Jessica's Case

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Exam questions:

Functional status: 

What category is the patient at midstance (WFL, inclined shank, reclined shank)?

What do you see in the transverse and coronal plane?

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

What is your hypothesis for what's driving gait changes? 

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:

What muscles are lacking appropriate tonic (stabilizing postural) control? Isolated motor control? 

Sensory Perception and Pain:

What are your concerns around negative neuroplastic changes?

Relevant systems screening:

Individual:

 

Key findings: What are the suspected drivers and limiting factors? What do you see as his resources? 

Intervention:

Goals 

What are relevant goals?

Body Structure and function:

Current age: 

30 year old: 

Activities:

Current age

30 year old: 

Environment, Participation, and Personal Factors:

Current age

30 year 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?

 

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? 

Strengthening questions

What motor learning strategies will you try to maximize his motor skills?

Demonstrate the progressive resistive exercises you plan to do. How will you modify for him? 

Pain and Health Condition Education :

How will you discuss his health condition with him?

What does he need to know about pain?

Systemic Access To Resources:

Case 1

Case 1

Name: M.R 

Age/gender: 6 years + 10 months 

Health condition/medical background:  This is a little guy I’ve been seeing on and off for a few years with a wild foot.  He doesn’t have a diagnosis other than acquired foot deformity (ah, that word but it is his rx in the EMR) and generalized weakness. I thought initially he had some type of muscular dystrophy but genetics and muscle biopsy were negative. I serial casted him a couple years ago with decent results and he looks good in AFOs after. Late last year he underwent casting in club foot clinic with good results and they put him in hinged AFOs. A couple of months ago he has bilateral TALs and tendon transfer on the left. I don’t have a video post surgery but he looks similar. His ankle range is definitely better.  I am attaching a couple of photos and videos but I have more from over the years if you want to see anything else. 

Exam findings: 

generally decreased proximal strength, single leg balance  and endurance 


Functional status: independent with functional mobility, can ride a scooter, runs but not quickly, difficulty with jumping and single leg activities 


Relevant structural/functional MS findings:  decreased DF and Eversion (L more than R)


Relevant NM exam findings from physical exam:

Great toe tends to be maintained in extension

Sensory/ pain:

his mother told me at the end of last session that he has been complaining of foot pain/fatigue and asking for massage at the end of the day. My plan was to assess plantar fascia and intrinsically next session


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

mom is really concerned about his foot structure and looking for answers as to what is causing this, she wants him to be able to do everything kids his age can do


Regular/goal activities: 


Structural demands of current/goal environments:   stairs to access apt and at school 


Patient Goal(s): 

 run faster, to play


Caregiver Goal(s) 

mom is really concerned about his foot structure and looking for answers as to what is causing this, she wants him to be able to do everything kids his age can do


Engagement with therapy and orthoses: 

very playful and good with therapeutic activities, needs frequent redirection to stay on task but he’s 6 
He will wear orthotics but often wants a break from them if he has been wearing all school day. 

 

Clinical questions: is there anything else I can do to help with this foot structure? (I have some ideas now after this course). I think it’s really impacting his balance since he is weight bearing on the lateral side