Case Study 3: "S"

Exam questions (Manual Page A-5):

Functional status: 

Loading response:

How does S achieve foot flat during loading response R?

Look at S’s trunk during weight acceptance R. What factors are contributing to what you see?

​Midstance: Does S’s R LE have (1) shank WFL, (2) excessively reclined shank, or (3) excessively reclined shank?

​Terminal stance: What is the position of the R ankle, hip, and knee at terminal stance? Is she achieving therapeutic gait?

Look at the end of terminal stance R and the knee extension moment that occurs: what is your hypothesis for why the knee extends at that time?

What powers swing R for S? What sources of power for swing are lacking?

 

Musculoskeletal findings:

What is your hypothesis for S'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?

Which muscles might have altered line of pull related to her functional foot posture?

Neuromotor and Motor control findings:

In which muscle groups do you observe

Impaired timing for function?

Altered tonic contraction?

​What strategies are available to S for balance reactions?

Sensory Perception and Pain:

What is your hypothesis for the impact of S’s cortical map due to her neurological health condition and her current motor experience?

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 S?

What areas might be hypoperceptive for S?

 

Relevant systems screening:

What screening questions do you have for S?

Individual:

What does  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 S?

Goals (Page A-11):

What are relevant goals for S?

Body Structure and function:

8 year old S: 

DKM (Adult S): 

Activities:

8 year old S: 

DKM (Adult S): 

Environment, Participation, and Personal Factors:

8 year old S: 

DKM (Adult S): 

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

 

Neuroplasticity questions (Page B134-B143)

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

 

Strengthening questions (Page B118 - B133):

What motor learning strategies will you try to maximize S's motor skills?

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

 

Manual Therapy (Page B106 - B116):

Demonstrate the joint mobilizations that might be appropriate for S.

Demonstrate the soft tissue mobilizations that might be appropriate for S.

How might you help minimize tonic muscle contractions during manual therapy? 

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

What are your hypotheses around S's experience of pain? Discuss how you would you address this in a treatment session?

​S demonstrates negative language around her abilities, specifically around her R side, and shows frustration with tasks that are hard now that were easy for her prior to her stroke 2 years ago. Discuss strategies to improve her self-efficacy.

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? 

"S" Case Information 

8 year old  s/p cerebral infarction affecting right dominant side at age 6.

•Patient Goal(s): "shrug".

•Caregiver Goal(s) - Mother: "Keep improving how she walks".

Her mother communicates primarily in Spanish, S is bilingual. She communicates without apparent language or social impairment. 

Has a chihuahua named "Jerry". Dressed as Frida Kahlo last Halloween.