Suzy's Case

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 her 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 hermotor skills?

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

Pain and Health Condition Education :

How will you discuss his health condition with her?

What does she need to know about pain?

Systemic Access To Resources:

Name: Evie

Age/gender: 4 yo girl

Health condition/medical background:  Gibbus structural variant, bilateral clubfoot, potential tethered cord (she continues to be followed by orthopedic surgeon and neurologist for potential surgical intervention), congenital kyphosis with gibbus at approximate and including T-L level, extra ribs. Fusion of L-S spine is planned for future, but no dates indicated currently. There is question about whether condition of tethered cord is still correct. Orthopedist and neurologist continue to monitor. She has bowel and bladder function currently without need for catheterization. 

Exam findings: 


Functional status:  Evie is now walking independently as her primary form of household self mobility. She does frequently tire with community distances and frequently uses her walker on family walks around the neighborhood. 2 minute walk test she was able to cover 155 ft. 6 minute walk test she completed 407 ft with LOB X 6. 
Evie is able to ascend and descend stairs with 1 hand rail and 2 UE support on rail using an inconsistent reciprocal step to pattern preferring to sidestep. She is able to step over low obstacles, up to 5 inches high preferring to lead with R LE.
Evie is able to stand from sitting in middle of floor, moves into quadruped and pushes up to stand without assist, rise to stand from low chair or bottom of playground slide (indoor) and continue with standing and walking .


Relevant structural/functional MS findings: 

In standing Evie stands with 25 degrees knee flexion on L and 30 degrees knee flexion on R. In supine she is lacking 5 degrees knee extension on L and 8 degrees on R. Hamstring 90/90: - 55 degrees on R and -60 degrees on L.


Relevant NM exam findings from physical exam:

Sensory/ pain:

Decreased sensation in LEs and feet- unable to feel hot items but some response to cold, inconsistent pain response to injury or cuts. 


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


Regular/goal activities: 


Structural demands of current/goal environments:   She does have stairs at home, struggles with ambulating on uneven ground but loves to play to playground and in her back yard.


Patient Goal(s):  

Play with friends, keep up with her older brother, dance


Caregiver Goal(s) 

Would like Evie to be able to walk the 1/2 mile to and from school each day if possible. Improve participation with peers including finding a dance class. Stand and walk with knees straighter


Engagement with therapy and orthoses: 

Loves participating in therapy but does fatigue by the end of an hour session. Currently have not found any orthoses that she tolerates throughout her day. Previously used ADM brace at night to address clubfoot but has outgrown them. She has tried DRAFOs, Solid ankle AFOs, articulated AFOs. 


Clinical questions: 

Finding an appropriate orthoses that helps with efficiency of gait to decrease fatigue

Any other treatment ideas/techniques to improve alignment and function to decrease long term pain and limitations 

 

Case 1

Case 1