Hip Pain due to a Non-Displaced Proximal Femoral Fracture

 The patient is a 96 yo male who had a fall at home and was taken to the hospital on 05-08-2022. Imaging revealed that the patient has a "non-displaced fracture of the proximal left femur along the greater trochanter extending to the superolateral margin of the implant" (prosthetic from an old total hip replacement). This was being managed conservatively. When he fell, he also landed on his left shoulder, and was also diagnosed as having a left rotator cuff tear. He was discharged to a SNF on 05-11-2022. I treated the patient on 06-04-2022.

Prior to treating him, I saw him during his OT treatment session while the COTA was applying shortwave diathermy (SWD) to his left shoulder. The COTA informed me that he was requesting to have SWD also applied to his left hip due to constant pain and discomfort at rest, aggravated by movement. When he was wheeled-in to the PT room, in addition to the shortwave diathermy, he also wanted me to apply Biofreeze to help alleviate the pain. I asked him to rate his pain at rest and with movement. He rated them 4/10 and 8/10, respectively.  He required help to get the LLE on to the mat (during sit-to-supine) and, once supine on the mat,  he was unable to move the LLE in any direction.

I asked the patient if it was OK to try something different  instead of  SWD - assisted priming in supine (APS) exercises. I told him that the pain he is experiencing is most probably due to immobility. I started with unilateral movement of the LLE but he was apprehensive, and exhibited guarding. As a result, pain was not relieved. I thought of the "mirror system" and how it has been used in pain management. I asked him to perform bilateral, symmetrical lower extremity movements (VIDEO 1). After pain was relieved, he was able to perform reciprocal, unilateral lower extremity movements pain-free. At the end of the treatment session, he did not have pain at rest and during movement. He had pain during weight bearing in sitting and in standing. He was also able to move the LLE to do a heel slide without any assistance, and move the LLE to the edge of the mat to transfer from supine-to-sit independently.

ASSUMPTIONS:

1. There has been an explosion of interest in mirror therapy / the mirror system. When using this treatment paradigm, the brain is "tricked" into thinking that the affected extremity can move by looking at a mirror image of the moving unaffected extremity. Pain is relieved by performing bilateral, symmetrical movement of the extremities, albeit a visual illusion.

When I started the treatment session, I had the patient perform unilateral APS exercises. The patient was complaining of pain while performing the assisted movement. This prompted me to have the patient perform bilateral, symmetrical movements (with mirror therapy in mind) with the elastic providing assistance to complete the task. The patient did not complain of pain while performing bilateral, symmetrical hip flexion - a task that is more difficult because it also involves activation of the lower abs. I used bilateral, symmetrical hip flexion to prime for pain-free unilateral, reciprocal hip flexion.

Pain relief could have been brought about by (1) activation of some substrates of the mirror system or (2) increased spinal stabilization required to complete bilateral, symmetrical hip flexion.

2. APS exercises are effective for addressing pain brought about by immobility. Because the movement is completely controlled by the patient, they are allowed to slowly explore pain-free ranges, and progress to movement throughout the available range of motion on their own volition.

3. APS exercises are useful in eliminating / minimizing guarding against movement which occurs every time a therapist moves a patient's limb.

4. The patient can complete each movement independently, and can be cued to move only in a pain-free range. This "movement exploration" in a pain-free range is not possible when the therapist is moving the patient's limb. APS exercises eliminates / minimizes kinesiophobia.

5. The therapist can observe the patient move, formulate assumptions as to the cause of their pain, and effectively make decisions how to cue the patient to correct their movement to minimize / eliminate their pain.