3. Patient History
Birth date: January 2, 2012
Hospital: GHS
Brody is a triplet and was born at 28 weeks and 5 days.
Brody was in the NICU at GHS for 5 months and was discharged to go home May 29, 2012
Age: 5 years old
Brody was born with retinopathy of prematurity and a lot of his diagnoses come from his visual
deficits. Brody also had necrotizing enterocolitis, which is found in 1 in 5 preemies, when he was
born. He is fed through a G-tube.
On June 20, 2016 Brody had a status/posed bilateral VDRO (Varus Derotation Osteotomy) and
Dega Osteotomy.
4. Patient History
Brody attends school at the Washington Center at Hollis. There he sees PT, OT, and speech.
Some of Brody’s favorite things to do are being outside and in the pool. He loves to listen, especially to
a good story. He likes music (every once in a while you can catch Peter playing him some ACDC).
Brody has a great sense of humor. He laughs at jokes right on cue. He also loves birds. He has two
birds at school named Carlos and Lucy that sit in his chair with him.
Brody communicates through his eyes, his smile, by kicking, and by the noises he makes. You will know
when he likes something and when he does not like something. In speech, they are working on pairing
auditory sounds and visual cues. He can light up a room with his laugh and smile.
Things that tend to bother Brody are when we stretch his hips. If he is not ready or warmed up for this,
he will typically grimace. He will let you know through that grimace, or by making it pretty difficult for
you to do the movement. He also is not fond of PA systems.
5.
6. Developmental Milestones
Children at the age of 5 should be reaching age-appropriate gross motor skills/ developmental
milestones including:
Standing on one foot for at least 10 seconds
Walking on a balance beam
Hopping forward on one foot
Catches tennis sized ball
Somersaults
Throws at a target
Propels self on swing
Can possibly skip
8. Cerebral Palsy
Neurological Disorder
Etiology: non-progressive brain injury or malformation
This typically occurs while the brain is still developing, but can also occur before birth, during birth (10% of cases), or
directly after birth
CP effects body movement and muscle coordination along with muscle tone, posture, reflex, control, and balance
The extent of the disorder varies from person to person
Other complications can be associated with CP such as:
Intellectual impairment
Seizures
Vision or hearing impairments
86% have oral motor dysfunction involving swallowing, breathing, and communicating
9. Cerebral Palsy
Diagnosing cerebral palsy can take from 3-5 years (the brain needs to be fully developed to
diagnose)
Cerebral Palsy can be classified in many different ways including:
Severity Level– mild, moderate, severe
Topographical Distribution– plagia/paresis– quadriplegic, diplegic, hemiplegic
Motor Function- spastic (70-80% of CP cases), non-spastic (20% of cases)
Muscle Tone- hypertonia (stiff, generally associated with spastic motor function), hypotonia (floppy,
generally associated with non-spastic motor function)
Gross Motor Function Classification System (GMFCS)- Levels I-V
10. Spastic vs. Non-Spastic
Spastic (pyramidal)- increased muscle tone; two groups of fibers are involved with voluntary
movements. These fibers run from the cortex to the brainstem. Generally, they are accountable
for communicating the brains intent for movement to the nerves in the spinal cord that then
stimulate the event. The muscles are continually contracted in kids with spastic CP making their
arms and legs stiff, rigid, and resistant to flexing and/or extending. Their movements are jerky
and awkward. The injury occurs at the pyramidal tract in the brain and is known as upper motor
neuron damage.
Non-Spastic (extrapyramidal)- decreased or fluctuating muscle tone. Non-spastic CP can be
characterized by involuntary movements, which stress can worsen. These movements can be
slow or fast and can also be repetitive or rhythmic. The injury occurs outside the pyramidal tract
in places like the basal ganglia, thalamus, and cerebellum.
Mixed- characterized by some limbs being affected by spasticity and some by athetosis.
11. Athetosis
Athetosis is distinguished by problems with posture and movements such as wide-ranged,
uncontrolled movements. This can be associated with spastic cerebral palsy.
Children with athetosis generally cannot sit, walk, talk, or hold onto objects. With that being said,
these children have above-average intelligence, with or without learning disabilities.
Common characteristics of children with athetosis:
Moving the head and eyes to one side to facilitate movement in the body
Total flexion and total extension
Large, fast movements with the head turned to one size
Non-verbal
12. Hypertonia
This is the largest group of kids with CP.
These patients are typically diagnosed with quadriplegia, diplegia, or hemiplegia.
Kids with hypertonia are known to have a wide range of abilities. Some children can be mildly
affect only having trouble with running, writing, and pronouncing certain words, but otherwise
doing most things children their age are engaging in. Others are very involved and have difficulty
holding their heads up, using their arms to reach or grasp, and making more than a few sounds.
Other characteristics include:
Stiffness
Less range of motion
Using a limited number of muscles to make movements happen
13. Goals
Peter’s goals:
Minimize hospitalizations
Minimize respiratory infections
Have Brody assist with sit to stand
Decrease respiration rate from about 24 breaths to 22 breaths for 10 consecutive measurements within two sessions
Hold vowel sounds during therapy (indirectly indicative of respiratory function)
Preserve range of motion and strength
Go from sit to stand with 30 degrees of flexion in the knees and push up to full extension 10x
Family goals:
Get stronger where he can
For Brody to be able to assist with movement/transfers as he gets older and bigger
Concerning surgery, recover without having strength and stretching set backs
14.
15.
16. Treatment Plan
After undergoing the hip surgery, Brody was referred to physical therapy by his doctor at Shriners
Hospital for Children for purposes involving range of motion, bed mobility, strength, balance, and
standing in a stander.
Peter has worked with Brody in both the pool and on land. The pool is just so beneficial because of the
heated water. The warmth is more therapeutic as his stiff muscles are looser, his joints feel better, and
the stretches and ranging aren’t as painful for him. Things that Brody grimaced at on land, did not
bother him at all in the pool.
The pool also challenges the respiratory system. It is harder for him to breathe in the pool because of the
pressure the water places on the lungs.
The pool can also help facilitate movement as it is a movable environment. (reciprocal movements)
We work a lot to maintain flexibility, increase strength, he rides the adaptive bike at school, works with
the stander and the gait trainer which are utilized to give him some weight bearing
17. Treatment Plan: Land
Scar tissue massaging
Scars limit his respiration because of severity
Joint mobilization
Weight shifts
Standing
Sitting
Sit to stand transitions
Using AFOs and knee immobilizers
Began standing for 10+ seconds
Stretching
Stretch the trunk- loosens up the respiratory system helping him breathe
Thoracic rotation in extension
Decrease in breathes per minute by the end of the session
45 breaths per minute to 33 breaths per minute
Maintain flexibility and range of motion
Adaptive bike
18.
19. Treatment Plan: Pool
Scar tissue massaging
Joint mobilizations
Strength- preventing atrophy
Kicking- moving against resistance of the water
Reciprocal movements
Pushing off
Sit to stand transitions
Stretching- maintain flexibility and range of motion
20.
21. Progress Evaluation
Since Brody is a case of spastic quadriplegia and is really involved, we will see relatively small
progress. With that being said, we would not use something like the GMFM to evaluate.
Instead, Peter uses things like evaluating his kicking, whether or not he got sick for the quarter,
and how he does/helps with sit to stand to justify his continued therapy. Though things in this
nature might have miniscule significance in the GMFM, it has great significance to mom, the
family, and Peter.
One big take-aways I had during my internship is that with patients that are as involved as Brody
was that you might not see a lot of progress in these patients, but if you can keep them or their
impairments from getting worse, that is a win.
GMFCS Level V – severe head and trunk control limitations. Requires extensive use of assisted technology and physical assistance; and transported in a manual wheelchair, unless self-mobility can be achieved by learning to operate a powered wheelchair.
Brain damage or malformations:
Periventricular leukomalacia (PVL) – damage to the white matter of the brain tissue
Intracranial hemorrhage (IVH) – brain hemorrhage
Hypoxic-ischemic encephalopathy (HIE) or intrapartum asphyxia – lack of oxygen to the brain (asphyxia)
Cerebral dysgenesis – brain malformation or abnormal brain development
Insurance and diagnosis
muscle tone and how muscles work together. Proper muscle tone when bending an arm requires the bicep to contract and the triceps to relax. When muscle tone is impaired, muscles do not work together and can even work in opposition to one another.
Spasticity implies increased muscle tone. Muscles continually contract, making limbs stiff, rigid, and resistant to flexing or relaxing. Reflexes can be exaggerated, while movements tend to be jerky and awkward. Often, the arms and legs are affected. The tongue, mouth, and pharynx can be affected, as well, impairing speech, eating, breathing, and swallowing.
The GMFCS is a universal classification system applicable to all forms of Cerebral Palsy. Using GMFCS helps determine the surgeries, treatments, therapies, and assistive technology likely to result in the best outcome for a child.
The GMFCS addresses the goal set by organizations such as the World Health Organization, or WHO, and the Surveillance of Cerebral Palsy in Europe, or SCPE, which advocate for a universal classification system that focuses on what a child can accomplish, as opposed to the limitations imposed by his or her impairments.
The GMFCS uses head control, movement transition, walking, and gross motor skills such as running, jumping, and navigating inclined or uneven surfaces to define a child’s accomplishment level. The goal is to present an idea of how self-sufficient a child can be at home, at school, and at outdoor and indoor venues.
The 12-Step Diagnostic Process entails the following steps:
Step 1: Parental Observation
Step 2: Clinical Observations
Step 3: Motor Skill Development Analysis
Step 4: Medical History Review
Step 5: Documenting Associative Conditions, Co-Mitigating Factors, and Ruling-Out Other Conditions
Step 6: Obtaining Test Results
Step 7: Diagnosis
Step 8: Obtaining a Second Opinion
Step 9: Determining Cause
Step 10: Care Team Assembly
Step 11: Care Plan Creation
Step 12: Embracing a Life with Cerebral Palsy
Functional
objective
Spastic, hypertonic movement
C-diff
Things that Brody wouldn’t be able to do, he could do in a pool
The pool is fun and motivating for the kids as they get so excited just in their anticipation of the pool.
Strength- prevent atrophy
Aqua Therapy:
Benefits of water therapy include:
Provides resistance
Encourages a wider range of movement and opposition
Alleviates stress and tension
Reduces pain and tension in muscles and joints
Protects against injury
Improves cardiovascular conditioning since the heart pumps more blood per beat when body is submerged in water
Decreases post exercise discomfort
alking in water provides more than 10 times more resistance than walking on land, which means an aquatic therapy patient receives the benefit of deep, intense exercises while in a soothing and comforting environment.