Occupational Therapy for a 7-Year-Old Post-Surgical Patient (Right Achilles Tendon + Popliteal Fossa) with History of Prematurity and Muscle Atrophy

Clinical Context Summary

• Surgical history: Right Achilles tendon repair + popliteal fossa surgery (likely involving the hamstring or posterior knee structures - common in children with spastic equinus gait or congenital contractures)
• Prematurity: Increased risk of neurodevelopmental sequelae (cerebral palsy spectrum, hypotonia, motor coordination disorders, sensory processing deficits)
• Muscle atrophy: Post-surgical disuse atrophy + possible pre-existing neurogenic or disuse atrophy from prematurity
• Age 7: School-age child - occupational roles include self-care, play, and academic participation

Step 1: Occupational Therapy Models of Practice (MOPs)

1. Model of Human Occupation (MOHO) - Kielhofner

2. Person-Environment-Occupation-Performance Model (PEOP)

3. Canadian Model of Occupational Performance and Engagement (CMOP-E)

Step 2: Frames of Reference (FORs) - How to Intervene

FOR 1: Biomechanical Frame of Reference

• Principles: Improve muscle strength, joint range of motion (ROM), and endurance through purposeful, occupation-based activity
• Application:
  • Progressive resistive activities disguised as play (kicking a ball, pedaling a tricycle, obstacle courses)
  • Stretching and ROM exercises embedded in ADL tasks (e.g., dorsiflexion during dressing, stair practice)
  • Splinting/orthotics to maintain tendon length and prevent re-contracture
  • Aquatic therapy - water buoyancy reduces load on the healing tendon while allowing active movement
  • Monitoring muscle bulk recovery using circumference measurements
• Outcome measures: Manual Muscle Testing (MMT), goniometry (ROM), dynamometry

FOR 2: Neurodevelopmental Treatment (NDT) / Bobath Approach

• Principles: Normalize postural tone, facilitate typical movement patterns, integrate sensory feedback into functional movement; the OT uses handling techniques to inhibit abnormal patterns and facilitate normal ones
• Application:
  • Address compensatory movement strategies the child has developed (e.g., toe-walking gait, hip hiking)
  • Facilitate weight-bearing through the right lower extremity in functional positions
  • Incorporate play at floor level, transitions (sit-to-stand), and stair negotiation
  • Coordinate with PT on gait retraining
• Why prematurity matters: Preterm infants have higher rates of spasticity, hypotonia, and abnormal primitive reflex integration - NDT directly addresses these residual patterns in school-age children

FOR 3: Sensory Integration (SI) Frame of Reference - Ayres

• Principles: A child's ability to process proprioceptive, vestibular, and tactile input determines their capacity to plan and execute movement (praxis)
• Application:
  • Proprioceptive input through weight-bearing, jumping, and resistive activities to enhance body schema of the right leg
  • Tactile desensitization of the surgical scar (scar massage, textured surfaces) if hypersensitivity is present
  • Vestibular activities (swings, balance boards) to improve postural stability and balance
  • "Sensory diet" - home program of calming and alerting sensory activities to support attention and participation in school
• Assessment tools: Sensory Integration and Praxis Tests (SIPT), Sensory Processing Measure (SPM)

FOR 4: Developmental Frame of Reference

• Principles: Development is sequential; if trauma (prematurity + surgery) has created gaps in development, the OT bridges them by identifying the child's current functional level and targeting the next developmental step
• Application:
  • Assess gross motor milestones vs. age expectations (jumping, hopping, skipping - all dependent on the right Achilles/popliteal region)
  • Focus on age-appropriate play skills: ball sports, playground activities, bicycle riding
  • Address fine motor and ADL skills that may have been secondarily delayed by mobility restrictions during recovery (e.g., independent dressing requiring foot manipulation)

FOR 5: Rehabilitation Frame of Reference (Compensatory Approach)

• Principles: When restoration of function is incomplete, teach compensatory strategies and provide adaptive equipment to maximize participation
• Application:
  • Adaptive footwear with heel lifts if full dorsiflexion is not recovered
  • Adapted physical education strategies for school
  • Energy conservation techniques for a child who fatigues easily due to muscle atrophy
  • Assistive technology for mobility within school if needed

Step 3: OT Intervention Approach Framework

Step 4: Assessment Tools Recommended

Step 5: Multidisciplinary Considerations

• Orthopedic surgeon: Confirm surgical outcomes, weight-bearing precautions, return-to-activity timeline
• Physical therapist: Gait retraining, strengthening, balance (primary lower extremity role)
• OT: ADL independence, upper-extremity compensation, sensory processing, school participation, play, adaptive equipment
• Neonatology follow-up: Monitor for prematurity-related neurodevelopmental sequelae (visual-motor integration, learning difficulties)
• School team: IEP/accommodation planning for PE restrictions and fatigue
• Family: Central to carryover - home exercise program, splint compliance, emotional support

Summary: OT Priority Hierarchy for This Child

1. Biomechanical FOR - address atrophy and ROM directly through purposeful activity
2. NDT FOR - normalize movement patterns shaped by prematurity and post-surgical compensation
3. MOHO model - ensure the child's motivation and roles (student, player, peer) are addressed, not just the physical deficit
4. Developmental FOR - close developmental gaps in age-appropriate play and motor skills
5. SI FOR - address proprioceptive deficits and scar hypersensitivity
6. Compensatory/Rehabilitation FOR - fill remaining gaps with adaptive strategies for school and home

Updated OT Plan: Right Leg Monoparesis + Post-Surgical + Prematurity + Muscle Atrophy (Age 7)

What Monoparesis Changes

1. Neurogenic atrophy - from the underlying condition causing monoparesis (perinatal injury, prematurity-related neural insult, surgical nerve involvement)
2. Disuse atrophy - from post-surgical immobilization and limb avoidance
3. Learned non-use - a critical neuroplasticity concept: the brain progressively suppresses motor representation of the paretic limb when compensation by the unaffected side is easier and more rewarding

Revised Conceptual Model Hierarchy

Primary Model: Model of Human Occupation (MOHO)

Secondary Model: Person-Environment-Occupation-Performance (PEOP)

• Person: Paretic right LE, atrophied muscles, sensory deficits from prematurity
• Environment: Ramp vs. stair access at school, floor surfaces, PE adaptations
• Occupation: Walking, running, dressing (shoes/socks on right foot), toileting, playing with peers
• Performance: Functional independence with the right leg participating as much as possible

Frames of Reference - Updated for Monoparesis

FOR 1: Neurodevelopmental Treatment (NDT) - NOW PRIMARY

• Rationale: NDT uses therapeutic handling to facilitate normal postural tone, movement initiation, and quality of movement in the paretic limb; directly counters abnormal compensatory movement patterns
• Key application:
  • Facilitate active weight-bearing through the right foot and ankle (critical after Achilles repair)
  • Work on sit-to-stand, floor-to-stand, and stair negotiation using the right LE as an active participant
  • Inhibit trunk-shift compensations (child leaning left to avoid loading the right leg)
  • Normalize foot placement and push-off during gait (popliteal fossa and Achilles tendon are both gait-critical structures)
  • Incorporate NDT handling during ADL tasks: dressing, bathing, transitions

FOR 2: Motor Learning / Task-Oriented Training (TOT)

• Principles:
  • Massed practice of functional tasks that require right leg participation
  • Variable practice conditions (different surfaces, speeds, environments) to promote generalization
  • Feedback: use mirrors, verbal cues, video, and intrinsic sensory feedback
  • Shaping: progressively increasing task difficulty as performance improves
• Application for this child:
  • Kicking a ball with the right foot (graded - stationary ball → moving ball → target kicking)
  • Right-foot pedaling on a tricycle/bicycle
  • Stair climbing alternating feet (not step-to pattern)
  • Obstacle courses requiring right LE weight shift and balance
  • Floor games requiring weight-bearing transitions (kneeling, half-kneeling, standing)
• Why it works for monoparesis: Task-oriented training directly exploits neuroplasticity - "use it and improve it" - and reverses learned non-use by making the right leg succeed at meaningful tasks.

FOR 3: Biomechanical Frame of Reference

• Address the atrophy: Graded resistance activities using the right leg (sand play, water resistance, weighted ankle cuffs during play as tolerated)
• ROM maintenance: Post-Achilles repair dorsiflexion range preservation through functional stretching (e.g., standing on a wedge during play, stair stretches)
• Endurance building: The atrophied leg fatigues faster; progressive activity duration in therapy
• Splinting/orthotics: AFO (Ankle-Foot Orthosis) or dynamic splint may be appropriate to support ankle stability during ambulation while neurological retraining proceeds - to be decided with the orthopaedic surgeon and physiatrist

FOR 4: Sensory Integration (SI) - Ayres

• Prematurity commonly disrupts proprioceptive processing - the brain's sense of where the right leg is in space
• Monoparesis may involve reduced afferent feedback from the right leg, compounding the motor deficit
• A child who cannot feel the right leg accurately will not use it effectively
• Application:
  • Proprioceptive loading of the right leg: joint compression activities (weight-bearing on right leg, jumping on a trampoline, leg press-type play)
  • Tactile input to the right foot and lower leg: textured surfaces, massage, sensory bins
  • Vibration to paretic muscles to enhance motor cortex activation
  • Vestibular activities to challenge and improve balance and postural stability on the right side (balance board, wobble cushion, therapy ball)

FOR 5: Developmental Frame of Reference

• Hopping on right foot - typically mastered by age 5-6; likely absent or markedly impaired
• Skipping - requires alternating leg dissociation; will be compromised
• Ball sports skills - kicking, catching while standing, running games
• Fine motor skills as secondary concern - prematurity may have also affected hand function for school tasks (writing, cutting)

FOR 6: Compensatory / Rehabilitation FOR

• Adaptive equipment: Velcro shoe closures (avoids difficulty with fine motor task of lacing with paretic posture), sock aid, long-handled shoehorn
• AFO or ankle support for school ambulation if needed
• Environmental modifications: Grab rail for toilet/bath if balance is impaired, non-slip mat for shower
• School accommodations: Seated participation in certain PE activities, modified sports rules, extra time for transitions between classrooms

The Learned Non-Use Problem - Critical Priority

The paretic limb attempts movement → fails or is inefficient → the brain learns to suppress its motor representation → the child compensates entirely with the unaffected left leg → the right leg's cortical representation shrinks further

1. Force use of the right leg in therapy through task design (e.g., activities that physically require right leg weight-bearing or kicking)
2. Eliminate compensatory patterns in therapy sessions - do not let the child always shift to the left leg
3. Make right leg use rewarding - success-graded activities, positive reinforcement, play-based challenges where right-leg use is fun
4. Home program - educate parents and teachers on how to cue right leg use during daily routines without frustrating the child
5. Constraint approaches (adapted CIMT principles for lower extremity) - during specific therapy activities, limit reliance on the left leg to force right LE engagement

Specific Occupational Goals (SMART Framework)

Assessment Tools Updated for Monoparesis

OT Intervention Approach Summary

MONOPARESIS + POST-SURGICAL + PREMATURITY + ATROPHY (Age 7)
│
├── MODEL: MOHO → Address volition, habituation, environment
├── MODEL: PEOP → Improve person-environment-occupation fit
│
├── FOR 1: NDT → Facilitate quality movement in paretic right leg (PRIMARY)
├── FOR 2: Motor Learning/TOT → Task-specific repetitive practice (PRIMARY)
├── FOR 3: Biomechanical → Rebuild muscle strength and ROM (SECONDARY)
├── FOR 4: Sensory Integration → Proprioceptive feedback to right LE (SECONDARY)
├── FOR 5: Developmental → Bridge motor developmental gaps
└── FOR 6: Compensatory → Adaptive equipment + school/home modifications
        │
        ├── COUNTER: Learned Non-Use → Force right LE engagement
        └── TEAM: OT + PT + Orthopaedics + School + Family

Key OT Principle for This Child

1. How monoparesis changes the OT picture - it shifts the focus from pure physical rehab to neurologically-informed motor relearning, with learned non-use as the central concern
2. Models of Practice
   • MOHO (volition, habituation, performance, environment)
   • PEOP (person-environment-occupation fit)
3. Frames of Reference - prioritized for monoparesis
   • NDT (primary) - facilitate quality movement in the paretic right leg
   • Motor Learning / Task-Oriented Training (primary) - repetitive, meaningful, task-specific practice
   • Biomechanical (secondary) - rebuild atrophied muscles
   • Sensory Integration - proprioceptive input to right LE
   • Developmental - bridge motor gaps from prematurity
   • Compensatory - adaptive equipment, school modifications
4. Learned Non-Use - strategies to counter cortical suppression of the right leg
5. SMART occupational goals - dressing, stairs, kicking, PE, toileting, seated posture
6. Assessment tools - PEDI-CAT, GMFM-88, COPM, SPM, Modified Ashworth Scale

• Do you want a written summary or document format of the full plan?
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• Is there a specific occupational area (self-care, school, play) you want focused on?