This document provides a medical history and treatment plan for Brody Long, a 5-year-old boy diagnosed with severe quadriplegic spastic cerebral palsy. Brody was born prematurely at 28 weeks and spent 5 months in the NICU. He communicates non-verbally and relies on a G-tube for feeding. His physical therapist, Peter, develops goals focused on improving Brody's strength, range of motion, respiratory function, and independence with transfers. Treatment involves stretching, strengthening, and mobility exercises both in the pool and on land to address Brody's tight muscles and limited movement. Progress is evaluated based on small functional gains rather than standardized tests, as significant improvements are unlikely given Bro

1. Brody Long
Cerebral Palsy

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.

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

7. Diagnosis
 Quadriplegic Spastic Cerebral Palsy
 Severe
 Hypertonic
 Level V GMFCS
 Athetosis

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

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

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

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.

23. Resources
 http://www.cerebralpalsy.org/about-cerebral-palsy/types-and-forms