Fine Tuning Your Home Care Patient's Squat

Fine Tuning Your Home Care Patient's Squat

 

 

The previous post discussed the techniques and benefits of both the Box Squat and the Face the Wall Squat.  Both types of squats are performed using body weight, and they are very helpful in providing external cues for performing a correct squat.  In the Home Care setting, I have the majority of my patients (most of which are elderly) perform squats while holding onto their kitchen sink.  The kitchen sink is a great place to perform standing exercises at home because it is stable enough to support you if you lose your balance (unlike holding onto the back of a chair which may tip over).  I include squats in almost all of my home treatments because of its functional everyday value.  However, most of my patients require verbal and tactile cues to perform the squat correctly.  Incorrect performance may cause more harm than good, so it is extremely important to cue your patients as needed.

 

 

I first have my patient stand comfortably facing the sink with their feet shoulder width apart.

 

As they squat, I make sure that their knees are in proper alignment in reference to their feet, their lower back remain straight (not vertical), and their body weight shifts posteriorly onto their heels as they hinge at the hips.

 

Many patients squat vertically.  They keep a straight spine, and lower themselves vertically toward the floor.  Their knees cross anterior to their toes, causing excessive stress on the knees

 

This is incorrect.  You want to maintain a straight lower back.  However you should do this by hip hinging, not by holding a vertical position

 

If the patient squats incorrectly, I will place a chair behind them for an external/visual cue.  I then ask them to lower themselves as if they are trying to sit in the chair. 

 

The chair will provide them with the "motivation" to hinge their hips, pushing their butt back to the chair.  As you can see, the lower back remains straight, not vertical

 

If the chair cue doesn't work I have my patient step as close to the sink as possible, placing their feet under the cabinet so that their knees come close to touching the cabinet door

 

Upon squatting, if still performed incorrectly with anterior knee translation in relation to the feet, the knees will hit the cabinet doors which will prevent any further anterior motion. 

 

As they continue to lower themselves, they will have no other option than to hinge at the hips, driving their butt back.  This will transfer their body weight onto their heels and should correct their squat

The Wall Squat

The Wall Squat

 

 Does the exercise above look familiar to you?  It may, especially if you have had Physical Therapy or Personal Training before.  In this exercise, a therapy ball is placed between the wall and your lower back.  You lean back against the ball, compressing it into the wall as you lower yourself into a squat, and return to upright.  This may be a leg strengthener, but how functional is it?  The squat is one of the most prevalent activities of your day.  Getting up and down from the edge of your bed in the morning, moving from the sitting to standing position from your chair at work, lowering yourself to pick something up from the floor are all examples of squatting activities.  In these activities, you must rely on your ankle, knee, hip and trunk stability to safely and efficiently lower your body and raise your body.  If you lean back too far, you will fall back, and if you shift forward onto your toes too much, you will fall forward.  There is no "safety mechanism" such as the therapy ball rolling on the wall to maintain your trunk's vertical orientation as you raise and lower your body. 

I prefer to customize my patient's exercises to be as efficient and focused as possible.  If I want them to strengthen their legs and I choose the squat as one of the exercises, they must first squat properly.  To do this, I have them train with a "real-life" version of the squat.  Instead of the Therapy Ball-Wall Squat, I will use the Box Squat or the Face The Wall Squat.

 

 

Above is the Box Squat.  Here, a bench, chair or plyo-box is placed behind you.  You hinge at your hips and push your butt back towards the box as you lower yourself down into the seated position.  Initially, I will have patients lower to the seated position, rest and then return to standing.  However, as they become stronger, I progress this exercise by having them lower themselves until they just about touch the box, and then return to stance.  Taking away the rest portion of the activity makes it more challenging due to the increased control and stability that is needed.  In the box squat, you must hip hinge and maintain proper knee alignment.

 

Do not allow the knees to cross anterior to your toes and do not allow the knees to "cave in" towards each other.

 

The Facing Wall Squat is another great activity that teaches proper squat technique while relying on your own body's feedback mechanism for stability rather than an external support.

Here, you stand close to the wall, facing it and lower yourself into a squat.  Your goal is to avoid hitting your knees or your head on the wall.  You will feel your weight shift back onto your heels and must stabilize to avoid falling backward.  Because of your position, the wall will give you the proper feedback to prevent your knees from shifting anterior to your toes.

 

The Therapy Ball Wall Squat reminds me of the Smith Machine.





The Smith Machine is another type of external support mechanism that in my opinion, reduces the use of your joint stabilizers to perform a movement such as the Bench Press, Shoulder Press or the Squat.

Here, the Smith Machine controls the bar, preventing it from shifting forward or back.  All you have to do is raise and lower it.  Less stabilization is required than if you had to control a free weight.

 



The Smith Machine Squat is similar to the Therapy Ball Wall Squat, as it prevents you from shifting forward or back as you raise and lower your body.  Less ankle, knee, hip, and trunk stability is required than if you were to perform a free standing squat (Box Squat or Face Wall Squat) that does not provide an external support system.

In my opinion, if a person can not do a proper body weight squat, then I would not have them perform a Smith Machine Squat using resistance/weight.  It is more important to perfect the squat movement prior to adding resistance to it.  I choose to use help my patients learn to properly squat for their everyday needs, rather than provide a bunch of external support so that they can increase the amount of weight that they squat.  If they can not squat their bodyweight properly, you should not be adding resistance to the movement.  This will only lead to bad habits, worse technique and injury.

Following Your Surgeon's Weight-Bearing Status Prescription

Following Your Surgeon's Weight-Bearing Status Prescription

 

 

Following ankle injury or surgery, your doctor/surgeon may place weight bearing precautions on the affected leg upon allowing you to walk.  There are a few common weight bearing statuses such as:

 

FWB which is Full Weight Bearing (no restrictions)

WBAT means Weight Bearing As Tolerated (still no precautions, but use pain as the guide)

PWB is Partial Weight Bearing (see below)

TTWB stands for Toe Touch Weight Bearing  (practically non weight bearing) which means you can only touch the floor gently with the toes on the affected leg just for balance, not for weight bearing)

NWB is Non Weight Bearing

 

PWB can be specified as a percentage or an actual weight amount.  Your doctor/surgeon may request 25% PWB, 50%, 75%, etc... Or the surgeon may state you can place up to 25 pounds, 50 pounds, etc... on the affected leg.  Most people have no clue what 50 pounds of weight on one leg feels like, and most are discharged home from the hospital without being educated on this.  Usually, it is a matter of simply feeling what the required weight on one leg feels like in order to consistently adhere to the weight bearing status. 

 

I take a dial scale to my client's home in order to provide this education.  I use a dial scale because it allows you to see exactly how much weight you are placing on it, and you can adjust the amount as needed by either shifting more weight onto the scale (and the affected leg) or off the scale onto the unaffected leg.  Most clients already know their total body weight.  So if they weigh 160 pounds, and the doctor places them on 25% PWB, that means they can only place 40 pounds on their affected leg.  I place the scale on the floor and assist the client into standing.  Their stronger, unaffected foot is placed on the floor next to the scale.  They try to stand as close to their usual standing posture as possible (upright, shoulders back, with their feet/ base of support either shoulder or pelvic width apart).  Then they place the affected side's foot on the scale and slowly shift their weight onto the scale until the prescribed weight is reached.  They repeat this a few times until they are comfortable maintaining this weight bearing status.  Then I have them walk while adhering to the weight bearing status.  After walking, I have them go back to the scale and ask them to again place the appropriate weight on the affected leg.  However, this time I do not allow them to look at the scale while doing this.  They must adjust by feel, without the visual feedback of watching the changing scale numbers.  I repeat this process until they are consistently placing the proper weight on their leg.  

First you must know your client's total body weight



Have them add or remove body weight from the scale using the affected leg

 

   



Signs of Infection Following Hip or Knee Surgery

Signs of Infection Following Hip or Knee Surgery

 

 

Following hip or knee joint replacement surgery, approximately 1% of patients are at risk of infection.  Some common signs of infection are:  Increased pain or stiffness in a previously well-functioning joint, swelling, warmth and redness around the surgery site, incision drainage, fevers, chills, night sweats, or increased fatigue.  Below are examples of what an infected knee and hip look like.

 

 

    

 

 

If any of these signs are present, or you are even the least bit suspicious that your surgical site may be infected, you must see your surgeon as soon as possible.



Maintaining Hip Precautions Following Hip Replacement

Maintaining Hip Precautions Following Hip Replacement

 

 

For a few months following a Total Hip Replacement with a Posterior Surgical Approach, the 3 main precautions are: No hip flexion greater than 90 degrees, no hip internal rotation, and no hip adduction past neutral. 

Avoid crossing your legs to minimize hip adduction. 



Avoid standing and crossing your ankles, as this also adducts the hip past neutral

 

When seated, if your knees are in this position, you are in neutral hip rotation

If your knees are in the position shown above, then your hips are internally rotated 

 

 

The photo above shows an acceptable seated hip position.  If you look at the femur bone (thigh) and approximate the spine location, you can see that the hips are flexed less than 90 degrees. 

 

Bending too far forward while sitting in a chair will cause you to flex your hips more than 90 degrees.  This is not good

Seated marching will also flex your hips more than 90 degrees - Also not good

For some patients, these precautions may be difficult to maintain due to forgetfulness.  However, not abiding by these "rules" may lead to hip dislocation during the time immediately following surgery.  Sometimes, the surgeon is very emphatic about these precautions, especially with patients who have already experienced a dislocated hip post-op and have needed a hip revision.  When treating these patients, I am very cautious and follow the precautions as closely as possible.  These precautions should also be considered when the patient is walking, particularly upon changing directions.  If the hip replacement was on the right side, I will advise patients to make all 180 degree turns to the left, avoiding turning to the right.  Or, I will encourage smaller "baby steps" if they must turn to the right, using a marching technique.  With this, I am trying very hard to teach my patient to avoid planting the foot on the operative side prior to turning toward that side, because doing so will create a relative internal rotation of that hip. 

Assuming my right hip was replaced, the following pictures will demonstrate how planting the right foot and turning to the right is actually creating right hip internal rotation:

Standing with hips in neutral
 

Slight right hip internal rotation in stance



This shows what maximum hip internal rotation looks like in stance without attempting to turn.  Notice the angle of my feet are at 90 degrees

 

Maintaining right foot planted, and continuing to turn to the right by leading with the left foot, it can be seen that the right hip is internally rotate excessively.  Again, the angle of my feet is about 90 degrees

 So if you are trying to stick to the surgeon's precautions as closely as possible, remember not only to assess your patient when he/she is in the sitting position but also during dynamic activities such as walking.

 

 

 



The KB Fitness Anchor

The KB Fitness Anchor

 

 

Using a resistance band or tube is very common for both rehab and fitness purposes.  If you are using one band/tube, you can train bilaterally by anchoring the center of the band so that there are two ends that you can grip with each hand

2-arm Row using one band, anchored using your feet



Some tubing or bands are sold with nylon webbing folded over itself for a thicker end, to act as an anchor to be used in a closed door.  However, many times this anchor is still too thin and will be pulled through the door frame during training.

 

The KB Door Anchor provides a thick buckle anchor which will not be pulled through the door.  It can be used with any of your current resistance tube or bands and can be connected to the existing anchor for a more secure hold.

 

 

Go to KB Products and get free shipping within the United States.

 



Standing Hip Exercises

Standing Hip Exercises

 

 

I apologize for the long hiatus in blog posts.  I recently relocated from Florida to Rhode Island and am just now in the process of unpacking. 

 

Today's post deals with a common question I get form my patients.

 

During Physical Therapy treatments for hip, knee, ankle or spine, a common series of exercises that may be prescribed include standing hip extension, abduction and adduction.

HIP EXTENSION

HIP ADDUCTION

HIP ABDUCTION

For most patients, I will have them perform these exercises on both legs, the affected as well as the unaffected, in order to include both open and closed kinetic chain activities.  Not only will these exercises strengthen the free moving hip extensors, abductors and adductors (open chain), but they will also force the patient to stabilize on the non-moving extremity (closed chain).  This allows them to include ankle stability, balance, hip stability, and even trunk stability training to their program.  Many times, weak hip stabilizers can lead to other problems, such as knee pain.  Further explanations of the above exercises can be seen on the S.O.D. Patella-Femoral Pain Syndrome DVD Rehab Set.      



Minimizing Strain On Your Lower Back

Minimizing Strain On Your Lower Back

 

 

When performing any type of exercise in the prone position (lying on your stomach), whether for fitness or rehabilitation, in order to minimize the strain on your lower back, consider placing 1 to 2 pillows under your pelvis. 

 

Observe that just by being in the prone position, the lumbar spine is already in an extended position.  Lifting your arm or leg will create hyperextension in the lower back , which may be uncomfortable particularly for anyone recovering from lower back injury/surgery

 

At rest, with a pillow under the pelvis, you can see that the lower back is in a neutral position

 

Upon lifting an arm or leg now, lumbar hyperextension is avoided and the lower back is spared.



Postural Habits

Forming New Postural Habits

 

 

As a Home Care Physical Therapist, I see how my patients spend a great deal of their time during the day.  Some try to be very active, while others try to do as little as possible.  Upon arriving at their home, I observe their postural habits quickly.  Some of them don't seem to move between visits.  They may be slumped to one side in their recliner.  Upon standing up to walk, they take on the same posture, slumped to one side.  This slouching posture creates muscle tightness, which may later affect lung expansion and the ability to take deep breaths.  I explain to them that if they are not motivated to perform an entire exercise routine, then they should just focus on one thing, maintaining proper sitting posture.  This would improve their walking and standing tolerance.  Considering the fact that they spend the majority of their day sitting in their chair, sitting with correct posture is not much to remember, but it is more difficult than you think. 

 

 

Some want to just place pillows at their sides to stop them from collapsing in the chair.  However, this does not allow them to strengthen their trunk.  It only passively positions them.  Pillow propping is useful with patients who have such weakness in their trunk that they can not safely maintain the seated position.  It also helps prevent the development of sores.  However, I am not talking about patients who have these deficits.  I am focusing on patients who do have the strength to make postural corrections, but choose not to because it is "too difficult" for them.

 

Quick Tip:

 

I frequently recommend to family members or caregivers that if the patient is not compliant with the requests to correct their seated posture, then they can do little things throughout the daily routine, such as relocating the silverware or their glass of water to the side that the patient is slouching away from.  They can do the same thing with the remote to the TV.  This would force the patient to actively move their trunk in the position that they are frequently avoiding.  You just have to remain persistent about placing the remote or the dinner utensils to the "avoidance" side.  If this becomes consistent, you would be amazed at how many times your patient will correct their posture in order to reach for their cup of water.  This repetitive activity will be part of their exercise program.