of abnormalities is not possible on the basis of
anatomical data alone.
In chronic pain, psychosocial dimensions become relevant, and are important to explain how
people respond to back pain.
The mechanism leading to lesser core activation in Non-specific LBP is probably closely
related to arthrogenic muscle inhibition. This phenomenon is most commonly observed in the
quadriceps muscle after traumatic and experimental knee injury, and is also encountered in the
calf muscles after ankle injury.
Arthrogenic muscle inhibition refers to a mechanism by which pain in a skeletal joint leads to
reduced neural drive to the muscle(s) that move or stabilize that joint.
Arthrogenic inhibition is thought to be caused by a change in the discharge of articular sensory receptors
due to factors such as swelling, inflammation, joint laxity, and damage to joint afferent.
Electromyogram (EMG) evidence of reduced neural drive to the core muscles in back pain
patients includes diminished EMG activity of Transversus Abdominis, and alterations in the
timing of the recruitment of the short (deep) fascicles of the Multifidus in response to
perturbations.
.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 29

PURPOSE: To find the effect of core muscle activation training on Non-specific low back pain.

CASE DESCRIPTION: This case study was done on a 42-year-old male who had been
suffering from low back ache for 5 months. He had come to Dr. Baba Saheb Ambedkar
Hospital’s physiotherapy department for physiotherapy treatment on 22 February 2022.
[22/02/22 to 17/03/22]

OUTCOME: Low back pain and radicular symptoms were reduced after 21 days of core muscle
training with improved independence in all activities of daily living.

CONCLUSION: Core muscle activation training helps in the conservative management on Non-
specific low back pain, reducing pain and improving function outcome.
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 30

CASE DESCRIPTION:
A. CHIEF COMPLAINT:

This case study was done on a patient with a complaint of backache with pain spreading down
both legs symmetrically till back of the knees which interfered with their ADLs. He complained
of the pain in the lumbar region, did not have any complain of numbness. Pain increased on
sitting upright, standing for more than 15 minutes and walking for more than 100 steps, relieved
on rest.

B. HISTORY

1. History of Present Illness:

Pain assessment:
•Mechanism of injury: None
• Onset: Gradual
• Duration: 5 months
• Site: Lower Back
• Any radiation: posteriorly till popliteal fossa (bilateral)
• Type of pain: Dull aching
•Nature of pain: Constant
• Aggravating factors: sitting upright, standing for more than 15mins, walking 100+ steps
•Relieving factor: Rest and forward bending
• Diurnal variation: Not present
• Severity of pain: level 6
• Intensity of pain: VAS(NPRS) score at rest-6/10,
VAS(NPRS) score while walking/standing for long- 8/10

•Stiffness: present lower back

• Paraesthesia/ heaviness: absent
• Associated problems: none

2. Medical or Surgical History: none

3. Personal/ Family/ Occupational History: none

4. Socioeconomic status: Lower middle class

CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 31

C. OBJECTIVE ASSESSMENT

1. ON OBSERVATION:

Posture:
• Forward head posture with protracted shoulders
• Lumbar lordosis increased
• Pelvic anteriorly tilted

Gait: normal (slumped & slowed after 100 steps)

2. ON PALPATION:

Tenderness: Axially over L5-S1,

D. ON EXAMINATION:

1. MOTOR EXAMINATION:

Range of Motion:
For flexion /extension ranges modified Schober’s test was used
For side flexion and rotations universal goniometer was used

Movement Active Passive End Feel

Lumbar Flexion 2 INCHES 3 INCHES Firm

Extension 2 INCHES 2 INCHES Firm

Side flexion Rt. 0-30 DEGREES 0-35 DEGREES Firm
Side flexion Lt. 0-25 DEGREES 0-30 DEGREES Firm
Rotation Rt. 0-30 DEGREES 0-35 DEGREES Firm
Rotation Lt. 0-25 DEGREES 0-30 DEGREES Firm

Manual Muscle Testing:

Left Movement Right

4 HIP FLEXORS 4
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 32

4 HIP EXTENSORS 4
5 HIP ABDUCTORS 5
5 HIP ADDUCTORS 5
5 HIP EXTERNAL 5
ROTATORS
4+ HIP INTERNAL 5
ROTATORS

Muscle - Grade
Trunk Flexors - 3
Trunk Extensors - 3

Muscle length Testing: Tightness in hamstrings and piriformis present

Special Test-
Straight Leg Raise Test: Positive
Slump Test: Negative

Imaging: No Imaging Done

Functional outcome - Oswestry disability index score - 23

PHYSIOTHERAPEUTIC INTERVENTION:

Started from 22nd February till 17th May, one session was given on alternate days.

Physiotherapy focus:
• Pain Relief
• Improve and maintain ROM of lumbar joints
• Improving Length Tension Relationship of core muscle
• Core muscle training

Intervention (protocol)
• Hot pack over lower back for 15 minutes
• Ultrasound Therapy over the tender region: L5-S1 axially, 1 MHz, 0.5watt/cm2 for 5 minutes
in circular pattern.
• Interferential Therapy: 4 pole Vector at Lower Back. In prone lying, 80-120Hz, 10 minutes
• Stretching of bilateral hamstrings (2x 3*30 seconds hold)
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 33

• Core muscle activation program, which included (2x 10*3):

1. Transversus Abdominis activation with a pressure biofeedback by contracting the
abdominals with help of verbal commands and visual cues. There was drop of 6-10 mm
Hg pressure on biofeedback (2x5*3*10 sec hold)
2. Semi crunches (which were progressed to full crunches by week 3)(2x 10*10 sec hold)
3. Pelvic tilts in supine with bent knee holds (2x 10*10 sec hold) (progressed to cat camel and
added lion’s stretching)
4. Gluteal bridging, holding pelvis up for 10 seconds and down, pelvis in neutral.
5. Straight leg raises with Dorsiflexion 30 degrees elevated above the plinth (2x 5*10sec hold)
(progressed to add prone and side lying SLRs as well)
6. Prone on elbows (2x 10*10sec hold) (progressed to prone on hands and 3 point prone
on hands)

OUTCOMES:

VAS at rest: 2/10

VAS while standing 30+ minutes: 3/10

VAS while walking 1Km+: 2/10

Radicular symptoms: none

Functional outcome - Oswestry disability index score - 7

Range of Motion
Movement Active Passive End Feel
Lumbar Flexion 4.5 INCHES 4.5 INCHES Firm

Extension 2.5 INCHES 2.5 INCHES Firm

Side flexion Rt. 0-40 DEGREES 0-45 DEGREES Firm
Side flexion Lt. 0-35 DEGREES 0-40 DEGREES Firm
Rotation Rt. 0-35 DEGREES 0-40 DEGREES Firm
Rotation Lt. 0-35 DEGREES 0-40 DEGREES Firm
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 34

Manual Muscle Testing

Left Movement Right
4 HIP FLEXORS 4

4 HIP EXTENSORS 4
5 HIP ABDUCTORS 5
5 HIP ADDUCTORS 5
5 HIP EXTERNAL 5
ROTATORS
5 HIP INTERNAL 5
ROTATORS

Muscle - Grade
Trunk Flexors - 5
Trunk Extensors - 5

DISCUSSION:
In this case study we saw how functional outcomes and pain can be significantly improved upon
clinically by focusing on Core muscle strengthening and relaxation, initially the isometric hold
part of programming proved to be effective in quickly subsiding the pain and discomfort at the
end of week 1, further progressing the strengthening and core activation exercises lead to
resolution of radicular symptoms within a short time period too.
It shows how non-specific low back can be effectively managed by controlled activation of core
muscle and abdominal muscle strength development, paired with relaxation and pain relief
adjuncts (like IFT).

CONCLUSION:
So, with this study we conclude (with reasonable confidence) that ‘Better the core, healthier the
back’ and simple strengthening of core musculature and proper intersegmental mobility of spine
can be used to achieve just that and treat long standing chronic back ache. Leading to good
stability of back and thus less back pain and good functionality overall.

REFERENCE:
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 35

• Russo M., Deckers K., Eldabe S., Kiesel K., Gilligan C., Vieceli J., Crosby P. 2018. Muscle
Control and Nonspecific Chronic Low Back Pain. Neuromodulation 2018; 21: 1–9

• Nava-Bringas, Tania Inés et al. ‘Association of Strength, Muscle Balance, and Atrophy with
Pain and Function in Patients with Degenerative Spondylolisthesis’. 1 Jan. 2014: 371 – 376.

•Kalichman L, Hunter DJ. Diagnosis and conservative management of degenerative

lumbar spondylolisthesis. Eur Spine J. 2008;17(3):327-335.

• Ilves, O., Häkkinen, A., Dekker, J., Wahlman, M., Tarnanen, S., Pekkanen, L., Ylinen, J.,
Kautiainen, H., & Neva, M. (2017). Effectiveness of postoperative home-exercise compared with
usual care on kinesiophobia and physical activity in spondylolisthesis: A randomized controlled
trial. Journal of Rehabilitation Medicine, 49(9), 751-757.

• Kisner C. Colby L.A.: therapeutic exercises foundation techniques; 5th edition

• Vikrant.G. R., Lawrence Mathias, Mohd Meraj Ghori, effectiveness of core stabilization
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 36

CASE STUDY 5

To study the short-term effects of Strength and Gait training on functional outcomes in
secondary parkinsonism.

BACKGROUND:
Secondary parkinsonism is similar to Parkinson disease, but the symptoms are caused by
certain medicines, a different nervous system disorder, or another illness.
Parkinsonism refers to any condition that involves the types of movement problems seen
in Parkinson disease. These problems include tremors, slow movement, and stiffness of the
arms and legs.
Secondary parkinsonism may be caused by health problems, including:
 Brain injury
 Diffuse Lewy body disease (a type of dementia)
 Encephalitis
 HIV/AIDS
 Meningitis
 Multiple system atrophy
 Progressive supranuclear palsy
 Stroke
 Wilson disease

PURPOSE: To study the short-term effects of strength and gait training on functional
outcomes in secondary parkinsonism.

CASE DESCRIPTION: This case study was done on a 76-year-old male who had been having
difficulty in walking and changing positions, he also had a tendency to fall on the left side when
standing independently (without support) since last 2 years. Patient was seen in Dr. RML
Hospital’s NH wards for physiotherapy treatment on 2 June 2022.
[02/06/22 to 16/06/22(d/c)]

OUTCOME: Function (Gait and balance variables) were significantly improved after 2 weeks
of specific Strength and Gait training.

CONCLUSION: Strength training and functional (gait and co-ordination) training can
significantly improve functional outcomes in secondary parkinsonism patients.

CASE DESCRIPTION:
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 37

A. CHIEF COMPLAINT:

This case study was done on a patient with a complaint of imbalance and cane-dependant
ambulation and left sided weakness, which interfered with their ADLs. He complained of
difficulty in speech, writing and community ambulation, did not have any complain of numbness
or pain.

B. HISTORY

1. History of Present Illness: Progressive gait difficulties and slowing movements since last
2 years
• Associated problems:
High Blood Pressure (on medications)
Type ii Diabetes Mellitus (controlled with meds)

2. Past medical or Surgical History:

Recurrent TIA & Right Posterior cerebral artery infarct (2014 till presently)
CAD (2014) (for which CABG was done April 2014)
 Ecosprin (for clot prevention)
 Clopivas (for clot prevention)
 Trajenta (diabetes)
 Rasalect (for tremors, stiffness)
 Amantrel (for tremors, stiffness, slowness of movements)
 Syndopa Plus (for tremors, stiffness, slowness of movements)
 Qutan (for mood disorders)
 Vital 4G (multivitamin)
 Calinept (vitamin D)
Taking home based physiotherapy treatments on-&-off since 2018.

3. Personal/ Family/ Occupational History: Family history of hypertension

4. Socioeconomic status: Upper middle class

C. OBJECTIVE ASSESSMENT

1. ON OBSERVATION:
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 38

Patient status: conscious & co-operative

Facial symmetry: Bilaterally symmetrical
Attitude of limbs: Elbow flexion, knee & hip flexion
External aid: Cane
Wound/pressure sores: None

Posture:
• Head tilted to right
• Right shoulder depressed
• Forward head
• Hyper-kyphosis T-Spine
• Rounded shoulders
• Sitting: with posterior pelvic tilt & slumped

Gait:
• Step length reduced bilaterally
• Heel strike absent
• Decreased arm swing
• Turning in sections

2. ON PALPATION:

Tone: firm (Biceps, Hamstrings & adductors)

Tenderness: None

D. ON EXAMINATION:

1. VITALS:
• Pulse rate: 83 bpm
• RR: 15 Bpm
• BP: 115/75 mmHg

2. HMF:
• Orientation: oriented (TPP)

• Attention:
Sustained- intact
Selective- intact
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 39

Alternating- intact
Divided- Affected

• Memory: Intact (Immt, Sht, Lng)

• Communication: Dysarthria

• Executive Functions:
Calculation: intact
Abstract Thinking: intact
Reasoning & problem solving: intact
Judgement: intact

• Perception: Intact (all 3 Domains)

3. HMF:
• Oculomotor (CN-III): affected
• Vestibulocochlear (CN-VIII): affected
• Glossopharyngeal (CN-IX): affected

4. Sensory Examination:
• Superficial:
Pain- intact
Touch- intact
Temperature-
intact Pressure-
intact

• Deep:
P/K/V- intact

• Combined Cortical:
Tactile Localization- intact
2-Point Discrimination- intact
Stereognosis- intact
Barognosis- intact
Graphesthesia- intact
Texture- intact
Double S Stimulation- intact

5. Motor Examination:
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 40

• Tone: normal 2+
• Reflexes:
Brachioradialis reflex & Jaw jerk: (normal only on reinforcement by Jendrassik maneuver)
Rest: normal

MANUAL MUSCLE TESTING:

SHOULDER (R) (L)

FLEXORS 4- 4-
EXTENSORS 4 4
ABDUCTORS 3+ 3+
ADDUCTOR 4+ 4+
S
INTERNAL 4- 4-
ROTATATO
RS
EXTERNAL 4- 4-
ROTATORS

ELBOW (R) (L)

FLEXORS 4+ 4+
EXTENSORS 4+ 4+

WRIST (R) (L)

FLEXORS 4 4
EXTENSORS 3+ 3+

HIP (R) (L)

FLEXORS 4+ 4+
EXTENSORS 3+ 3+
ABDUCTORS 4- 3+
ADDUCTORS 4- 3+
INTERNAL 3+ 3+
ROTATATOR
S
EXTERNAL 4- 4-
ROTATORS

KNEE (R) (L)

 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 38

FLEXORS 3+ 3+
EXTENSORS 4- 4-

ANKLE (R) (L)

DORSIFLEXO 3 3
RS
PLANTERFL Couldn’t be Couldn’t be
EXORS assessed assessed

Region Grade
C-spine Flexors 3
C-spine Extensors Couldn’t be assessed
Trunk Flexion 3
Trunk Extension Couldn’t be assessed
Trunk Rotation 3

RANGE OF MOTION

SHOULD AROM (L) PROM (L) End Feel Normal AROM (R) PROM (R) END
ER (L) FEEL (R)
Flexion 0-170° 0-175° Firm 0-180 0-175° 0-180 Firm
Extension 0-45° 0-55° Firm 0-45° 0-55
Abduction 0-170° 0-175° Firm 0-180 0-170 0-175 Firm
Adduction 170-0 175-0 Firm 180-0 170-0 175-0 Firm
Internal 0-60° 0-70° Firm 0-70 0-60° 0-70 Firm
Rotation
External 0-80° 0-90° Firm 0-90 0-80 0-90 Firm
Rotation

ELBOW AROM(L) PROM(L) End Feel Normal AROM (R) PROM (R) End Feel
(L) (R)
Flexion 0-120° 0-130° Soft 0-140 0-125° 0-140 Soft
Extension 120-0 130-0 Hard 140-0 125-0 140-0 Hard
Forearm 0-60° 0-70° Firm 0-80 0-70° 0-80 Firm
Supination
Forearm 0-75° 0-80° Hard 0-90 0-85° 0-90 Hard
Pronation
 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 39

WRIST AROM(L) PROM(L) End Feel Normal AROM(R) PROM (R) End Feel
(L) (R)
Flexion 0-55° 0-70° Firm 0-80 0-65° 0-75 Firm
Extension 0-60° 0-70 Firm 0-70 0-65° 0-70 Firm
Radial 0-10 0-20 Firm 0-20 0-15 0-20 Firm
Deviation
Ulnar 0-20 0-30 Firm 0-30 0-25 0-30 Firm
Deviation

HIP AROM (L) PROM(L) End Feel Normal AROM(R) PROM (R) End Feel
(L) (R)
Flexion 0-100° 0-120 Soft 0-120 0-110 0-120 Soft
Extension 0-10° 0-20° Firm 0-20 0-15° 0-20 Firm
Abduction 0-30° 0-40 Firm 0-40 0-35 0-40 Firm
Adduction 30-0° 40-0° Firm 40-0 35-40 40-0 Firm
Internal 0-25° 0-45 Firm 0-45 0-35 0-45 Firm
Rotation
External 0-25° 0-45 Firm 0-45 0-35 0-45 Firm
Rotation

KNEE AROM(L) PROM(L) End Feel Normal AROM(R) PROM(R) End Feel
(L) (R)
Flexion 5-110 0-120 Soft 0-130 5-115 0-120 Soft
Extension 110-5 120-0 Firm 130-0 115-5 120-0 Firm

ANKLE AROM (L) PROM(L) End Feel Normal AROM(R) PROM (R) End Feel
(L) (R)
Dorsiflexio 0-10° 0-15° Firm 0-20 0-10 0-20 Firm
n
Plantarflex 0-30° 0-40 Firm 0-50 0-35 0-45 Firm
ion

Cervical AROM PROM End Feel Normal

Flexion 0-15 0-16 Firm 0-45
Extension 0-17 0-20 Firm 0-50
 CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 40

Side Flexion Left: 0-8 Left: 0-10 Firm Left: 0-45

Right: 0-10 Right: 0-12 Right: 0-45
Rotation Left: 0-30 Left: 0-35 Firm Left: 0-90
Right: 0-40 Right: 0-45 Right: 0-90

Thoracolumbar Measurement (cm) Difference Normal

Flexion 49-51 2 cm 7 cm
Extension 49-48.5 0.5 cm 4 cm

Ranges: On the left side of the body and axial skeleton are affected the most.

Balance:
Romberg’s test- positive (12 sec max)
Sharpened Romberg’s test- positive (2 sec)

Co-ordination:
Non-equilibrium co-ordination: intact (good)
Equilibrium co-ordination: poor (inability to perform dynamic tasks/turning and velocity tasks
on command)
• micrographia

Imaging:
• Brain CT revealed cerebral atrophy with periventricular white matter changes and
hypodense lesions in white matter & subcortical regions.
• Poorly defined hypodensities are seen in bilateral subcortical & deep periventricular
cerebral white matter suggestive of chronic ischemic lesions.
• Findings consistent with presynaptic dopaminergic dysfunction.
~Suggestive of Secondary Parkinsonism

Functional outcome –
Modified Hoehn and Yahr scale (initial eval): stage 2.5

PHYSIOTHERAPEUTIC INTERVENTION:

Started from 02nd June till 16th June, one session was given on 5 weekdays (for 2 weeks till
discharge).
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 41

Physiotherapy focus:
• Gait:
-Heel strike improvement
-Improve step length
-Improve arm swing
• Relieve postural stress
• Address balance deficits
• Address ROM deficits on left side of the body

Intervention (protocol)
1. Weight bearing exercises to promote joint control and proprioception along with balance
training:
• Standing balance: patient made to stand with the help of
cane. (Initially maximal assistance was given.)
• Weight shifting on affected hand in sitting position. (Progressed to weight shifting on hips
while standing)
• Prone on hand with support. (Support was removed gradually)
• Pelvic bridging-In supine line position with knees flexed, (2x 5*10sec hold).
• Weight bearing on hand (Progressed to 3 point prone on hands)
• Gait:
Tandem, Grapevine and Backward walking (2 rounds each) (reinforcement on step length and
width)
Turning on command (reinforcement towards lesser turning radius)
Stopping and starting on command
Arm swing assist (using 2 canes during straight line walk)

2. Strengthening:
• Active assisted movements for upper limb and lower limb.
• PNF pattern for both upper limb and lower limb.
• Anterior and posterior pelvic tilt supine lying (towel press).
• SLR 3xDirections
• Dynamic quadriceps and VMO strengthening.
• Lumbar rotation with minimal manual support.
• Activation of gluteus maximus-Buttock squeeze

3. Hand activities
Ball grip (smiley ball), Pen spin, coin drop, collecting pens, rubber band abductions.

All exercises and progressions: taught and explained to attendants for @ Home sessions.

OUTCOMES:
After 2 weeks of Strengthening, Balance and Co-ordination exercises
CASE STUDIES (ORTHOPEDIC & NEUROLOGICAL REHABILITATION) 42

Balance:
• Romberg’s test- positive (50 second max)
• Sharpened Romberg’s test- positive (15 seconds)

Equilibrium co-ordination: Fair

• Able to perform dynamic tasks/turning and velocity tasks reasonably well on command

Functional outcome –
Modified Hoehn and Yahr scale (final eval.): stage 2.5

Range of Motion and Strength:

• Self-reported and observable improvements in left side ROM and strength were noticed within
2 weeks.
• Self-reported confidence and independence in ADL were also reported.
• Independent Ambulation (without assistive device) possible for 40+ steps
• Gait was observably symmetrical (respective to initial evaluation) and step length was fair.
• Able to pick up objects from the floor

DISCUSSION:
In this case study we saw how Gait quality, Range of motion and strength can be significantly
improved over just 2 weeks through gait training, strengthening exercises and functional
training. Self-reported confidence and quality of ADLs can be significantly impacted and
improved through these means, even with significant functional decline. Progression of disease
symptoms and loss of function can be adequately controlled and managed through strength and
gait training.

CONCLUSION:
So, with this study we can conclude that even a short period of strength, balance and co-
ordination exercises can improve functional outcomes in a patient with secondary parkinsonism
and (chronic)progressive functional decline.

REFERENCE:

• O'Sullivan, Susan B.; Schmitz, Thomas J.; and Fulk, George D., "Physical
Rehabilitation, 6th edition" (2014).
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• Toole, T. et al. ‘The Effects of a Balance and Strength Training Program on Equilibrium
in Parkinsonism: A Preliminary Study’. 1 Jan. 2000: 165 – 174.
• Cruickshank, Travis M et al. “A systematic review and meta-analysis of strength training
in individuals with multiple sclerosis or Parkinson disease.” Medicine vol. 94,4 (2015):
• Mak, M., Wong-Yu, I., Shen, X. et al. Long-term effects of exercise and physical therapy
in people with Parkinson disease. Nat Rev Neurol 13, 689–703 (2017).
• Carvalho, Alessandro et al. “Comparison of strength training, aerobic training, and
additional physical therapy as supplementary treatments for Parkinson's disease: pilot
study.” Clinical interventions in aging vol. 10 183-91. 7 Jan. 2015
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