Case Study 1: "T"

Exam questions (Manual Page A-5):

Functional status: 

Loading response:

1. What is T's movement system's strategy for shock absorption for R? for L?

2. Does the shank move anteriorly or posteriorly during loading response R/L?

Midstance: Does T have (1) shank WFL, (2) excessively reclined shank, or (3) excessively reclined shank?

Terminal stance: Is T achieving therapeutic gait? What's a major terminal stance resource that T demonstrates?

What are 5 MAJOR resources T has for gait?

Musculoskeletal findings:

What is your hypothesis for T's hindfoot group based on the DF stress test  (WFL/pronated/supinated)?

What joints are likely to be restricted?

What soft tissue structures are likely to be restricted?

What structures are receiving excessive stress in the movement system?

Neuromotor and Motor control findings:

What do you see as T's primary impairment as it comes to muscle activation and timing?

What balance strategies is T likely to use? 

Sensory Perception and Pain:

What areas might be at risk for:

Tissue damage pain

Lack of awareness of tissue damage pain (hypoperception)

Amplified pain

What sensations might be scary for T?

What areas might be hypoperceptive for T?

How would you evaluate hypo- and hyper-perception in T's lower extremities?

Relevant systems screening:

How does T's health condition of congenital HIV impact her movement system, now and in the future?

Individual:

What does T like to do? Where does she like/need to go? What are her goals as an 8 year old girl? How does she feel about therapy, braces, and casting? (If unknown, put yourself in her shoes and decide for 8 year old you.)

Key findings: What are the suspected drivers and limiting factors for T?

Goals (Page A-11):

What are relevant goals for T?

Body Structure and function:

8 year old T: 

DKM (Adult T): 

Activities:

8 year old T: 

DKM (Adult T): 

Environment, Participation, and Personal Factors:

8 year old T: 

DKM (Adult T): 

What are goal areas that might be in conflict (ICF levels/family goals/patient goals/team member goals)? Who is right?

Manual Therapy (Page B106 - B116):

Demonstrate the joint mobilizations you would likely need to perform for T.

Demonstrate the soft tissue mobilizations that might be important for T.

Strengthening questions (Page B118 - B133):

What motor learning strategies will you try to maximize T's motor skills?

Demonstrate the progressive resistive exercises you plan to do with T. How will you maximize this exercise for T?

Neuroplasticity questions (Page B134-B143)

Demonstrate/describe 3 activities to promote neuroplasticity/cortical map plotting of the LEs for T. Bonus points for creative activities/games NOT mentioned in the manual. How will you progress the complexity for cortical map development?

Pain and Health Condition Education (Page B144-B149):

What are your hypotheses around T's experience of pain? Discuss how you would you address this in a treatment session.

What are your personal ethics around educating T around her health conditions (diplegic CP, congenital HIV), and at what ages? What questions do you have to inform your opinions and decisions in this area?

Community Activity Engagement:

(Covidnotwithstanding): What active regular exercise/sport activities might be engaging for T? What does T need for age-appropriate community access?

Systemic Access To Resources:

As compared to her age-matched peers, what relevant resources might be harder for S to access due to societal structures? How can you as her PT support her to counteract those disadvantages? 

Case 1

Case 1

"T" Case Information

8 year old female

Dx: spastic diplegia, developmental delay, congenital HIV, history of neglect

MRI: bilateral periventricular white matter abnormalities 

Birth History: maternal HIV and exposure to cocaine and marijuana

 

T is currently living with her Aunt who has been her foster mother since age 2 .Aunt is not aware of her developmental history prior to 2 years old. Patient began walking at 4 years old. Had orthotics and received botox previously but has not had either in "a long time." Was receiving Home Health PT beginning at 2 1/2 years until about 5 or 6 years of age. 

 

Aunt states that T has been having more trouble walking long distances; tires more easily and therefore they are resorting to pushing patient in umbrella stroller more and more often. 

 

Objective measurements: 

Dorsiflexion:             LEFT                    RIGHT

     Knee extended   R1 -68, R2 -46     R1 -58, R2 -44

     Knee flexed        R1 -48, R2 -30     R1 -48, R2 -34

     Calcaneus can get to midline

     Cavus midfoot

 

Current treatment plan: 

Receiving serial casting by a colleague; has had 4 series of casts thus far and the following measurements: 

 Dorsiflexion:             LEFT                    RIGHT

     Knee extended   R1 -35, R2 -15     R1 -30, R2 -12

     Knee flexed        R1 -18, R2 -6     R1 -14, R2 --5

 

Plan to complete serial casting and transition into hinged AFOs with ongoing PT consisting of gait training, strengthening, balance and functional skills.