Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
PHYSICAL THERAPY PATIENT MANAGEMENT DOCUMENTATION
Administrative Information:
Medical Diagnosis: Myelomeningocele, T10-T12, hydrocephalus, bilateral clubfeet
Referral Source:
Ann Gates, M.D. Children’s Hospital of Kansas City
Diane Folks, Educator Adeline Preschool
Reason for Referral to Physical Therapy:
Need for improved mobility
Setting for Physical Therapy Services:
Preschool
Home
Type of Insurance:
Private funding and federal funding (PL 94-457)
Informed Consent:
Medical authorization: Signed 2/5/2001 by parent
Educational authorization to begin services:
IFSP (Individualized Family Service Plan)1 signed 5/10/2001
EXAMINATION:
General demographics:
Name:
Date of birth (DOB):
Age:
Sex:
Race:
Ethnicity:
Language:
Education:
Michelle D.
NA
4 years, 8 months
Female
Caucasian
American
English
Preschool
Social history:
Cultural/religious: Catholic
Family and caregiver resources:
Family receives the newsletter from the Spina Bifida Association
Social interactions, social activities, support systems:
Both parents are living at home and provide needed transportation for Michelle to attend
therapy and other social, educational, medical, activities.
Employment/work (job/school/play):
Michelle attends the Adeline Preschool.
Growth and development: Weight and height are not proportionate.
Developmental history:
Michelle was born full-term, delivered by C-section. She had delayed motor milestones as
follows:
2 months Head control in vertical suspension
4 months Rolling with assistance
6 months Prone on elbows
7 months Prone crawling
Attempting to assume sitting by pushing legs under her.
12 months Sitting by propping on her legs with both elbows
Attempting to pull to stand
18 months Ambulating with a parapodium + standby assistance
Hand dominance: Michelle is right-handed.
Living environment:
Devices and Equipment (including assistive devices, sensory aids, and other equipment
to facilitate function):
Michelle wears glasses (200/20) for her vision.
IFSP – A plan that is mandated by public law, the Individuals with Disabilities Education Act (IDEA), to provide families with the
support needed to manage children at risk for developing significant developmental delays. The IFSP assumes that family
functioning influences the child’s development, thus family members are key to the services provided to these children. This type of
therapy is sometimes called, “family-centered” intervention.
1
Physical Therapy Management Documentation – page 1
Case Study: SPINA BIFIDA
Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
At age 12 months she began using a parapodium for standing and initial
Ambulating. She used a parallel pusher (very elongated walker) for assistance
when attempting to ambulate with her parapodium.
At age 18 mos. She ambulated with a parapodium alone.
A manual wheelchair has been ordered from the local vendor. Key
features include a low seat for ease of transfers to/from the floor.
Bilateral hip-knee-ankle-foot orthoses have been ordered and will be fitted
as soon as they are completed by her orthotist at the hospital.
HKAFO with rollator walker; parapodium – free standing
Living environment and community characteristics (including type of residence):
Michelle lives in a split-level home with a single step to enter the back door. She lives in
a small community on the outskirts of town. This community has accessible schools,
community resources, and recreational facilities.
Living with:
Michelle lives with both parents and a 2-year-old sister. Her maternal grandmother lives in
the same town.
Environmental barriers:
Michelle is carried up and down the twelve (12) steps leading to the basement.
Environmental resources:
The community is accessible for all of Michelle’s current activities.
Projected discharge destination: N.A.
General health status (self-report, family report, caregiver report):
General health perception:
Michelle says that she is happy. Her parents report that, despite several hospitalizations
for surgery, etc, Michelle appears to be very healthy.
Physical function (e.g. Mobility, sleep patterns, restricted bed days):
Michelle is able to get around her house (<25 feet), but is unable to travel long distances
in her community and with her preschool class for fieldtrips.
Physiological functions (e.g. Memory, reasoning ability, depression and anxiety)
Michelle’s teacher reports that Michelle, while alert and cooperative in school, has some
difficulty with puzzles.
Role function (e.g. Community, leisure, work, social):
Michelle attends school regularly, goes to church every Sunday, and participates in
functions with the local Spina Bifida Association chapter.
Social function (e.g. Social activity, social interaction, social support)
Michelle engages in some cooperative play with her classmates at her preschool. She
gets along well with her 2-year-old sister.
Social/health habits:
Behavioral health risks (e.g. Smoking, drug abuse)
None.
Physical Therapy Management Documentation – page 2
Case Study: SPINA BIFIDA
Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
Level of physical fitness
Michelle is currently participating in a recreational swimming program once per month at
her local community center under the supervision of a physical therapist.
Family history
Family health risks:
Father smokes 1 pack a day. The father is obese.
Mother is obese.
Medical/surgical history
Cardiovascular: No evidence of heart problems at present.
Endocrine/metabolic:
No evidence of problems at present.
Gastrointestinal: No problems at present.
Genitourinary:
Uses intermittent catheterization to manage bladder needs.
Uses a bowel program to manage bowel movements (under supervision of RN at school).
Michelle is learning to perform her own catheterization at the present time.
Gynecological: No problems at present.
Integumentary: Problems with redness over ischial tuberosities with sitting > 30
minutes on hard surfaces.
Musculoskeletal: Born with bilateral clubfeet (talipes equinovarus)–fixed PF and forefoot inversion.
Bilateral serial casting used to realign feet.
Surgical repair of clubfeet at age 7 months with subsequent use of
AFO’s post-surgery.2
ROM on day 5 – WNL at hips and knees.
Tendency of hips to fall into external rotation in prone and supine
At 6 months of age, Michelle developed hairline fractures of her of her LE’s bilaterally.
Neuromuscular: Born with myelodysplasia - lesion at T10-12
Repair of lesion at 24 hours. Post-surgical positioning:
Supine with LE’s elevated slightly higher than her head, using a roll under her hips
Evidence of enlarged ventricles at birth, but not necessitating
immediate repair.3 A ventriculoperitoneal shunt was placed in her right lateral ventricle at
age 11 months.
Obstetrical
N.A.
2
Surgery for talipes equinovarus should be reserved until the child is between four and eight months of age. The general
principle involves: 1) releasing the medial structures, by lengthening the flexor tendons and the tibialis posterior tendon and 2)
releasing the posterior structures, by transecting the posterior joint capsule and lengthening the Achilles tendon. A more extensive
role may sometimes be required. The calcaneus can also be repositioned laterally and a more complete correction achieved. Pins
are left in place for about six weeks to help stabilize the correction. Casting should be continued for two to three months after
therapy. Prognosis: With adequate treatment, be it conservative or surgical, it is very likely that the positional deformity can be
eliminated and the ability to ambulate adequately on the affected foot can be achieved. Certain elements of the deformity, such as
the smallness of the foot, the calf hypoplasia, and the minimal shortening, cannot be corrected, but these rarely have a large affect
on the patient's functional ability.
3
Hydrocephalus involves accumulation of cerebrospinal fluid (CSF) in the ventricles of the brain, with an increase in the pressure
inside the head. There are two sources of this pressure. One is that of the CSF itself, but a much higher pressure is produced by the
heart in order to pump blood to the brain. If the CSF pressure rises, it eventually interferes with the blood supply to the brain,
depriving it of oxygen and glucose. Initially this causes tiredness, irritability and drowsiness, but if it progresses then loss of
consciousness will result as the brain begins to shut down.
The immediate effects of this interference with the blood supply disappear if the CSF pressure is returned to normal, such as by
ventricular tap or insertion of a shunt. However, in most cases the process has been continuing for some time before diagnosis of
hydrocephalus is made. During this time the interference with the blood supply leads first to a 'dying back' of the very fine blood
vessels in the brain. Even this process is largely reversible if prompt action is taken, but at this time there is often insufficient clinical
evidence to suspect hydrocephalus. The next stages involve progressive damage to the actual nerve cells in the brain and to their
eventual destruction, and this cannot be reversed. Because of the areas of the brain most affected, functions associated with
thought and learning as well as with coordinated skilled movement begin to deteriorate. The precise effects differ between
individuals and are further complicated by other abnormalities as well as by the pre-existing degrees of ability and personality of
each person affected. It is not surprising therefore that while, for instance, learning disorders are common amongst those with
hydrocephalus, their exact effects vary considerably. People with hydrocephalus generally score better on verbal IQ than on
performance IQ and this is thought to reflect the distribution of nerve damage in the brain as described above. Generally speaking,
people who have had hydrocephalus since birth or childhood have, as a group, a lower average IQ than a comparable group without
hydrocephalus, but it is important to realize that there is a wide range in each group, and some people with hydrocephalus have
very high scores.
Physical Therapy Management Documentation – page 3
Case Study: SPINA BIFIDA
Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
Prior hospitalizations, surgeries, and pre-existing medical and other health-related conditions:
Michelle remained hospitalized after birth until the lesion and
surgical repair of her back healed.
Casting for clubfeet was well managed by her orthopedist while she was
hospitalized.
Psychological
Potential learning disabilities associated with hydrocephalus.
Pulmonary
No problems are evident at this time.
Current condition/chief complaint:
Concerns that lead the patient/client to seek the services of a PT:
Michelle is getting new braces and must learn to walk.
Concerns or needs of patients/clients who require the services of a PT
Parents want Michelle to learn how to walk with her new braces.
Current therapeutic interventions: None at present
Mechanism of injury or disease (include date of onset and course of events)
Onset and pattern of symptoms: Congenital spinal cord lesion
Patient/client, family, significant other and caregiver expectations and goals for the therapeutic intervention:
The parents would like Michelle to be independent in dressing, donning and
doffiing her new braces, and performing her catheterizations independently.
Patient/client, family, significant other and caregiver perceptions of
patient’s/client’s emotional response to the current clinical situation:
Michelle has been very cooperative in therapy in the past. It generally takes her
about a week to warm up to new therapists.
Previous occurrence of chief complaints:
This developmental disability has impaired her mobility since birth.
Prior therapeutic interventions:
Michelle was seen weekly in the Spina Bifida Clinic her casting
was monitored. The PT educated the parent re: skin care,
therapeutic positioning, and activities to promote normal motor
development.
Instruction of parents in skin care with orthotic devices and appropriate wearing
schedules to prevent skin breakdown.
When Michelle learned how to ambulate with the parapodium, she practiced
falling and coming to standing as well as practicing her balance limits.
Functional status and activity level
Current and prior functional status in self-care and home management, including ADL’s and IADL’s:
Michelle can feed herself independently. She needs assistance putting on her
clothing as well as verbal guidance donning and doffing her parapodium.
Current and prior functional status in work (job/school/play, community and leisure actions, tasks, or
activities)
Medications:
Medications for current condition:
None
Medications previously taken for current condition:
None
Medications for other conditions
On an antibiotic for urinary tract
Infection (X 6 weeks)
Other Clinical Tests
Laboratory and diagnostic tests:
Prenatal testing of mother: AFT (A high level of alpha feto protein indicates the possible presence
of neural tube defect, eg spina bifida. A low level indicates the possible presence of
Down's Syndrome.
Ultrasound revealed the thoracic lesion and the hydrocephalus
CT scan of head and neck for hydrocephalus
Urinanalysis for UTI (urinary tract infection)
Review of available records (e.g. medical, educational, surgical):
Additional records unavailable.
Review of other clinical findings (e.g. Nutrition and hydration)
None.
Physical Therapy Management Documentation – page 4
Case Study: SPINA BIFIDA
Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
Systems review:
Overall Growth and Development:
Height:
25th percentile
Weight:
65th percentile
Cardiovascular/Pulmonary System:
Heart rate:
110 bpm (WNL)
Respiratory rate:
26 breaths per minute (WNL)
Blood pressure:
100/60 (WNL)
Edema:
none
Integumentary System:
Integumentary disruption: none at present
Continuity of skin color:
normal
Pliability (texture):
normal
Presence of scar formation:Well-healed scar at T10-12 lumbar area.
Musculoskeletal System:
Gross symmetry:
Standing: Michelle has a tendency to lean to her right side when standing in
her parapodium.
Sitting: Michelle tends to lean to her right side when sitting with or without her
parapodium.
Activity specific: Michelle demonstrates a preference to transfer and rotate her body to
her right side. She must be prompted to rotate her body to her left side for
transfers.
Gross Range of Motion:
Michelle is developing slight flexion contractures of her hips and knees bilaterally.
Her feet are essentially fused in a neutral ankle position.
Gross Strength: Michelle’s upper extremity strength is grossly within normal limits.
Neuromuscular System:
Gait:
Michelle currently uses a swivel gait with her parapodium and
rollator walker.
Locomotion (includes transfers, sit-to-stand, transitions, and bed mobility):
Without her parapodium:
Michelle is able to perform all transfers in her bed independently.
Michelle needs moderate assistance to climb into her bed (30” off
the floor) and to transfer to/from a child-sized chair.
Michelle can travel up and down stairs scooting on her bottom.
With her parapodium:
When she is wearing her parapodium, she needs minimal assistance unlocking
her parapodium and safely seating herself.
Michelle has the arm strength to transfer from sit-to-stand with standby
assistance, primarily to lock her parapodium.
Balance:
Michelle demonstrates good standing balance using her
parapodium.
Motor function (motor control, motor learning)
Michelle demonstrates good control of her upper extremities, head and neck.
She has difficulty controlling muscles below her waist. She is quick to learn
transfers and appears to do best with variable practice and delayed feedback.
Communication, Affect, Cognition, Learning Style:
Communication (ability to make needs known):
Michelle can communicate her needs, but tends to be echolaic (i.e., uses
“cocktail” chatter, echoing the inquisitor, rather than responding directly to
questions.)
Orientation X 3 Michelle is oriented to person, place, and time, as appropriate for
her age.
Emotional/behavioral problems
Currently, Michelle does not have any noticeable problems.
Learning barriers:
Michelle has been referred to occupational therapy for possible perceptual motor
problems as they relate to position in space.
Education needs:
Educational needs for placement into kindergarten are currently
being reviewed. A battery of cognitive and perceptual motor tests has been
requested.
Physical Therapy Management Documentation – page 5
Case Study: SPINA BIFIDA
Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
Tests and Measures: (Tests performed in her preschool setting).
 AEROBIC CAPACITY AND ENDURANCE – Walks X 15 feet using parapodium and rollator walker without a
rest. Walks a total of 50 feet in 5 minutes.
 ANTHROPOMETRIC MEASUREMENTS – WNL for height and weight
 AROUSAL, ATTENTION, AND COGNITION – IQ 90 with learning disability.
 ASSISTIVE AND ADAPTIVE DEVICES – parapodium is in good repair, but knee joint is malaligned; rollator
walker is too short.
 COMMUNITY AND WORK (JOB/SCHOOL/PLAY) INTEGRATION OR REINTEGRATION – participates in all
preschool activities except exterior play area where terrain is uneven.
 CRANIAL NERVE INTEGRITY – Currently no evidence of cranial nerve involvement
 ENVIRONMENTAL, HOME, AND WORK (JOB, SCHOOL, PLAY) BARRIERS – not examined.
 ERGONOMICS AND BODY MECHANICS – not examined.
 GAIT, LOCOMOTION , AND BALANCE  INTEGUMENTARY INTEGRITY – evidence of redness over ischial tuberosities bilaterally after sitting for 30
mnutes in classroom chair.
 JOINT INTEGRITY AND MOBILITY –
 MOTOR CONTROL AND MOTOR LEARNING
 MUSCLE PERFORMANCE (INCLUDING STRENGTH, POWER, AND ENDURANCE)
 NEUROMOTOR DEVELOPMENT AND SENSORIMOTOR INTEGRATION:
PEDI
 ASSESSMENT OF ORAL MOTOR FUNCTION – not assessed.
 POSTURE – Sitting posture without support is marked by lumbar kyphosis.
 PROSTHETIC REQUIREMENTS - NA
 RANGE OF MOTION – Hips and knees lack 10 degrees bilaterally. Ankles are fixed at neutral.
 REFLEX INTEGRITY – LE – absent DTRs, righting and equilibrium reactions involving the lower extremities (in
sitting, all fours, & standing) are impaired.
 SELF-CARE AND HOME MANAGEMENT (Including ADL’s & IADL’s ) - not assessed
 SENSORY INTEGRITY (INCLUDING PROPRICEPTION AND KINESTHESIA) – copmlete sensory loss below
T10
 VENTILATION, RESPIRATION (GAS EXCHANGE), AND CIRCULATION – not assessed.
EVALUATION4:
4
A dynamic process in which the physical therapist makes clinical judgments based on data collected during the
examination. This process also may identify possible problems that require consultation with or referral to another
provider.
Physical Therapy Management Documentation – page 6
Case Study: SPINA BIFIDA
Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
DIAGNOSIS (see practice patterns in Guide to Physical Therapy Practice):
The diagnostic group for spina bifida is:
5B
Impaired neuromotor development
Supported by examination findings of:
 Clumsiness during play
 Delayed motor skills
 Delayed oral motor development
 Impaired arousal, attention, and cognition
 Impaired locomotion
 Impaired sensory integration
5C
Impaired motor function and sensory integrity associated with nonprogressive disorders
of the central nervous system – congenital or acquired in infancy or childhood
Supported by examination findings of:
 Difficulty negotiating various types of terrain
 Difficulty planning movements
 Difficulty with manipulative skills
 Difficulty with positioning
 Frequent falls
 Impaired affect
 Impaired arousal, attention, and cognition
 Impaired expressive or receptive communication
 Impaired motor function
 Loss of balance during daily activities
 Inability to keep up with peers
 Inability to perform work (job/school/play) activities.
Other patterns to consider:
 Fractures (4G, 4H, 4I)
 Decubitus ulcer (7B, 7C, 7E)
 Congenital musculoskeletal anomalies (4A,4B,4F, 4I, 5B, 5C)
 Congenital anomalies of the central nervous system (5B, 5C)
 Other
Other complications to consider:
 Seizures
 Hydrocephalus
 Urinary tract infections
 Behavior disorders
 Obesity
 Tethering of the spinal cord
 Shunt malfunction
Physical Therapy Management Documentation – page 7
Case Study: SPINA BIFIDA
Diagnosis and Prognosis for Pediatric Clients
Catherine Thompson
PROGNOSIS (including Plan of Care):
Level of optimal improvement (prognosis for optimal function, expected
outcomes)
 Pathology 

Impairments 

Functional limitations 

Disabilities 

Risk reduction/Prevention 

Health, wellness, and fitness 

Societal resources 

Patient/client satisfaction 
Anticipated goals: (long-term and short-term goals)
Amount of time required:
Expected range of visits is 6-90 visits over the course of 12
months.
Intervention to be used (frequency and duration):
(See pages 335-344 in the Guide to Physical Therapist Practice)
Discharge plan:
INTERVENTION:
Coordination, communication, and documentation: (See pages 335 and 354 in the Guide to
Physical Therapist Practice)
Patient/client-related instruction: (See pages 336 and 355 in the Guide to Physical Therapist
Practice)
Procedural interventions5: (See pages 337-344 and 356-363 in the Guide to Physical Therapist
Practice)
5
Examination findings that may direct the type and specificity of the procedural intervention may include:
PATHOLOGY/PATHOPHYSIOLOGY
IMPAIRMENTS
FUNCTIONAL LIMITATIONS
DISABILITY
RISK REDUCTION/PREVENTION NEEDS
HEALTH, WELLNESS, AND FITNESS
Physical Therapy Management Documentation – page 8
Case Study: SPINA BIFIDA