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Sushi's case

Age/gender: 5 year old girl

Health condition/medical background:  Health condition: familial dysautonomia. Reported to have been a toe walker. They put her in the new suresteps that come up high in the back of the calf, but allow df. Mom thinks thinks they caused her compensation with supination. She overpowers them into knee hyperxtension anyway.. I think they dont grip her calcaneous well, so it slips forward in the orthotic and she plantarflexes over the back. I started seeing her after a 7 week hospital stay. Since then she has been in and out of the hospital with pneumonia. She failed her swallow study and i think she may be having micro aspirations of her saliva ( she intermittently makes a funny noise followed by a gulp- i told them to discuss with md). So respiratory may be playing a role here ( she has a mild pectus and high ribs. I tried an abdominal binder - it made a subtle difference in her posture.

Initially she had almost no DF range.. as she began walking much of it returned and some of the genu recurvatum got better. She still lacks neutral df.I included  her standing on a wedge bc that takes the pf tightness out of the picture and after a min or two she does come out of the hyperextension somewhat. 


 I tried to correct her during gait. When i tried at first, she wouldnt weight bear for long enough to take a long stride forward with the other foot.. once i gave her my hand to hold she was able to walk forward with very little  assistance to correct the supination. I couldnt control the knee hyperextension though ( maybe if someone else was holding her hand..) . Where would you go from here? 

Exam questions:

Functional status: 

Loading response: 


Terminal Stance: 


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 the patient improved selective motor control for one muscle group, what would it be?​

Sensory Perception and Pain:

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

How might lack of sensory information be contributing to her 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 body systems might be impacting function?


Regular/goal activities:

Structural demands of current/goal environments:

Patient Goal(s):

Caregiver Goal(s)

Engagement with therapy and orthoses: 

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



What are relevant goals?

Body Structure and function:

5 years old: 

45 years old: 


5 years old: 

45 years old: 

Environment, Participation, and Personal Factors:

5 years old: 

45 years old: 

​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.

Demonstrate the soft tissue mobilizations that might be appropriate.

What extra strategies might you use to increase the effectiveness this patient?


Neuroplasticity questions

Demonstrate/describe 3 activities to promote neuroplasticity/cortical map plotting of foot/ankle for J. Bonus points for creative activities/games NOT mentioned in the course. How will you progress the complexity for cortical map development? R hip range of motion and balance will limit J’s ability to reach her right foot with her left hand for activities. How can you modify for her?  

Strengthening questions

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

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

Pain and Health Condition Education :

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

What should the patient know about her health condition now, and what do you want to teach her as she gets older? 

What are 3 resources you can see for her movement system?

Systemic Access To Resources:

Case 1

Case 1

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