SlideShare a Scribd company logo
Virtual Clinical
Examnination:
IPP-Cerebral Palsy
(long case)
Prof. Anisuddin Bhatti
Dr. Ziauddin University
Hospital,
Clifton, Karachi.
Secretary,
Orthopaedic Faculty,
CPSP.
Virtual Clinical Examination: (VCE)
• A Virtual Patients (VPs) in clinical examinations
instead of real patients.
• A Computer-based programs with a VPs that simulate
real-life clinical scenarios.
• Requires a linear dialogue between examiner and
examinee, for which VPs need to be adapted
accordingly.
Harless et al 1971 & Cook et al, 2010.
Virtual Clinical Examination
• Provides an Interactive role to the examinee, as opposed
to passively watching videos/ visuals and answering
written or oral questions.
• Examinee is required to interact with the examiner by
posing and answering questions regarding evolving
condition of the V. patient presented.
(Huang G, Reynolds R, Candler C).
Interactive Paper Patients (IPPs)
• The simulator, computer-based photo, video or scenario used in VCE is
referred as an IPP.
• IPP is presented phase wise to allow an interactive dialogue
between Examinee with examiner
• IPPs has been extensively used for the Cognitive Assessment in:
o Modified Essay Questions (MEQs)
o Task Oriented Assessment of Clinical Skill (TOACS)
o Objective Structured Assessment of Technical Skills (OSATS)
o Patient Management Problems (PMPs)
o Workplace Based Assessment (WPBA):
Mini-CEX & Direct observation of procedural skills (DOPS).
o Virtual Clinical examination (VCE)
(Huang G, Reynolds R, Candler C).
VCE Process
• IPPs reveal patient condition and workup phase-wise.
• Examiner poses questions to the examinee after
description of each phase.
• Student ask additional questions about patient condition,
investigation or response to therapy.
• Examiner responds verbally or furnishes Laboratory
reports / Imaging films.
• Answers are scored phase-wise on a key.
Long case: KEY - CONNTEMPORARY
Answers are scored phase-wise on a key.
Excellent, Good, Adequate, Inadequate, Poor
Examiner 1: [both examiners R Silent Observer]
A. History Taking & Examination: Examinee’s attitude, behavior,
communication skill, clinical examination skill.
B. Presentation skill: Correct history, relevant exam findings, Positive /
negative findings.
C. Order relevant Investigation & justify. He shall be shown that report ,
Xray, MRI, CT etc
D. Differential Diagnosis & confirmation of diagnosis most suitable.
Examiner 2:
A. Management plan. Discussion: What, How, When & When not.
B. Complications. Why & how to manage
C. Recent advances.
Long case: KEY – Virtual Examination
Answers are scored phase-wise on a key.
Excellent, Good, Adequate, Inadequate, Poor
Examiner 1: [one examiner may act as simulator – IPP]
A. Examiner presents: Short history with Picture, video, Scenario.
Student advised to ask additional question from examiner.
A. Examiner poses questions to the student after description of each phase.
B. Student be advised to ask further questions and asked for relevant
investigation & justify. What U want to evaluate with that investigation.
He shall be shown that Lab. report , Xray, MRI, CT etc
A. Differential Diagnosis & confirmation of diagnosis most suitable.
Examiner 2:
A. Management plan. Interactive Discussion: What, How, When & When not.
B. Complications. Why & how to manage
C. Recent advances.
VCE:
Case Example
Long case:
Cerebral Palsy
Plz look at these Pictures:
A 9-year old boy presented with tip toe walking since age 2
years and having difficulty in walking for the last 3 years. He
is able to sit at ease. Very enthusiastic & cooperative.
Q.1. U may ask few
question for patient
condition?
Q.1. Key
1. Birth history: Liquor aspiration - Birth Asphyxia. Delayed
milestones for one year. mentally alert, Intelligent, he study in
class 3.
2. Development history: Walked independently for 6 years,
deteriorated with difficulty in walking, for the last 3 years. He
manage his daily accustomed habits independently.
3. He is an independent walker, sometimes need support, when
outside [functional walker].
Q.2. How
would you
proceed to
reach
diagnosis in
your mind ?
Q.2. Key
Exmine to
1.Asses his Gait, Posture, walking ability
2.Perform multiple clinical test to look for spasticity,
hyperreflaxia, Contractures: static & dynamic.
Okay. Plz. Look at his Gait &
Posture again.
Q.3. What type of gait is this?
Q.4. What type of walker he is?
Let him speak freely to justify
Q.3a. Key.
• Spastic Diplegic
• Jump gait [Unstable]
• Decompensated with Pes
Plano-Valgus.. A Danger sign.
Q.3b. Key. Interactive discussion continued
GAIT PATTERNS
• Different Gait patterns observed in CP depends on the
involvement of spasticity or contracture of different muscles:
• Variations relates to topographical type of CP { Hemiplegia,
Diplegia, monoplegia. With or without Ataxia etc}.
• Best seen in contrast between unilateral spastic CP and bilateral
spastic CP.
Q.3c. Key. Spastic Diplegia Gaits:
Four common patterns of gait in spastic Diplegia.
[Rodda et al.]
• Type 1 – True equinus
• Type 2 – Jump gait
• Type 3 – Apparent equinus
• Type 4 – Crouch gait
Q.3c.
Rodda et al. JBJS. 2004
Q.4. Key: Waking Pattern
Assessment to Qualify as walker can be made best after the age 7 years. Till than
brain maturation reach to a plateau.
TYPES OF WALKING:
• Walker: when child could walk a minimum of 15 meters without
falling. [Independent walker]
• Functional Walker: when a child could walk only with crutches
[Community walker].
• Non-Walker: when child could walk with aid of mobility device
or only in parallel bars
Q.5.How would you proceed
further to reach definite
diagnosis and plan treatment?
Q.5. Key: Clinical examination
Detailed clinical Examination. Examiner interact here.
1. In systemic examination he has no significant abnormality.
Plz Proceed
2. Focused Neuro - MSK examination: to terform certain clinical
test to evaluate for spasticity & contractures: Dynamic & satatic.
3. Examiner asks to name such test (?/9 tests).
4. Plz perform ?? Test on examiner 1 OR he just ask how to do and
what are pre-Requisites of that test. OR He may show U test in
video and ask you few question to know ur knowledge & skill.
Clinical Evaluation: Tests
Q.6. Which test is
this?
Q.7. What are the
Findings?
Q.8. Is there any flaw
while performing this
test.
Q.6,7,8 Key
Q.6. Thomas test… for Hip Flexion contracture. FFC
Q.7. Knee cntracture & Hamstring spasticity
Q.8. Flaws: Pillow & Soft bed. Modified Thomas at
edge of bed to exclude Knee contracture. Not
done
Speaking on Flaws test your knowledge & Skill.
Thomas Test- Modified:
to exclude Knee Contracture, avoid flaw
Staheli’s Hip Flexors Stretch test: Hip FFD
• More accurate for FFD hip
• Prone position
• Pelvis over table edge
Thomas test
Staheli’s
Q.9. Which tests R this.
What R the
Findings.
Any Flaw in
performing
tests?
Q.9. Key
9.A. Combined Abduction test. 700 . Adductors contracture
bilateral.
Flaw: Not significant. Individual side may b done.
9.B. Pop Angle test. +900 . Significant Hamstring contracture /
Spasticity.
Flaw: not significant
9.C. Silverskiold test. Negative. Combined Gastro-Solus
contracture.
Adductor Longus Stretch Test
• Hip abduction angle in Knee extension & flexion
When measurements are same: Adductors tight. Why?
• Hip abduction improves on Knee flexion: Gracilis tight
Same angle
Adductors tight
Abduction
improved
Gracilis is tight
Gracilis spasticity – Phelp’s Test
• Passive abduction with knee in extension.
• Improved hip abduction with knee flexion indicates
Gracilis / medial hamstring tightness. Why?
Popliteal Angle: Normal ranges in Children. Discussion
• 1-3 yrs mean angle 60 [00-150]
• @ 4 yrs mean angle 170 in girls, 270 in boys [50-450].
• >5 yrs mean angle 260 little change [0-50]
• PoP angle of >500 in above age groups indicate abnormal
hamstring tightness.
Katz, Kalman. University Telaviv Israel. J Ped ortho 1992. 12:229-231
POP Angle: Hamstring Stretch Test: Discussion
• Hip flexed to 900 & knee
extend
• Measure Popliteal angle
900 flexion to 00 extension
• Hamstring Shift:
Difference b/t Rt & Lt
measurements
00
900
500
RtLt
Achilles Stretch Test: Discussion
Silverskiold test- Gastroc. vs Soleus
“Spastic Gastrocnemius contracture”
Correction of ankle
equinus with
Knee flexion indicates
Predominantly
gastrocnemius
Contracture. Why?
Q.10. Which tests are being performed
What R Findings?
What is wrong in
performing these
tests ?
Q.10.a. Key
10.A. Rectus Strech test: Aly Duncan test.
Pelvis rise on knee flexion.
10.B. Hip Rotation test: Anteversion
10.b. Key
Craig Test: FAV: Trochanteric Prominence Test
• Prone position and knee at 90°
flexion.
• Angle between the vertical line
and long axis of the leg at the
greatest prominence of the
greater trochanter palpated
laterally measures the amount
of FAV.
In recent studies, it has been found that trochanteric prominence test in combination
with hip internal rotation, X-rays is a better predictor of FAV and neck-shaft angle as
compared with computed tomography.
Q.11. Any additional
Clinical tests U Know.
Just name that?
11.a. Key. Rotational Malalignment/s
• Foot propagation
angle
• Tibial rotation
Foot – Thigh Angle
Q.11.b. Tibial torsion mal-alignment
Thigh foot Angle
• Prone position, knee in 90°
flexion, and neutral ankle
and hind foot position.
• Angle between the thigh
axis and foot axis (axis
between the 2nd and
3rd metatarsals) gives Tibial
torsional measurement
Differential diagnosis.
• Q.12. In what pathological status this clinical
condition occurs?
• Q.13 How would you confirm your best possible
diagnosis?
12, 13. Key
12. Cerebarl Palsy,
Spinal Dysraphysm,
Fredrix Ataxia &
Cerebral demyelination syndrome.
13. Detailed Birth history, Clinical examination, Observational gait
analysis, Video assisted observational gait analysis & Advanced
Imaging.
Use Algorythm: Diagnostic Matrix
Q.14. How can you classify his
functional disability ?
Q.15. In which functional
disability class (level) he fits &
Justify?
Let him speak freely to justify
14.a. Key: Gross Motor Function Assesment
GMFCS
GROSS
MOTOR
FUNCTION
CLINICAL
SCORE:
LEVELS
14.b Key:
Q.15. Is there any
Advance Clinical or
laboratory tests
available to check CP
Patients Motor
functions & disabilty?
15.a. key Advanced tests
• Foot propagation angle
• Observational Gait Analysis & Video Assisted OGA
• Videographic Gait analysis:
Gait Laboratory test: Computer base gait and indiviual muscle
functions programme, that include:
oEMG Muscle charting.
o3D camera gait analysis.
oFoot pressure Pedography.
15.b. Advanced tests:
Repeated examination &
careful analysis of the gait [VAOGA/
Gait laboratory] & posture
and recognition of potential skeletal
changes lead to better judgment
to correct or prevent structural
changes reasonably early i.e before
15 (13) years. (Molnar-Gordon)
Gait Laboratory
Plays important
role in accurate
Judgment
Video Assisted
Observational
Gait Analysis
NED University Gait Laboratory:
Videographic gait analysis
Gait Lab test being performed on patients during CP workshop on
19 March 2011
Gait Laboratory:
PEDOGRAM: Cavovarus & Planovalgus
EMG: Indicating spastic, normal & Weak Muscles
Management Plan: 9 yr aged, boy, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Recall findings:
Examiner helps to recall
findings.
1. Functional walker
2. GMFC-2
3. Thomas’s FFC 15-200
4. Combined Abduction 700
5. Phelp’s positive
6. Pop angle +900
7. Silverskiold’s Negative [-150]
8. Pes-planovalgus
9. Ely’s Positive
10. Stable pelvis & Spine
11. Upper limb Normal
12. No neuro deficit
Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.16. What shall be
the objective to
treat him?
Q.17. How shall U
manage him?
16. & 17 Key: management Plan
16. a. Help him to be an independent walker without
support.
b. prevent deterioration of pes planovalgus and
develop crouch gait
17. A. 3-4 weeks pre-operative rehabilitation training exercises /
physiotherapy & Occupational therapy.
B. Exclude structural abnormalities on X-ray.
C. Reconstructive surgery @ Knee & Ankle
C. Postoperative Rehabilitation programmes
Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.18. What shall be
contraindications other
than general well
being?
Q.19. Let us know Ur
plan of Reconstructive
surgery as u decided?
No need to go in
detailes of surgical
steps
18 & 19. Key. Contra Indications & Recon Surgery
18. Reconstructive surgery is better in Spastic Cerebral palsy, best in
Hemiplegia than diplegia. Before embarking to surgery.
MUST MUST: Exclude Ataxia, chorioform movements & other
abnormal features of basal ganglia involvement.
19. A. Reconstructive surgery @ Knee & Ankle +/- Hip
Hamstring Fractional Lengthening, Keats transfer to adductor
tubercle, TAL, 1/2 Tibialis Anterior Transfer to neck of talus.
[+/- Adductor Myotomy without Neurectomy]
19.B. Postoperative Rehabilitation programmes
Quad strengthening and Gluteal Muscle development excercises.
Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.20. Describe
postoperative
care?
Let him speak freely
20. Key. Rehabilitation Programme.
Rehab programme
• Hospital & home bases exercises
• Muscle streghening execrcise
• Occupational therapy
Bracings – Temporary addjuncts
• AFO
• KFO
References
• VCE Guidelines Designed by:
DR. Sirajul Haque Shaikh, Director DME. CPSP, Karachi.
• References:
1. Harless et al 1971
2. Cook et al, 2010.
3. Huang G, Reynolds R, Candler C.
• Clinical Material:
Prof. Anisuddin Bhatti’s collection
• Videos Prepared @ DZUH Clifton, Karachi
Assisted by: Dr. Sadam Mazar Baloch & Dr. Nida Hameed
Anis Bhatti _ virtual clinical exam Cerebral Palsy: long case

More Related Content

What's hot

Jose Austine- Orthopaedic evaluation of cerebral palsy
Jose Austine- Orthopaedic evaluation of cerebral palsyJose Austine- Orthopaedic evaluation of cerebral palsy
Jose Austine- Orthopaedic evaluation of cerebral palsy
Jose Austine
 
Congenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano ValgusCongenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano Valgus
Anisuddin Bhatti
 
Proximal fibular osteotomy
Proximal fibular osteotomyProximal fibular osteotomy
Proximal fibular osteotomy
Atanu Kayal
 
DDH
DDHDDH
Rickets and osteomalacia by gk yadav
Rickets and osteomalacia by gk yadavRickets and osteomalacia by gk yadav
Rickets and osteomalacia by gk yadav
Gopal Kumar Yadav
 
Clinical Examination of the Hip
Clinical Examination of the HipClinical Examination of the Hip
Clinical Examination of the Hip
orthoprince
 
Congenital scoliosis
Congenital scoliosis Congenital scoliosis
Congenital scoliosis
Chandramani Roy
 
Developmental dyspalsia of hip
Developmental dyspalsia of hipDevelopmental dyspalsia of hip
Developmental dyspalsia of hip
Sai Prasanth Grandhi
 
Arthrogryposis
ArthrogryposisArthrogryposis
Arthrogryposis
Sitanshu Barik
 
Ddh 1
Ddh 1Ddh 1
Approach to limping child
Approach to limping childApproach to limping child
Approach to limping child
Hardik Pawar
 
Floating Knee
Floating KneeFloating Knee
Floating Knee
Dr Rohil Singh Kakkar
 
Examination of the child with cerebral palsy
Examination of the child with        cerebral palsyExamination of the child with        cerebral palsy
Examination of the child with cerebral palsy
Maulik Patel
 
Revision tha
Revision thaRevision tha
Revision tha
Asish Rajak
 
Developmental Dysplasia of Hip
Developmental Dysplasia of HipDevelopmental Dysplasia of Hip
Developmental Dysplasia of Hip
Daniel Augustine
 
Dual mobility cups (6)
Dual mobility cups (6)Dual mobility cups (6)
Dual mobility cups (6)
jatinder12345
 
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes diseaseClassification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Sitanshu Barik
 
Kienbock Disease
Kienbock DiseaseKienbock Disease
Kienbock Disease
drmbhama
 
Pediatric ACL Injuries
Pediatric ACL InjuriesPediatric ACL Injuries
Pediatric ACL Injuries
Children's Health
 
Blounts dx presentation22
Blounts dx presentation22Blounts dx presentation22
Blounts dx presentation22
EnejoJoseph
 

What's hot (20)

Jose Austine- Orthopaedic evaluation of cerebral palsy
Jose Austine- Orthopaedic evaluation of cerebral palsyJose Austine- Orthopaedic evaluation of cerebral palsy
Jose Austine- Orthopaedic evaluation of cerebral palsy
 
Congenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano ValgusCongenital vertical talus Pes Plano Valgus
Congenital vertical talus Pes Plano Valgus
 
Proximal fibular osteotomy
Proximal fibular osteotomyProximal fibular osteotomy
Proximal fibular osteotomy
 
DDH
DDHDDH
DDH
 
Rickets and osteomalacia by gk yadav
Rickets and osteomalacia by gk yadavRickets and osteomalacia by gk yadav
Rickets and osteomalacia by gk yadav
 
Clinical Examination of the Hip
Clinical Examination of the HipClinical Examination of the Hip
Clinical Examination of the Hip
 
Congenital scoliosis
Congenital scoliosis Congenital scoliosis
Congenital scoliosis
 
Developmental dyspalsia of hip
Developmental dyspalsia of hipDevelopmental dyspalsia of hip
Developmental dyspalsia of hip
 
Arthrogryposis
ArthrogryposisArthrogryposis
Arthrogryposis
 
Ddh 1
Ddh 1Ddh 1
Ddh 1
 
Approach to limping child
Approach to limping childApproach to limping child
Approach to limping child
 
Floating Knee
Floating KneeFloating Knee
Floating Knee
 
Examination of the child with cerebral palsy
Examination of the child with        cerebral palsyExamination of the child with        cerebral palsy
Examination of the child with cerebral palsy
 
Revision tha
Revision thaRevision tha
Revision tha
 
Developmental Dysplasia of Hip
Developmental Dysplasia of HipDevelopmental Dysplasia of Hip
Developmental Dysplasia of Hip
 
Dual mobility cups (6)
Dual mobility cups (6)Dual mobility cups (6)
Dual mobility cups (6)
 
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes diseaseClassification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
 
Kienbock Disease
Kienbock DiseaseKienbock Disease
Kienbock Disease
 
Pediatric ACL Injuries
Pediatric ACL InjuriesPediatric ACL Injuries
Pediatric ACL Injuries
 
Blounts dx presentation22
Blounts dx presentation22Blounts dx presentation22
Blounts dx presentation22
 

Similar to Anis Bhatti _ virtual clinical exam Cerebral Palsy: long case

Mock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptxMock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptx
Anisuddin Bhatti
 
Mock ExaminationLong case Cerebral Palsy .pptx
Mock ExaminationLong case Cerebral Palsy  .pptxMock ExaminationLong case Cerebral Palsy  .pptx
Mock ExaminationLong case Cerebral Palsy .pptx
Anisuddin Bhatti
 
Mock vce lahore 4.8.20 2
Mock vce lahore 4.8.20 2Mock vce lahore 4.8.20 2
Mock vce lahore 4.8.20 2
Anisuddin Bhatti
 
Anis bhatti cp 2 clinical assesment 2020
Anis bhatti cp 2  clinical assesment 2020Anis bhatti cp 2  clinical assesment 2020
Anis bhatti cp 2 clinical assesment 2020
Anisuddin Bhatti
 
Virtual clinical examination
Virtual clinical examinationVirtual clinical examination
Virtual clinical examination
Anisuddin Bhatti
 
Prof. Anisuddin Bhatti Cerebral Palsy case Orthopaedic Examination lecture o...
Prof. Anisuddin Bhatti Cerebral Palsy case  Orthopaedic Examination lecture o...Prof. Anisuddin Bhatti Cerebral Palsy case  Orthopaedic Examination lecture o...
Prof. Anisuddin Bhatti Cerebral Palsy case Orthopaedic Examination lecture o...
Anisuddin Bhatti
 
Anis Bhatti-virtual cln exm Congwnital Knee dislocation:Short Case
Anis Bhatti-virtual cln exm Congwnital Knee dislocation:Short CaseAnis Bhatti-virtual cln exm Congwnital Knee dislocation:Short Case
Anis Bhatti-virtual cln exm Congwnital Knee dislocation:Short Case
Anisuddin Bhatti
 
Jess ctev
Jess ctevJess ctev
Jess ctev
Sitanshu Barik
 
Surgery revision
Surgery revisionSurgery revision
Surgery revision
Pardeep Omani
 
Genetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is tGenetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is t
JeanmarieColbert3
 
Ullswater Physio CPD
Ullswater Physio CPDUllswater Physio CPD
Ullswater Physio CPD
Mary McCance MSc MCSP HCPC
 
OSCE paeds.pptx
OSCE paeds.pptxOSCE paeds.pptx
OSCE paeds.pptx
Smriti Arora
 
Why jonny cant operate
Why jonny cant operateWhy jonny cant operate
Why jonny cant operate
fgetty01
 
meu workshop Osce ospe an introduction
meu workshop Osce ospe an introductionmeu workshop Osce ospe an introduction
meu workshop Osce ospe an introduction
Devan Pannen
 
411weil
411weil411weil
411weil
afacct
 
Basic Assessment skills
Basic Assessment skillsBasic Assessment skills
Basic Assessment skills
John Ayamga Pt Bawku Agana
 
Special_test_for_all_joints.pdf
Special_test_for_all_joints.pdfSpecial_test_for_all_joints.pdf
Special_test_for_all_joints.pdf
Femoralboii
 
OSCE AND OSPE, DIFFERENTIAL SACALE
OSCE AND OSPE, DIFFERENTIAL SACALEOSCE AND OSPE, DIFFERENTIAL SACALE
OSCE AND OSPE, DIFFERENTIAL SACALE
sakshi rana
 
Ijsrp p10588
Ijsrp p10588Ijsrp p10588
Ijsrp p10588
khushali52
 
Osce and ospe
Osce and ospeOsce and ospe
Osce and ospe
sonal patel
 

Similar to Anis Bhatti _ virtual clinical exam Cerebral Palsy: long case (20)

Mock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptxMock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptx
 
Mock ExaminationLong case Cerebral Palsy .pptx
Mock ExaminationLong case Cerebral Palsy  .pptxMock ExaminationLong case Cerebral Palsy  .pptx
Mock ExaminationLong case Cerebral Palsy .pptx
 
Mock vce lahore 4.8.20 2
Mock vce lahore 4.8.20 2Mock vce lahore 4.8.20 2
Mock vce lahore 4.8.20 2
 
Anis bhatti cp 2 clinical assesment 2020
Anis bhatti cp 2  clinical assesment 2020Anis bhatti cp 2  clinical assesment 2020
Anis bhatti cp 2 clinical assesment 2020
 
Virtual clinical examination
Virtual clinical examinationVirtual clinical examination
Virtual clinical examination
 
Prof. Anisuddin Bhatti Cerebral Palsy case Orthopaedic Examination lecture o...
Prof. Anisuddin Bhatti Cerebral Palsy case  Orthopaedic Examination lecture o...Prof. Anisuddin Bhatti Cerebral Palsy case  Orthopaedic Examination lecture o...
Prof. Anisuddin Bhatti Cerebral Palsy case Orthopaedic Examination lecture o...
 
Anis Bhatti-virtual cln exm Congwnital Knee dislocation:Short Case
Anis Bhatti-virtual cln exm Congwnital Knee dislocation:Short CaseAnis Bhatti-virtual cln exm Congwnital Knee dislocation:Short Case
Anis Bhatti-virtual cln exm Congwnital Knee dislocation:Short Case
 
Jess ctev
Jess ctevJess ctev
Jess ctev
 
Surgery revision
Surgery revisionSurgery revision
Surgery revision
 
Genetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is tGenetic disorder - Philadelphia chromosomeYour assignment is t
Genetic disorder - Philadelphia chromosomeYour assignment is t
 
Ullswater Physio CPD
Ullswater Physio CPDUllswater Physio CPD
Ullswater Physio CPD
 
OSCE paeds.pptx
OSCE paeds.pptxOSCE paeds.pptx
OSCE paeds.pptx
 
Why jonny cant operate
Why jonny cant operateWhy jonny cant operate
Why jonny cant operate
 
meu workshop Osce ospe an introduction
meu workshop Osce ospe an introductionmeu workshop Osce ospe an introduction
meu workshop Osce ospe an introduction
 
411weil
411weil411weil
411weil
 
Basic Assessment skills
Basic Assessment skillsBasic Assessment skills
Basic Assessment skills
 
Special_test_for_all_joints.pdf
Special_test_for_all_joints.pdfSpecial_test_for_all_joints.pdf
Special_test_for_all_joints.pdf
 
OSCE AND OSPE, DIFFERENTIAL SACALE
OSCE AND OSPE, DIFFERENTIAL SACALEOSCE AND OSPE, DIFFERENTIAL SACALE
OSCE AND OSPE, DIFFERENTIAL SACALE
 
Ijsrp p10588
Ijsrp p10588Ijsrp p10588
Ijsrp p10588
 
Osce and ospe
Osce and ospeOsce and ospe
Osce and ospe
 

More from Anisuddin Bhatti

Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptxWhy Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
Anisuddin Bhatti
 
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptxPrinciples, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Anisuddin Bhatti
 
VERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptxVERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptx
Anisuddin Bhatti
 
Principles of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptxPrinciples of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptx
Anisuddin Bhatti
 
CLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.pptCLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.ppt
Anisuddin Bhatti
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
Anisuddin Bhatti
 
Mock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptxMock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptx
Anisuddin Bhatti
 
Mock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptxMock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptx
Anisuddin Bhatti
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
Anisuddin Bhatti
 
Mock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptxMock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptx
Anisuddin Bhatti
 
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic HipsBhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
Anisuddin Bhatti
 
Pakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention programPakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention program
Anisuddin Bhatti
 
Post Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limbPost Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limb
Anisuddin Bhatti
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limb
Anisuddin Bhatti
 
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of RxPost Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
Anisuddin Bhatti
 
LCPD Perthes'_ management
LCPD Perthes'_ managementLCPD Perthes'_ management
LCPD Perthes'_ management
Anisuddin Bhatti
 
1 perthese diagnosis & classification
1 perthese diagnosis & classification1 perthese diagnosis & classification
1 perthese diagnosis & classification
Anisuddin Bhatti
 
4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above
Anisuddin Bhatti
 
3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocols3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocols
Anisuddin Bhatti
 
2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age 2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age
Anisuddin Bhatti
 

More from Anisuddin Bhatti (20)

Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptxWhy Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
 
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptxPrinciples, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
 
VERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptxVERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptx
 
Principles of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptxPrinciples of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptx
 
CLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.pptCLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.ppt
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptxMock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptx
 
Mock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptxMock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptx
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptxMock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptx
 
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic HipsBhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
 
Pakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention programPakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention program
 
Post Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limbPost Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limb
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limb
 
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of RxPost Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
 
LCPD Perthes'_ management
LCPD Perthes'_ managementLCPD Perthes'_ management
LCPD Perthes'_ management
 
1 perthese diagnosis & classification
1 perthese diagnosis & classification1 perthese diagnosis & classification
1 perthese diagnosis & classification
 
4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above4 ddh principles & protocols 3 & above
4 ddh principles & protocols 3 & above
 
3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocols3a ddh open reduction principles & protocols
3a ddh open reduction principles & protocols
 
2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age 2 ddh principles & protocols of rx. 0 12 m age
2 ddh principles & protocols of rx. 0 12 m age
 

Recently uploaded

CBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdfCBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdf
suvadeepdas911
 
Cardiac Assessment for B.sc Nursing Student.pdf
Cardiac Assessment for B.sc Nursing Student.pdfCardiac Assessment for B.sc Nursing Student.pdf
Cardiac Assessment for B.sc Nursing Student.pdf
shivalingatalekar1
 
Does Over-Masturbation Contribute to Chronic Prostatitis.pptx
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxDoes Over-Masturbation Contribute to Chronic Prostatitis.pptx
Does Over-Masturbation Contribute to Chronic Prostatitis.pptx
walterHu5
 
vonoprazan A novel drug for GERD presentation
vonoprazan A novel drug for GERD presentationvonoprazan A novel drug for GERD presentation
vonoprazan A novel drug for GERD presentation
Dr.pavithra Anandan
 
Complementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLSComplementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLS
chiranthgowda16
 
Aortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 BernAortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 Bern
suvadeepdas911
 
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptx
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptxMuscles of Mastication by Dr. Rabia Inam Gandapore.pptx
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptx
Dr. Rabia Inam Gandapore
 
The Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of RespirationThe Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of Respiration
MedicoseAcademics
 
Chapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptxChapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptx
Earlene McNair
 
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Oleg Kshivets
 
CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1
CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1
CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1
rishi2789
 
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
bkling
 
Netter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdfNetter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdf
BrissaOrtiz3
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
Health Advances
 
All info about Diabetes and how to control it.
 All info about Diabetes and how to control it. All info about Diabetes and how to control it.
All info about Diabetes and how to control it.
Gokuldas Hospital
 
Role of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of HyperthyroidismRole of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of Hyperthyroidism
Dr. Jyothirmai Paindla
 
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptxEar and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Dr. Rabia Inam Gandapore
 
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptxREGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
LaniyaNasrink
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
rishi2789
 
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPromoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
PsychoTech Services
 

Recently uploaded (20)

CBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdfCBL Seminar 2024_Preliminary Program.pdf
CBL Seminar 2024_Preliminary Program.pdf
 
Cardiac Assessment for B.sc Nursing Student.pdf
Cardiac Assessment for B.sc Nursing Student.pdfCardiac Assessment for B.sc Nursing Student.pdf
Cardiac Assessment for B.sc Nursing Student.pdf
 
Does Over-Masturbation Contribute to Chronic Prostatitis.pptx
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxDoes Over-Masturbation Contribute to Chronic Prostatitis.pptx
Does Over-Masturbation Contribute to Chronic Prostatitis.pptx
 
vonoprazan A novel drug for GERD presentation
vonoprazan A novel drug for GERD presentationvonoprazan A novel drug for GERD presentation
vonoprazan A novel drug for GERD presentation
 
Complementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLSComplementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLS
 
Aortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 BernAortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 Bern
 
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptx
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptxMuscles of Mastication by Dr. Rabia Inam Gandapore.pptx
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptx
 
The Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of RespirationThe Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of Respiration
 
Chapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptxChapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptx
 
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
 
CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1
CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1
CHEMOTHERAPY_RDP_CHAPTER 2 _LEPROSY.pdf1
 
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
 
Netter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdfNetter's Atlas of Human Anatomy 7.ed.pdf
Netter's Atlas of Human Anatomy 7.ed.pdf
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
 
All info about Diabetes and how to control it.
 All info about Diabetes and how to control it. All info about Diabetes and how to control it.
All info about Diabetes and how to control it.
 
Role of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of HyperthyroidismRole of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of Hyperthyroidism
 
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptxEar and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
 
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptxREGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
 
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPromoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
 

Anis Bhatti _ virtual clinical exam Cerebral Palsy: long case

  • 1. Virtual Clinical Examnination: IPP-Cerebral Palsy (long case) Prof. Anisuddin Bhatti Dr. Ziauddin University Hospital, Clifton, Karachi. Secretary, Orthopaedic Faculty, CPSP.
  • 2. Virtual Clinical Examination: (VCE) • A Virtual Patients (VPs) in clinical examinations instead of real patients. • A Computer-based programs with a VPs that simulate real-life clinical scenarios. • Requires a linear dialogue between examiner and examinee, for which VPs need to be adapted accordingly. Harless et al 1971 & Cook et al, 2010.
  • 3. Virtual Clinical Examination • Provides an Interactive role to the examinee, as opposed to passively watching videos/ visuals and answering written or oral questions. • Examinee is required to interact with the examiner by posing and answering questions regarding evolving condition of the V. patient presented. (Huang G, Reynolds R, Candler C).
  • 4. Interactive Paper Patients (IPPs) • The simulator, computer-based photo, video or scenario used in VCE is referred as an IPP. • IPP is presented phase wise to allow an interactive dialogue between Examinee with examiner • IPPs has been extensively used for the Cognitive Assessment in: o Modified Essay Questions (MEQs) o Task Oriented Assessment of Clinical Skill (TOACS) o Objective Structured Assessment of Technical Skills (OSATS) o Patient Management Problems (PMPs) o Workplace Based Assessment (WPBA): Mini-CEX & Direct observation of procedural skills (DOPS). o Virtual Clinical examination (VCE) (Huang G, Reynolds R, Candler C).
  • 5. VCE Process • IPPs reveal patient condition and workup phase-wise. • Examiner poses questions to the examinee after description of each phase. • Student ask additional questions about patient condition, investigation or response to therapy. • Examiner responds verbally or furnishes Laboratory reports / Imaging films. • Answers are scored phase-wise on a key.
  • 6. Long case: KEY - CONNTEMPORARY Answers are scored phase-wise on a key. Excellent, Good, Adequate, Inadequate, Poor Examiner 1: [both examiners R Silent Observer] A. History Taking & Examination: Examinee’s attitude, behavior, communication skill, clinical examination skill. B. Presentation skill: Correct history, relevant exam findings, Positive / negative findings. C. Order relevant Investigation & justify. He shall be shown that report , Xray, MRI, CT etc D. Differential Diagnosis & confirmation of diagnosis most suitable. Examiner 2: A. Management plan. Discussion: What, How, When & When not. B. Complications. Why & how to manage C. Recent advances.
  • 7. Long case: KEY – Virtual Examination Answers are scored phase-wise on a key. Excellent, Good, Adequate, Inadequate, Poor Examiner 1: [one examiner may act as simulator – IPP] A. Examiner presents: Short history with Picture, video, Scenario. Student advised to ask additional question from examiner. A. Examiner poses questions to the student after description of each phase. B. Student be advised to ask further questions and asked for relevant investigation & justify. What U want to evaluate with that investigation. He shall be shown that Lab. report , Xray, MRI, CT etc A. Differential Diagnosis & confirmation of diagnosis most suitable. Examiner 2: A. Management plan. Interactive Discussion: What, How, When & When not. B. Complications. Why & how to manage C. Recent advances.
  • 9. Plz look at these Pictures: A 9-year old boy presented with tip toe walking since age 2 years and having difficulty in walking for the last 3 years. He is able to sit at ease. Very enthusiastic & cooperative. Q.1. U may ask few question for patient condition?
  • 10. Q.1. Key 1. Birth history: Liquor aspiration - Birth Asphyxia. Delayed milestones for one year. mentally alert, Intelligent, he study in class 3. 2. Development history: Walked independently for 6 years, deteriorated with difficulty in walking, for the last 3 years. He manage his daily accustomed habits independently. 3. He is an independent walker, sometimes need support, when outside [functional walker].
  • 11. Q.2. How would you proceed to reach diagnosis in your mind ?
  • 12. Q.2. Key Exmine to 1.Asses his Gait, Posture, walking ability 2.Perform multiple clinical test to look for spasticity, hyperreflaxia, Contractures: static & dynamic.
  • 13. Okay. Plz. Look at his Gait & Posture again. Q.3. What type of gait is this? Q.4. What type of walker he is? Let him speak freely to justify
  • 14. Q.3a. Key. • Spastic Diplegic • Jump gait [Unstable] • Decompensated with Pes Plano-Valgus.. A Danger sign.
  • 15. Q.3b. Key. Interactive discussion continued GAIT PATTERNS • Different Gait patterns observed in CP depends on the involvement of spasticity or contracture of different muscles: • Variations relates to topographical type of CP { Hemiplegia, Diplegia, monoplegia. With or without Ataxia etc}. • Best seen in contrast between unilateral spastic CP and bilateral spastic CP.
  • 16. Q.3c. Key. Spastic Diplegia Gaits: Four common patterns of gait in spastic Diplegia. [Rodda et al.] • Type 1 – True equinus • Type 2 – Jump gait • Type 3 – Apparent equinus • Type 4 – Crouch gait
  • 17. Q.3c. Rodda et al. JBJS. 2004
  • 18. Q.4. Key: Waking Pattern Assessment to Qualify as walker can be made best after the age 7 years. Till than brain maturation reach to a plateau. TYPES OF WALKING: • Walker: when child could walk a minimum of 15 meters without falling. [Independent walker] • Functional Walker: when a child could walk only with crutches [Community walker]. • Non-Walker: when child could walk with aid of mobility device or only in parallel bars
  • 19. Q.5.How would you proceed further to reach definite diagnosis and plan treatment?
  • 20. Q.5. Key: Clinical examination Detailed clinical Examination. Examiner interact here. 1. In systemic examination he has no significant abnormality. Plz Proceed 2. Focused Neuro - MSK examination: to terform certain clinical test to evaluate for spasticity & contractures: Dynamic & satatic. 3. Examiner asks to name such test (?/9 tests). 4. Plz perform ?? Test on examiner 1 OR he just ask how to do and what are pre-Requisites of that test. OR He may show U test in video and ask you few question to know ur knowledge & skill.
  • 21. Clinical Evaluation: Tests Q.6. Which test is this? Q.7. What are the Findings? Q.8. Is there any flaw while performing this test.
  • 22. Q.6,7,8 Key Q.6. Thomas test… for Hip Flexion contracture. FFC Q.7. Knee cntracture & Hamstring spasticity Q.8. Flaws: Pillow & Soft bed. Modified Thomas at edge of bed to exclude Knee contracture. Not done Speaking on Flaws test your knowledge & Skill.
  • 23. Thomas Test- Modified: to exclude Knee Contracture, avoid flaw
  • 24. Staheli’s Hip Flexors Stretch test: Hip FFD • More accurate for FFD hip • Prone position • Pelvis over table edge Thomas test Staheli’s
  • 25. Q.9. Which tests R this. What R the Findings. Any Flaw in performing tests?
  • 26. Q.9. Key 9.A. Combined Abduction test. 700 . Adductors contracture bilateral. Flaw: Not significant. Individual side may b done. 9.B. Pop Angle test. +900 . Significant Hamstring contracture / Spasticity. Flaw: not significant 9.C. Silverskiold test. Negative. Combined Gastro-Solus contracture.
  • 27. Adductor Longus Stretch Test • Hip abduction angle in Knee extension & flexion When measurements are same: Adductors tight. Why? • Hip abduction improves on Knee flexion: Gracilis tight Same angle Adductors tight Abduction improved Gracilis is tight
  • 28. Gracilis spasticity – Phelp’s Test • Passive abduction with knee in extension. • Improved hip abduction with knee flexion indicates Gracilis / medial hamstring tightness. Why?
  • 29. Popliteal Angle: Normal ranges in Children. Discussion • 1-3 yrs mean angle 60 [00-150] • @ 4 yrs mean angle 170 in girls, 270 in boys [50-450]. • >5 yrs mean angle 260 little change [0-50] • PoP angle of >500 in above age groups indicate abnormal hamstring tightness. Katz, Kalman. University Telaviv Israel. J Ped ortho 1992. 12:229-231
  • 30. POP Angle: Hamstring Stretch Test: Discussion • Hip flexed to 900 & knee extend • Measure Popliteal angle 900 flexion to 00 extension • Hamstring Shift: Difference b/t Rt & Lt measurements 00 900 500 RtLt
  • 31. Achilles Stretch Test: Discussion Silverskiold test- Gastroc. vs Soleus “Spastic Gastrocnemius contracture” Correction of ankle equinus with Knee flexion indicates Predominantly gastrocnemius Contracture. Why?
  • 32. Q.10. Which tests are being performed What R Findings? What is wrong in performing these tests ?
  • 33. Q.10.a. Key 10.A. Rectus Strech test: Aly Duncan test. Pelvis rise on knee flexion. 10.B. Hip Rotation test: Anteversion
  • 34. 10.b. Key Craig Test: FAV: Trochanteric Prominence Test • Prone position and knee at 90° flexion. • Angle between the vertical line and long axis of the leg at the greatest prominence of the greater trochanter palpated laterally measures the amount of FAV. In recent studies, it has been found that trochanteric prominence test in combination with hip internal rotation, X-rays is a better predictor of FAV and neck-shaft angle as compared with computed tomography.
  • 35. Q.11. Any additional Clinical tests U Know. Just name that?
  • 36. 11.a. Key. Rotational Malalignment/s • Foot propagation angle • Tibial rotation Foot – Thigh Angle
  • 37. Q.11.b. Tibial torsion mal-alignment Thigh foot Angle • Prone position, knee in 90° flexion, and neutral ankle and hind foot position. • Angle between the thigh axis and foot axis (axis between the 2nd and 3rd metatarsals) gives Tibial torsional measurement
  • 38. Differential diagnosis. • Q.12. In what pathological status this clinical condition occurs? • Q.13 How would you confirm your best possible diagnosis?
  • 39. 12, 13. Key 12. Cerebarl Palsy, Spinal Dysraphysm, Fredrix Ataxia & Cerebral demyelination syndrome. 13. Detailed Birth history, Clinical examination, Observational gait analysis, Video assisted observational gait analysis & Advanced Imaging. Use Algorythm: Diagnostic Matrix
  • 40.
  • 41. Q.14. How can you classify his functional disability ? Q.15. In which functional disability class (level) he fits & Justify? Let him speak freely to justify
  • 42. 14.a. Key: Gross Motor Function Assesment GMFCS
  • 44. Q.15. Is there any Advance Clinical or laboratory tests available to check CP Patients Motor functions & disabilty?
  • 45. 15.a. key Advanced tests • Foot propagation angle • Observational Gait Analysis & Video Assisted OGA • Videographic Gait analysis: Gait Laboratory test: Computer base gait and indiviual muscle functions programme, that include: oEMG Muscle charting. o3D camera gait analysis. oFoot pressure Pedography.
  • 46. 15.b. Advanced tests: Repeated examination & careful analysis of the gait [VAOGA/ Gait laboratory] & posture and recognition of potential skeletal changes lead to better judgment to correct or prevent structural changes reasonably early i.e before 15 (13) years. (Molnar-Gordon) Gait Laboratory Plays important role in accurate Judgment Video Assisted Observational Gait Analysis
  • 47. NED University Gait Laboratory: Videographic gait analysis Gait Lab test being performed on patients during CP workshop on 19 March 2011
  • 48. Gait Laboratory: PEDOGRAM: Cavovarus & Planovalgus EMG: Indicating spastic, normal & Weak Muscles
  • 49. Management Plan: 9 yr aged, boy, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Recall findings: Examiner helps to recall findings. 1. Functional walker 2. GMFC-2 3. Thomas’s FFC 15-200 4. Combined Abduction 700 5. Phelp’s positive 6. Pop angle +900 7. Silverskiold’s Negative [-150] 8. Pes-planovalgus 9. Ely’s Positive 10. Stable pelvis & Spine 11. Upper limb Normal 12. No neuro deficit
  • 50. Management Plan: 9 yr aged, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Q.16. What shall be the objective to treat him? Q.17. How shall U manage him?
  • 51. 16. & 17 Key: management Plan 16. a. Help him to be an independent walker without support. b. prevent deterioration of pes planovalgus and develop crouch gait 17. A. 3-4 weeks pre-operative rehabilitation training exercises / physiotherapy & Occupational therapy. B. Exclude structural abnormalities on X-ray. C. Reconstructive surgery @ Knee & Ankle C. Postoperative Rehabilitation programmes
  • 52. Management Plan: 9 yr aged, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Q.18. What shall be contraindications other than general well being? Q.19. Let us know Ur plan of Reconstructive surgery as u decided? No need to go in detailes of surgical steps
  • 53. 18 & 19. Key. Contra Indications & Recon Surgery 18. Reconstructive surgery is better in Spastic Cerebral palsy, best in Hemiplegia than diplegia. Before embarking to surgery. MUST MUST: Exclude Ataxia, chorioform movements & other abnormal features of basal ganglia involvement. 19. A. Reconstructive surgery @ Knee & Ankle +/- Hip Hamstring Fractional Lengthening, Keats transfer to adductor tubercle, TAL, 1/2 Tibialis Anterior Transfer to neck of talus. [+/- Adductor Myotomy without Neurectomy] 19.B. Postoperative Rehabilitation programmes Quad strengthening and Gluteal Muscle development excercises.
  • 54. Management Plan: 9 yr aged, CP child, Diplegic, Mentally alert, cooperative & enthusiastic for Rx Q.20. Describe postoperative care? Let him speak freely
  • 55. 20. Key. Rehabilitation Programme. Rehab programme • Hospital & home bases exercises • Muscle streghening execrcise • Occupational therapy Bracings – Temporary addjuncts • AFO • KFO
  • 56.
  • 57.
  • 58. References • VCE Guidelines Designed by: DR. Sirajul Haque Shaikh, Director DME. CPSP, Karachi. • References: 1. Harless et al 1971 2. Cook et al, 2010. 3. Huang G, Reynolds R, Candler C. • Clinical Material: Prof. Anisuddin Bhatti’s collection • Videos Prepared @ DZUH Clifton, Karachi Assisted by: Dr. Sadam Mazar Baloch & Dr. Nida Hameed

Editor's Notes

  1. 1. Birth history: Liquor aspiration Birth Asphyxia. Delayed milestones for one year. Intelegent. 2. Development history: Walked independently for 6 years, deteriorated with abnormal Gait for the last 3 years. He manage his daily accustomed habbits independently. 3. He is an independent walker with a Jump gai, sometimes need support, when outside.
  2. Exmine for Gait, Posture, walking ability multiple clinical test to look for soasticity, hyperreflaxia, Contractures:static & dynamic.
  3. 3. Spastic Diplegia. 4. By GMF Assesment: Print key as on next slide 5. GMFL: II (Walks with Jump gait BUT supported
  4. Detailed clinical Examination Focused MSK examination to terform certain clinical test o evaluate for spasticity & contractures: Dynamic & satatic
  5. Thomas test… Hip contracture Knee cntracture … Hamstring spasticity Flaws: Pillow & Soft bed. Modified thomas at edge of bed to exclude Knee contracture.
  6. 1. Cerebarl Palsy, Spinal Dysraphysm, Fredrix Ataxia & Cerebral demyelination syndrome. 2. Detailed Birth history & clinical examination. [Print two slides as key]
  7. 3. Spastic Diplegia. 4. By GMF Assesment: Print key as on next slide 5. GMFL: II (Walks with Jump gait BUT supported
  8. 1. Clinical video based analysis of Gait & Posture.
  9. 16. a. Help him to be an independent walker without support. b. prevent deterioration of pesplanovalgus and develop crouch gait 17. A. 4-6 weeks pre-operative rehabilitation training exercises / physiotherapy & Occupational therapy B. Reconstructive surgery @ knee & ankle C. Postoperative Rehabilitation programmes