James Creasey BSc (hons) MCSP Royal Bournemouth Hospital, Dorset, UK
A 37 year old lady presented to the lower limb rehabilitation team at the Royal Bournemouth Hospital In July 2011 with complex regional pain syndrome (CRPS) in her left foot, a condition that the patient had already experienced in her left wrist and hand. This started following a simple ankle inversion injury six months previously. She developed marked hypersensitivity of particularly her heel and was unable to weight bear through her left foot. She was non-weight bearing with elbow crutches and unable to wear shoes other than "Crocs”. The patient was unable to dorsiflex her foot further than 20 degrees of plantarflexion.
She had attended a two-week chronic pain residential program at the Royal National Hospital for Rheumatic Diseases, Bath. She was not taking any significant medications. The patient was managing to remain at work as a family support worker, and drove an automatic car.
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- Restore foot / ankle range of movement
- Wear any shoe
- Mobilise without aid using an acceptable gait
- Ride a standard cycle outside
History / Progression
This patient’s initial treatment consisted of desensitization of her heel, active range of movement of her foot and ankle, and seated proprioception work using various balance aids. She was attempting to wean herself into different footwear throughout the early therapy and over 4 months managed to wear shoes all day. She consistently struggled to achieve heel strike, by six months she was still walking on the ball of her foot. At this time, it was possible to add the use of a static exercise cycle and a cross trainer to her weekly program. This was the first time that she was able to manage some general exercise and was now 12 months after onset.
The AlterG Anti-Gravity Treadmill and physical therapy exercise became available to us 14 months after onset. At this point, the patient was still walking with two elbow crutches and no heel contact. Initial trials of the machine required bodyweight to be reduced to 30% to enable her to walk at 2KPH for 10 minutes. The patient was taught to use the machine independently and on average attended 3 times per week. Her initial goals were to increase her speed to 4KPH and to increase her time on the AlterG to 20 minutes. This was achieved over a three-week period. Throughout this time it was made clear that progression had to be achieved with respect to pain and latent pain.
For the second three weeks, her goal became incremental increases in bodyweight she was found to be able to tolerate a maximum of a 5% increase at any one time. At the end of this second period the patient had increased the bodyweight figure to 45%.
During weeks seven to nine the patient was not able to attend physiotherapy as often and therefore remained static at 45% bodyweight for 20 minutes at 4KPH.
Weeks ten to twelve the patient attended 4 times per week and progressed up to 55% body weight.
Weeks thirteen to fifteen BW was again increased to 60%.
Weeks sixteen to eighteen, progression was deliberately held at 60%. The patient had experienced an increase in her pain, particularly at weekends when she was not working or using the AlterG.
Following a second three-week cycle of acclimatization (weeks nineteen to twenty-one) to 60% bodyweight, it was possible to again add progression. Body weight was increased to 65%. The patient has remained at 65% up to the present day (6 weeks).
Throughout the process the patient has tried to achieve an average of three sessions per week for 20 minutes at 4KPH without incline. She has persisted with some other gym activities including static cycling (20 minutes) and cross-training (10-20 minutes). During weeks sixteen to eighteen some proprioceptive exercise involving wobble and rocker boards were added, but reduced significantly following the increase in the patient’s pain.