Recently, I had the opportunity to work with a patient who had traumatically injured her elbow. As many of you know, my rehabilitation style is non-traditional. I use Pilates-based rehabilitation to perform functional movements which focus on coordination of breathing and core stability to achieve appropriate body mechanics. So, you might be asking yourself “How in the world can that style of physical therapy be effective in helping an elbow injury?

Let me give you a little background about the patient. She is a newly married, nurse who enjoys strength training and running. She sustained a substantial strained ligament and nerve injury to her dominant arm when she fell running. Initially, she was unable to perform simple movements like grasping a fork or sleeping without pain and numbness into her hand. She was given a brace by her doctor and prescribed physical therapy.

At the start of physical therapy treatment, the patient was very guarded due to severe pain, so I was not able approach her care as I would for most sprains and strains. I needed to think outside the box. After brainstorming with Dr. Kelli Velez, I decided to focus on other body parts and the brain!
With any injury, the brain will automatically protect and inhibit movement to an injured area thus changing the awareness of the skin, muscles and joints in the region. No matter how small the movement we were attempting to do, the brain would not allow the arm to move pain free.

For the brain to be on board with treatment, we needed to tell the brain something new! We used mirror therapy and started to write numbers on the patient's skin around the injured area. We used the mirror to reflect the uninjured elbow, which would trick the brain to think it was looking at the injured elbow without pain.

To our brains, visual awareness and tactile touch are different sensations than an injury pain. You may have experienced this when the chiropractors at our office, assess your sensory system by using hot, cold, tapping, eye movements, or a toothpick on your area of pain. These sensations are perceived differently to our brain and affect the movement of the area, thus the entire body’s movement. Using this idea, the patient's pain started to decrease and she was able move her elbow and wrist with far less difficulty; thanks to the brain!

If you have ever been injured or sat on the couch binge watching your favorite show for more than three days, muscles start to atrophy. This also happened to the patient’s entire arm. Using my knowledge of stability and strengthening, it was time to use the Pilates equipment and different functional positions to wake up and activate the entire muscular system.

Your arm itself does not move alone. Your deep core system anticipates movement and stabilizes to create a fixed point for the limbs to move from. Many positions on the Pilates equipment are gravity free. This allows the body to gently strengthen while challenging core stability and awareness, as the equipment and your body move in multiple directions.
As weeks went on, the patient’s entire body began to stabilize and strengthen to support the healing elbow. When she could progress to bearing weight through the arm, crawling around like a baby, was the most effective exercise to strengthen the arm and stabilize the elbow functionally. The act of crawling on hands and knees is a precursor to upright activities.

By involving developmental positions, like crawling, the brain participates to normalize upright movement patterns. This is necessary to return to efficient movement without pain or compensation from other body parts. With enthusiasm, determination and out of the box rehabilitation techniques, the patient could get back to work, with the support of an elbow brace, but with the best core stability, postural strength and improved arm function to do the difficult job of a nurse.

Physical therapists do not need to be cornered into treating only one body part, but should always consider the goals of the person, not the injured region alone. Healthcare practitioners need to remain forward thinking; at times break the rules and think outside the box!

Dr. Amanda Heritage, DPT

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