Amara

Name: Amara

Age/gender:6 yo, she/her

Health condition/medical background:  Spastic CP, diplegia, One round of Botox injections last fall f/b serial casting

Exam findings: 


Functional status: Walking with walker at school, not at home (2 different parent households)

Walks in community with rest breaks, plays on playground with peers
Falls frequently when going too fast or with perturbation


Relevant structural/functional MS findings: 

Decreased L ankle DF ROM, hard end feel (feels like it is at the TC joint, not achilles; LLD (~1/4-1/2"), Decreased R trunk sidebend


Relevant NM exam findings from physical exam:

Increased tone in LEs, but at rest she can focus and ankle DF with AAROM, and EHL active

Falls frequently when going too fast or with perturbation

Question: what is "tone" for her? tonic contraction? Stiffness? Increased resistance to passive movement?

Sensory pain:

 low awareness, min pain unless she falls


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

Gets emotionally  dysregulated


Regular/goal activities: Ascend/descend stairs, ambulate with symmetric weightbearing, jump with symmetric take-off and landing, R and L SLS for 3 seconds


Structural demands of current/goal environments: Any stairs or ramps?

 

PT Goal(s):  ambulate level and uneven surfaces w/o LOB, prevent ankle/foot pain and deformity


Patient Goal(s):  Play with peers on playground


Caregiver Goal(s) -carry backpack to school, indep on 3-4 stairs, be like other kids


Engagement with therapy and orthoses: loves yoga, kitties, did not like e-stim. Compression vest trialed at school. Just placed K-tape on abdomen…


Clinical questions:  AFO’s: has had hinged and achieved PROM to 7-10 deg DF B with Botox and casting, but now tightening up again.  Recommending rigid, since she lost ROM. With heel wedges? 
Any other recommendations welcome
MD’s are recommending more Botox or not, but I don’t want to weaken her further.
Parents are going to 2 different MD’s and getting different treatment recommendations

 

Exam questions:

Functional status: 

What category is Amara's gait at midstance (WFL, inclined shank, reclined shank)?

Is her GS functioning eccentrically at LR? Midstance? Terminal Stance?

What do you see in the transverse and coronal plane?

What's your hypothesis for her variable step placement?

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 foot and ankle muscles are under-recruiting for tibial control in stance? For foot posture?

Sensory Perception and Pain:

Where might she be likely to experience pain in the future?

Relevant systems screening:

Individual:

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

Intervention:

Goals 

What are relevant goals for Amara?

Body Structure and function:

6 year old: 

30 year old: 

Activities:

6 year old: 

30 year old: 

Environment, Participation, and Personal Factors:

6 year old: 

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 her motor skills?

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

Pain and Health Condition Education :

How will you discuss Amara's health condition with her? With her family?

Systemic Access To Resources:

What systemic challenges might Amara face? How can you as her PT help to mediate this?

Case 1

Case 1