Understanding Rehabilitation ICF Case Study

Original Editors Naomi O'Reilly and ReLAB-HS

Top Contributors - Naomi O'Reilly, Oyemi Sillo, Ashmita Patrao, Tarina van der Stockt and Jess Bell      

History of Presenting Case[edit | edit source]

Grania is a 16-year-old girl who was referred to Physiotherapy in Primary Care. The referral stated they had concerns in relation to Grania’s balance and mobility as a result of hypermobility. She has frequent trips and falls that are having a noticeable impact on her everyday activities and limits her participation in activities both at home and at school. They have significant concerns in relation to Grania’s weight, and the impact that this may be having on her overall health and well-being and felt that this is contributing to her reduced balance, ability to move and her participation in physical activity.

This referral came on the back of a year of significant changes for Grania. She received an urgent review by Child and Adolescent Mental Health Services (CAMHS) following family difficulties and placement into care separately to her older sister. She was diagnosed with an acute stress reaction with increasing distress and behaviour escalation resulting in a crisis hospital admission and urgent Paediatric and Psychiatric review.

Subjective Information[edit | edit source]

Child’s History of Presenting Condition[edit | edit source]

Grania reports a long history of hypermobility. She explained that because of her hypermobility her balance is bad and that she frequently will trip or fall. Sometimes because she will roll over on her ankle but mainly because her knees will “pop out” and give way, which occur daily. As a result, she is fearful and quite anxious about doing any physical activity but does enjoy dancing, especially on Tik Tok, and will try to learn the dances. She reports intermittent pain in her feet or achy legs, mainly after she does a lot of walking or physical activity and knee pain going downstairs.

Grania reported that her weight is a problem and that she is waiting to go to the specialist programme to help her with this. She reports that she never feels full and that she eats if she feels upset or sad. She reported this has improved where she is living now and is not doing this as much, and has been learning more about food and is involved with food preparation, which she enjoys. Grania identified that her priority goal is to reduce how often her knees “pop out” and to stop falling. She would also like to be more active and would like to get involved with Physical Education (PE) at school and join a dance class but does not feel she would manage this currently.

Keyworker Concerns[edit | edit source]

Sharon is Grania’s key worker and reports that Grania struggles with any form of physical activity and is very anxious about trying new activities. She expressed concerns that Grania has poor self-confidence and has difficulty in interacting with her peers, appears to prefer to be on her own and stay in her room and will spend significant time on screens. She has difficulty with social cues and a poor understanding of personal boundaries or space, which may impact her interaction with peers and has difficulty expressing her feelings. Sharon reports that Grania has poor sleep patterns, she struggles to get to sleep at night, is fearful of the dark and will often not fall asleep till late. This means she is very fatigued in the mornings, which affects her mood and energy levels. Since moving into care Grania has managed to lose almost 7kg, but feel they need more support around managing her nutritional needs to help with weight loss. Sharon feels that developing her self-confidence, peer interaction and improving her physical fitness are the most important things for Grania, and would like support to increase her physical activity levels in a supported way without causing her further pain or discomfort.  

Social History[edit | edit source]

  • She is currently in care living in a residential home with 3 other young people, all older-aged 14 - 16 years.
  • She has 1 Sister - 17 years old. They have a very close and strong relationship. She was previously the main support person in the home. Her sister is also in care but not in the same place. They do get to see each other on a limited basis currently.
  • Monthly supervised visitation with Maternal Grandmother is allowed. Currently, she has no visitation with her parents but this may change.
  • Grania remains in the same school but now has to travel 45 mins there and back each day. Grania reports she has no friends in school but is “not bothered” by this, “I am happy with my own company”.

Birth History & Developmental History[edit | edit source]

  • No Information Available

Medical HistoryHypermobility Spectrum Disorder - No Information on when/who diagnosed or whether any investigations into same.[edit | edit source]

  • Urinary Incontinence and Enuresis - Improving with the management of constipation
  • Constipation & Gastrointestinal Complaints - Managed with medication (Dulpholax and Lactulose) - Some improvement with same but ongoing intermittent periods, unable to identify triggers.
  • Joint Swelling in Ankles - Has not yet been investigated by Rheumatology but awaiting same, but information available suggests that this may be associated with an increase in weight and decreased physical activity.
  • Generalised Learning Disability with a query of Mild Intellectual Disability or ASD - Awaiting Further Assessment

Weight History:[edit | edit source]

Limited History Available. Referred to Specialist Paediatric Weight Management Programme but delayed due to COVID-19

  • Age 16 years and 5 months = 106.3kg, Height 167cm, BMI > Percentile 99th - On Inpatient Admission

Family History[edit | edit source]

  • Sister recently diagnosed with Autism Spectrum Disorder.
  • Parents have a history of alcohol & drug addiction.  
  • Mother has a history of mental health difficulties and is known to Adult Mental Health Services.

Hobbies[edit | edit source]

  • Very creative:
  • Loves art, drawing and animation.  Enjoys music & dance - Watches on Tik Tok and try’s to learn them.
  • Loves Video Games - Has Playstation and Switch, which is her favourite.
  • Loves Japan and Japanese Culture, Anime in particular, which she would watch with her sister.
  • Physical Activity: Currently not meeting physical activity guidelines & reduced activity tolerance. Fear of movement+++.
  • Confidence: Low self-confidence with negative self-talk. Anxiety in relation to movement with fear of knees “popping out”

Patient Report Outcome Measures:[edit | edit source]

  • Movement ABC-2 Checklist: Red Zone - May Indicate Movement Disorder
  • Developmental Coordination Disorder Questionnaire 2007 (DCDQ-07): 21/75 - May Indicate DCD
  • Fear Avoidance Belief Questionnaire - Physical Activity Subscale (FABQ-PA):  20/24

Objective Assessment[edit | edit source]

Posture[edit | edit source]

A wide base of support, hyperextended knees, genu valgum & increased supination bilaterally with forefoot varus. Bilateral piezogenic papules of the heels are evident.

Gait[edit | edit source]

A wide base of support with external foot progression and abduction type swing pattern with genu valgum and knees locked into hyperextension during midstance. Decreased hip and knee flexion during the swing phase.

Tone[edit | edit source]

Low Tone Throughout, Core > Peripheral

AROM[edit | edit source]

In Supine - Full AROM Upper Limb & Lower Limbs.

Hypermobility is evident bilaterally at the Ankles (Inversion & Supination), Knees (15° hyperextension), Hips (Increased ER 90° & IR 75°), Elbows (10° hyperextension) and Shoulders (Multi-directional).

Bilateral pain-free Patellar Subluxations moving from full Knee Extension to Flexion, which occurs between 0 - 40 degrees.

Strength[edit | edit source]

4/5 Globally with poor muscular endurance and neuromuscular control

Knee Assessment[edit | edit source]

Bilateral Patella Alta, J Sign and Lateral Patellar Instability+++ - Possible Shallow Trochlea (No Imaging)

Beighton Scale[edit | edit source]

8/9 Unable to achieve Hands to Floor

Lower Limb Assessment Score[edit | edit source]

Right = Left 9/12

Functional Abilities[edit | edit source]

  • Single Leg Stance: No Support - Unable Bilaterally, Anxious+++ & With Support HHA x1  - 4 Secs Right, 6 Secs Left
  • Jump: Anxious++. With support able to jump < 5cm clearance, Genu Valgum on landing with decreased knee flexion
  • Stairs: 2 Feet to Step Ascending & Descending with Hand Rail Support x 2
  • Run: Unable and Anxious++
  • Kick Ball: Could complete bilaterally - Decreased force

Outcome Measures[edit | edit source]

  • BMI: > 99th Percentile -Very Overweight for Age (Weight 99.3kg, Height 167cm)
  • Movement ABC-2 Percentiles: Manual Dexterity 0.5th, Aiming & Catching 50th, Balance 0.1st and Total Score 0.5th
  • Paediatric Balance Scale: 44/56
  • FitBit Step Count: 2895 Daily Average in last Week
  • 30 Second Sit to Stand: 8 with assistance of arm rests (Borg 7/10)
  • 6 Minute Walk Test (6MWT): 380 metres. Complained of achy calf & shins at 5 minute 34 seconds but able to finish test. Borg 8/10 Outside Normal Range for Age (Lammers et al 2007)