Case Study : "O"

"O" Case Information 

Owen: 2 years 4 months old 

Birth History: born at 24 weeks 2 days GA as a triplet, weighing 1lb 10 oz

 

Medical/Surgical History: Spent ~6 months in NICU, IVH (unknown grade), hydrocephalus status post ventriculoperitoneal shunt, tracheostomy, Gastrostomy tube, bilateral hernia repairs, recent ventriculoperitoneal shunt failure/revision, failed decannulation attempt due to granuloma/stenosis

Milestones: Walking at ~22 months actual (18.5 months adjusted), weaned off vent full time at 17 months actual 

Mother reports increased loss of balance and onset of toe-walking following shunt revision 

Falls frequently. Not toleratingpassy muir valve currently.

Exam questions 

Functional status: 

Loading response:

1.   What is the direction of shank movement during loading response?

2.     How does O’s experience of shock absorption compare to that of a neurotypical peer? How might that impact him from a developmental kinesiopathological perspective?

​Midstance: Does O have (1) shank within functional limits, (2) excessively reclined shank, or (3) excessively reclined shank (for both right and left?

​Terminal stance: What is the position of the hip and knee at terminal stance? What element(s) are lacking for therapeutic gait?

How is the gastric soleus complex functioning for O during stand to squatting activities?

 

Musculoskeletal findings:

What is unique about O’s structure (anthropometrics)?

What is your hypothesis for O's hindfoot group based on the dorsiflexion DF stress test (within functional limts/pronated/supinated)?

​What joints are likely to be restricted?

What soft tissue structures are likely to be restricted?

Neuromotor and Motor control findings:

In which muscle groups to you anticipate finding

·       Decreased selective motor control?

·       Impaired timing for function?

·       Altered tonic contraction?

​What do you hypothesize is the mechanism of O’s regular falls?

Sensory Perception and Pain:

How does O’s altered gait pattern impact his sensory experience for cortical mapping?

What areas might be hypoperceptive for O?

​What areas are at risk for pain in O’s future due to his altered gait pattern? What age would you anticipate him developing pain?​

Relevant systems screening:

What would you note about O’s trunk posture and postural control?

How do O’s G-tube, history of bilateral hernias (repaired) impact his trunk muscle function?

How does having a trachea granuloma/stenosis and tracheostomy (and lack of Passy Muir valve tolerance) have on his trunk stability?

How is trunk stability impacting lower extremity function?

Individual:

What questions do you have about O’s individual characteristics? How might these impact your plan?

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

Goals 

What are relevant goals for O?

 

Body Structure and function:

2 year old O: 

Adult O: 

Activities:

2 year old O: 

Adult O:  

Environment, Participation, and Personal Factors:

2 year old O: 

Adult O

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

Manual Therapy 

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

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

What structures are receiving excessive stress in the movement system?

Strengthening questions 

What resources does O demonstrate in terms of muscle strength?

What are 2 key muscle groups you’d like to focus on? Demonstrate/describe how you will engage O in these activities

Neuroplasticity questions 

Demonstrate/describe 2-3 activities to promote neuroplasticity/cortical map plotting of the LEs for O. 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 

What are your hypotheses around O's experience of pain?

What are your goals for O in terms of his experience of pain as he grows up?

​​

Systemic Access To Resources:

What are resources are available to O for his developmental motor experience? What systemic barriers might he be at risk for facing as he gets older? How can you support O's resilience to those barriers as he develops? 

Case 1

Case 1