Wednesday, August 13, 2014

New Physical Therapist and Maybe a Brace

Allie met with a new physical therapist last week for an evaluation and had her first real PT session with her yesterday.  I've never seen Allie work so hard in a PT session and everything she worked on was challenging.  I'm feeling optimistic about this new therapy addition.

Yesterday, Allie walked on a treadmill for the first time while trying out an ankle foot orthosis (AFO).  Specifically, she tried a JumpStart Kangaroo AFO that looks like the one on the right.  I have been somewhat anti-brace because I really want her to work on developing strength to work around her increased muscle tone on her own, but she's been growing like a weed and her right leg seems to be getting tighter.  Her walking is getting more asymmetric as a result.  I explained my hesitancy to the PT and she said that her leg is going to get increasingly tighter unless she really stretches it out to work through her growth spurts.  The AFO would force Allie to keep her foot in a stretched position and she could wear it for just a few hours a day, maybe just in the evenings so she wouldn't have to wear it to school.  I was still not convinced until I saw her on the treadmill with the trial brace and she walked so much more evenly.  There were a solid 5 steps of perfect heel-toe cadence.  This all sounds worth a try.

The PT also asked if we'd consider Botox again for her leg.  Allie had an awful time with Botox in her arm, but Jonathan and I were both pleasantly surprised with how it worked on her leg and how the results stayed even after the Botox had worn off.  We meet with her physiatrist on Friday and plan to talk about maybe doing it again just on her leg.

Aside from the treadmill and brace discussion, Allie did a stair obstacle course during her session.  She also climbed a rock wall for the first time.  She was pretty good at going up but getting down was really hard for her.  She wanted to lay down on her stomach and slide down, which didn't work very well as you can imagine.



She also got to ride the tricycle around.  Note the duct tape to keep her right foot from slipping off the pedal.  It's nice to see her work so hard to push with her right leg.  It seems like she could build a lot of strength this way.


We also got a copy of her evaluation from last week.  Here are some of the highlights with some acronym expansion and images that help clarify the jargon.  Everything in parentheses is my addition.

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OBJECTIVE

Musculoskeletal:

Strength:  Strength was observed functionally.  No against gravity dorsiflexion observed on her RLE (right lower extremity) - with gait she doesn't achieve a heelstrike and when asked to duck walk she is unable to on the right. She can perform a squat to the floor and return to standing without UE (upper extremity) use but has a wide base of support and has increased pronation on the right.  Allie can stand from the floor with the use of her UE.  She can complete a bridge with nice extension from the floor and a sit up with UE assist or minimal assist without UE use.

Hip and knee range of motion within functional limits BLE (bilateral lower extremities) except right ankle - limited dorsiflexion on the right.  Difficult to measure accurately secondary to Allie being very mobile but she is lacking full neutral by at least 5 degrees.  She has increased dorsiflexion with her knee flexed so her gastroc (gastrocnemius muscle---the bulging part of her calf) is more involved in her limited range of motion. 


 

Bridge

Posture Assessment:  In standing, noted decreased weight bearing on her heel on the RLE.  Mild calcaneal valgus (flat feet).  In sitting, W sits but her mother corrects her to "criss cross" which she can self correct with cues. 
W sitting.  It's bad for your hips.
Neuromuscular:

Gait: Allie ambulates without a heelstrike on the RLE with a wide base of support, slightly abducted and with mild tibial valgus (knees too close to eachother; "knock knees").  She has a nice speed of gait but with a decreased step length on the RLE.  Allie runs on her toes with a wide base of support and decreased arm swing on the right.  She can complete 30ft in ~5.45 seconds.

Tone: Modified Ashworth Scale: 3 = Considerable increase in muscle tone, passive movement difficult in right gastroc.

Gross Motor Development:
The following was clinically observed during today's session:
  • Rolling: Can complete independently supine <-> prone (back to stomach and stomach to back).
  • Moving in/out of sitting: Preference for W sitting but can transition to sitting with LE crossed.  She can transition to kneeling and can maintain this for 10 seconds.
  • Transitioning to standing: With UE use.
  • Walking: Can walk down the hall on tip toes, difficult heel walking on the RLE secondary to lack of dorsiflexion, can walk backwards down the hall with decreased speed.
  • On a balance beam can walk ~2 steps but then steps off the beam with her right foot vs placing it in front of the left.
  • Jumping: Can jump from one rainbow stepping stone to another with a two foot take off and symmetrical landing.  Allie is able to jump forward 25" with a two foot symmetrical landing.  She can jump down without assist from an 8" step - she was fearful to try a higher step.  She can jump over a 3" hurdle with a 2 foot symmetrical landing - with the higher 6" hurdle she had frequent loss of balance and deferred to UE assistance.  She can jump 2-4 inches in the air on two feet.
  • Stair climbing: Allie can complete a reciprocal pattern up the stairs (only one foot touches each stair) with one hand held assist.  She descends the steps with one hand held assist or rail with a step to pattern (both feet touch each stair).
  • Single leg standing on right for multiple attempts, about 1 second
  • Single leg standing on left for multiple attempts, about 1 second
  • Throwing/catching: Allie can throw overhand and underhand with her left hand. She can throw a small ball ~5" or a larger ball ~10".  She does demonstrate good power but decreased accuracy with her throwing.  She has difficulty catching with a ball bounced to her or at her chest height - she doesn't use her right hand to assist with catching.  She does better trapping a ball when sitting. 
  • Kicking: Allie can kick a ball with preference for her left foot.  She can kick with the right foot but with less power and accuracy.  She does better with a static ball vs a rolled ball.
  • Tricycle: Allie was able to pedal several reps on each LE but required minimal assist to initiate the tricycle movement and keep her right foot in place - improved after using duct tape to stabilize the RLE.  Minimal assist to pedal 100 ft.  Required assistance with steering as well.
  • Climbing:  Allie could climb the ladder with moderate assistance for cues to hold on with BUE and completed a step to pattern up and down.

Standardized Test

The Peabody Developmental Motor Scales - 2nd Edition


Stationary:
Age Equivalent: 33 (months)
Percentile: 25

Locomotion:
Age Equivalent: 34 (months)
Percentile: 25

Object Manipulation:
Age Equivalent: 34 (months)
Percentile: 25

EVALUATION
Allie is a 3.5 year old female s/p (status post) an intra uterine CVA (cerebrovascular accident---a stroke) resulting in right hemiplegia presenting to outpatient physical therapy.  She is very pleasant and interactive and wants to be independent and do things herself.  She does have cautious periods with new activities such as climbing a ladder and riding the tricycle.  Her hemiplegia involves more of her UE but she does have gastroc tightness/spasticity limiting dorsiflexion with limits heelstrike and causes her to loose her balance with uneven surfaces.  She may benefit from an orthotic or splinting with a stretching program to assist with optimizing her gait pattern and assisting with balance.  She would also benefit from overall gross motor skill development including single limb stance, jumping, climbing, running, the stairs and throwing and catching. 

Prognosis: Patient's rehabilitation potential is good.  (I'm sure they say this for most kids but this is the first time I've seen it.  I'd be lying if I said I didn't feel some relief when I read this.)  The prognosis for stated goals is based on the following indicators: compliance with home program, likelihood to attend sessions, patient support system, patient motivation and interaction skills.  

Problem List / Impairments:
  • Balance
  • Range of motion 
  • Functional mobility
  • Gait abnormality 
  • Strength 
  • Coordination 
  • Motor planning 

Short Term Goals:
  1. Allison will gain >5 degrees of right ankle dorsiflexion to help prevent tripping and optimize gait pattern.  Time frame: 2 months.
  2. Allison will be able to perform single limb stance on each LE x3-5 seconds demonstrating improved balance.  Time frame: 2 months.
  3. Allison will be able to step onto uneven surfaces without falling 3/5 reps demonstrating improved balance. Time frame: 2 months.
  4. Allison will be able to jump over a 6" hurdle with a two foot take off and symmetrical landing.  Time frame: 2 months. 

Long Term Goals:
  1. Allison will ride a tricycle without LE stabilization x10 feet.  Time frame: 4 months.
  2. Allison will be able to consistently complete a reciprocal pattern ascending and descending the steps with one rail or less.  Time frame: 4 months.
  3. Allison will be able to catch a >5" ball with 2 hands 3/5 reps. Time frame: 4 months.

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