"J"

Name: "J" 

Age/gender: 18 yo, she/her

Health condition/medical background: 3 years post Left frontal intraparenchymal hemorrhage related to an underlying Left frontal Arteriovenous malformation (admitted after being admitted w/ acute mental status changes and seizures). She made a full neurologic/physical recovery. 6 months later, she was admitted for scheduled for Arteriovenous malformation glue embolization. The procedure was complicated by feeding vessel perforation and subsequent hemorrhage requiring clot evacuation, decompressive craniectomy, and medically induced coma. Hospitalization was prolonged and complicated by seizures, intracranial hypertension, autonomic dysfunction, thalamic storming, delirium, concern for meningitis, respiratory failure, tracheitis, hypertension, dysrhythmias, hyperglycemia, electrolyte abnormalities, constipation, urinary retention, and L LE thrombosis. She is now medically stable.

Exam findings: 


Functional status: She presents with right hemiplegia, with limited use of the right upper extremity and right lower extremity. Left upper and lower extremities have WFL motor control. She uses a wheelchair with E-fix with L joystick control for primary mobility. Ambulates short distances with min to mod A. 


Relevant structural/functional MS findings: 

R Hindfoot diagnosis group: neutral when near DF range--see video for finding in plantarflexion range.

R functional joint findings: R TC DF PROM: -15 with R2222222222 (hard push)


Relevant NM exam findings from physical exam:


Sensory pain: hypo/hyper perceptive? reports of pain? 


Relevant system screening findings (e.g. Autism spectrum, cardiopulm, GI health conditions): 

Prior to the neurological injury, has history of depression, and obesity.

J uses 1-3 words to communicate out loud, often with difficulty with word finding. She benefits from predictive text functions and cues from social partners for word finding. She is able to communicate well via writing using her phone. She huge fan of anime and k-pop. She is slightly boy crazy. 


Regular/goal activities: Attends high school, now in a non-diploma program. Enjoys watching anime and attending cosplay events. 


Structural demands of current/goal environments: no stairs in home, would like to be able to go up stairs at a family member's house.


Patient Goal(s): Walk further by myself, people not to notice my disability.


Caregiver Goal(s)She and her neurotypical brother live with their aunt, who also care for "J"s mother through long term illness until her recent passing. Her aunt wants J to be as independent as possible and able to live independently or as independently as possible when her aunt is no longer able to care for her. 


Engagement with therapy and orthoses: very willing to engage with therapy, is accustomed to wearing an AFO. 


 

Exam questions:

Functional status: 

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

Is the GS functioning eccentrically to control tibial motion and foot posture during LR? Midstance? Terminal stance? 

​Midstance: Does J’s R right lower extremity (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:

How might vision be impacting J’s motor experience? Her pre-existing diagnosis of depression?

Individual:

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

How are her personal interests a resource for physical therapy sessions?

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

Intervention

Goals 

What are relevant goals for J?

Body Structure and function:

18 year old J: 

43 year old J: 

Activities:

18 year old J: 

43 year old J

Environment, Participation, and Personal Factors:

18 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 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 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?

​J expresses to you that her Instagram only has pictures of her pre-injury. She talks about ideas she has for cosplay, but when she interacts with anime fan/cosplay groups online, she only uses pictures of herself pre-injury. As it relates to health condition education, how might you approach helping her progress toward being open to sharing her current image with the world?

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? 

Case 1

Case 1