Continuing Education to Elevate Function and Form
"TP"
Name: "TP"
Age/gender: 51 yo, he/him
Health condition/medical background: Hemorrhagic CVA in 2020
Clinical Presentation
TP is a 51 year old male who experienced a hemorrhagic CVA in 2020, resulting in right-sided spastic hemiparesis. Patient presented to me in May of 2022 with his R foot locked in severe PF. TP was provided an AFO in inpatient rehab that was pre-positioned in PF to accommodate the patient's foot position immediately after CVA. The patient's foot thus developed soft tissue changes and eventually became contracted. Patient had been regularly receiving botox injections every 6 months with no success. Patient eventually underwent a tendon lengthening procedure which allowed him to finally get his R heel on the ground. He was also fitted for a new AFO positioned in neutral DF. However, the following video shows his current gait.
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What brings you to present them as a case study? What is your clinical question?
TP ambulates with severe forefoot ABD, not just in his hemiparetic side, but also in his non-hemiparetic side. What's interesting is his R hip external rotators are not spastic, but his R hip internal rotators are; however, he still has significant R tibial lateral torsion in both OKC and CKC. We have been working hard to attempt to address these impairments through therapeutic exercise however, minimal progress has been made. I feel that his gait is heavily influenced by his R ankle positioning and his standard AFO is not sufficient because his R foot remains pronated within it. Any thoughts, tips, suggestions?
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Exam findings:
Functional status:
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What category is the gait at midstance (WFL, inclined shank, reclined shank)?
Is the GS functioning eccentrically at LR? Midstance? Terminal Stance?
What do you see in the transverse and coronal plane?
Relevant structural/functional MS 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?
Relevant NM exam findings from physical exam:
What foot and ankle muscles are under-recruiting for tibial control in stance? For foot posture?
What other muscles more proximal in the kinetic chain might be under-recruiting, impacting gait?
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Sensory, pain:
What is his pain experience? Sensation?
Relevant system screening findings (e.g. Autism spectrum, cardiopulm, GI health conditions):
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Regular/goal activities:
Structural demands of current/goal environments: Any stairs or ramps?
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PT Goal(s):
Patient Goal(s):
Caregiver/Family Goal(s)
Engagement with therapy and orthoses:
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Key findings: What are the suspected drivers and limiting factors? What do you see as his resources?
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Intervention:
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Goals
What are relevant goals ?
Body Structure and function:
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Activities:
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Environment, Participation, and Personal Factors:
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​What are goal areas that might be in conflict (ICF levels/family goals/patient goals/team member goals)? Who is right?
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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?
Neuroplasticity questions
Demonstrate/describe 3 activities to promote neuroplasticity/cortical map plotting of foot/ankle. Bonus points for creative activities/games NOT mentioned in the course. How will you progress the complexity for cortical map development?
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Strengthening questions
What motor learning strategies will you try to maximize motor learning?
Demonstrate the progressive resistive exercises you plan to do. How will you modify for him?
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Pain and Health Condition Education :
How will you discuss TP"s health condition with him?
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Systemic Access To Resources:
What systemic challenges might he face now or in the future?