Case Study 3: "J"
Exam questions (Manual Page A-5):
1. What is O'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 O have (1) shank WFL, (2) excessively reclined shank, or (3) excessively reclined shank?
Terminal stance: Is O achieving therapeutic gait? What's a major terminal stance resource that O demonstrates?
How is O maintaining momentum for gait?
What are 5 MAJOR resources O has for gait?
Coronal: Severe hindfoot, midfoot and forefoot pronation throughout. Medial rotation and adduction of knees during loading response and into midstance.
Sagittal: Swing: lack of knee extension at terminal swing. Stance: initial contact at forefoot, flatfoot with great effort. Shank is vertical at best during LR, shank is excessively inclined throughout. Lack of heel contact throughout, lack of heel contact at terminal stance.
What is your hypothesis for O'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?
Neuromotor and Motor control findings:
What do you see as O's primary impairment as it comes to muscle activation and timing?
What balance strategies is O 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)
What sensations might be scary for O?
What areas might be hypoperceptive for O?
How would you evaluate hypo- and hyper-perception in O's lower extremities?
Relevant systems screening:
What screening questions/concerns do you have?
How does having a tracheostomy (and lack of Passy Muir valve tolerance) have on his trunk stability?
How is trunk stability impacting LE function?
What does O like to do? Where does he like/need to go? What are his goals as a 2 year old toddler? How does he feel about therapy and braces? How does is family feel about therapy and braces? (If unknown, put yourself in his shoes and decide for 2 year old you as well as the shoes of his parents).
Key findings: What are the suspected drivers and limiting factors for O?
Goals (Page A-11):
What are relevant goals for O?
Body Structure and function:
2 year old O:
DKM (Adult O):
2 year old O:
DKM (Adult O):
Environment, Participation, and Personal Factors:
2 year old O:
DKM (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 (Page B106 - B116):
Demonstrate the joint mobilizations you would likely need to perform for O.
Demonstrate the soft tissue mobilizations that might be important for O.
Strengthening questions (Page B118 - B133):
What motor learning strategies will you try first to maximize O's motor skills?
Demonstrate the progressive resistive exercises you plan to do with O. How will you maximize this exercise for O?
Neuroplasticity questions (Page B134-B143)
Demonstrate/describe 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 (Page B144-B149):
What are your hypotheses around O's experience of pain? Discuss how you would you address this in a treatment session.
Community Activity Engagement:
(Covidnotwithstanding): What active regular exercise/sport activities might be engaging for O? What does O need for age-appropriate community access?
Systemic Access To Recourses:
As compared to his age-matched peers, what extra disadvantages in life does O face due to societal structures? How will you as his PT work to counteract those disadvantages?
"J" Case Information
15 year old with diplegic CP
In current episode of care with PT, very motivated. Patient’s goal: walk like everyone else, walk without braces (but not averse to wearing braces)
Ambulates with B loftstrand crutches, emerging independence without loftstrand crutches
Currently using solid AFOs without posting
8 years ago Tendon Lengthening B LE
1 year ago: B LE: zone 2 gastroc-soleus tendon lengthening; lateral column lengthening of the foot utilizing osteotomies of both calcaneus and cuboid; arthrodesis of calcaneocuboid joint
Amplified pain in R LE
Episodes of abrupt buckling of knees and fall
Goals: walk without braces, walk like everyone else
MS: Alignment at rest into pronation as in weightbearing. With correction, structural hindfoot varus, forefoot varus. Soft tissue and joint restriction for abduction and pronation of MTPs. Soft tissue, superficial and deep throughout system restricting toward pronation and TC DF. Elevated calcaneous with stiff heelcord.
NM: Lack of isolated motor control around the ankle. Step strategy for balance due to standing posture in hip and knee flexion, lack of motor control at ankle. Emerging control of hips and knees in more extension with ongoing PT.
Sensory and Pain: Amplified pain around R ankle and heel since surgery 9 months ago. Linked to epidoes of LE collapse/fall.
Other Systems: Reports episodes of dyspnea with minimal exertion, not predictable or related to a known health condition.
Individual: very engaged with therapy, willing to wear braces. Long term goals: walk like everyone else, walk without crutches or braces. Many questions about the pathophysiology of her motor control differences.