Cal Lyn

Name: Cal Lyn

Age/gender: 11 yo male

Health condition/medical background:  Medical diagnosis of hereditary spastic paraplegia with history of tethered cord, surgically repaired in 2016.

Exam findings: 


Functional status: Can walk for 30 min or ~1.5 miles before complaints of fatigue or asking to be carried. Still falling regularly, up to multiple times/week.


Relevant structural/functional MS findings: 

DF knee ext: R1 = 0R 5L; R2 = 10R 15L; DF knee flexed: R1 = 5B; R2 = 15R 20L; Hip ext strength: 3/5B; Hip abd: 3/5R 3+/5L; SL calf raises: R: 4/10 full-range from floor; L: 0/10


Relevant NM exam findings from physical exam:

Increased "tone" in plantar-flexors, adductors, quads, hip extensors

Question: how does "tone" present? Stiffness? Tonic contraction? Increased resistance to passive movement? 

Sensory pain:

Decreased sensation in feet; frequently experiences blisters on his feet without being aware. Infrequent reports of pain in proximal LE.


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

Hx of difficulty with bladder control; responded positively to recent neuromuscular re-education program for bladder control


Regular/goal activities: Attends school, ?


Structural demands of current/goal environments: Stairs! Has to go up/down a full flight of stairs at least 2x during the school day. 


Patient Goal(s): To walk and run as fast as peers. Jumping. Playing sports.


Caregiver Goal(s)For Cal's walking gait to appear as typical as possible.


Engagement with therapy and orthoses: I personally feel like he is, "burned out" with respect to physical therapy. Parents push hard for him to attend PT 2x/week. He wears orthotics, which family refer to as, "power socks." He is willing to wear them, but is frustrated with how long they to put on/take off.


Clinical questions: Uniqueness of his gait pattern. We recently trialed solid AFOs which failed for a few reasons, the primary ones being his inability to go down stairs in them, and he started having hip pain. Are there other options we can try? Should we have done something to modify the solids or pushed for a longer trial?

 

Exam questions:

Functional status: 

What category is Cal Lyn 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 these gait changes for Cal Lyn? 

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:

How does "tone" present for Cal Lyn?

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

Sensory Perception and Pain:

What are your concerns around negative neuroplastic changes for Cal Lyn?

Relevant systems screening:

Individual:

How can we support Cal Lyn around his burn out for therapy? Donning of braces? 

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

Intervention:

Goals 

What are relevant goals for Cal Lyn?

Body Structure and function:

11 year old: 

30 year old: 

Activities:

11 year old: 

30 year old: 

Environment, Participation, and Personal Factors:

11 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 for Cal Lyn.

Demonstrate the soft tissue mobilizations that might be appropriate for Cal Lyn.

What extra strategies might you use to increase the effectiveness for Cal Lyn?

 

Neuroplasticity questions

Demonstrate/describe 3 activities to promote neuroplasticity/cortical map plotting of foot/ankle for Cal Lyn. 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 Cal Lyn's motor skills?

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

Pain and Health Condition Education :

How will you discuss Cal Lyn's health condition with him?

What does he need to know about pain?

Systemic Access To Resources:

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