Case Study 3: "J"

Exam questions 

Functional status: 

Loading response: Where is shock absorption happening for J during loading response? What are the force vectors at the ankle and knee?

​Midstance: Does J have (1) shank within functional limits, (2) excessively reclined shank, or (3) excessively reclined shank?

​Is this an adaptive strategy for her movement system?

Musculoskeletal findings:

​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:

In which muscle groups do suspect atypical tonic contraction?

If you had a magic wand and could grant J improved selective motor control for one muscle group, what would it be?​

Sensory Perception and Pain:

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

How might lack of sensory information be contributing to J’s gait impairment?

What areas might be at risk for:

Tissue damage pain

Lack of awareness of tissue damage pain (hypoperception)

Amplified pain

Relevant systems screening:

What other systems might be important for J?

Individual:

How does J’s daily motor experience contribute to her motor impairment?

How are her personal interests a resource for PT sessions?

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

Goals 

What are relevant goals for J?

Body Structure and function:

15 year old J: 

43 year old J: 

Activities:

15 year old J: 

43 year old J

Environment, Participation, and Personal Factors:

15 year old J: 

43 year old J

​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 that might be appropriate for J.

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

What extra strategies might you use to increase the effectiveness for J?

 

Neuroplasticity questions

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

Strengthening questions 

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

Demonstrate the progressive resistive exercises you plan to do with J. How will you modify for her? 

Pain and Health Condition Education 

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

  • How you will discuss J's health condition and potential to reach her goals of "walking like everyone else"?​

  • What are 3 resources that help J's movement system?

Systemic Access To Resources

As compared to her age-matched peers, what relevant resources might be harder for J to access due to societal structures? How can you as her PT support her 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 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 Right leg
Episodes of abrupt buckling of knees and fall
Goals: walk without braces, walk like everyone else

Musculoskeletal: 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.

Neuromotor: 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.

 

Case 1

Case 1