CEREBRAL PALSY

GENERAL INFORMATION
Pts name: A.B.
Age: 5 y/o & 2 mos.
Sex: Male
Address:Dili, Bauang, La Union
Civil Status:Single
Citizenship: Filipino
Handedness: ®
Occupation: N/A
Religion: Roman Catholic
Referring Unit: Walk In
Referring Dr.: N/A
Rehab Dr: Dr. M
Date of Referral:N/A
Date of Consultation: June 15, 2020
Date of IE: June 18, 2020
Diagnosis: Cerebral Palsy; GD
SUBJECTIVE

Informant: Biological Mother

Credibility: Good
Educational Attainment: College Graduate

C/c: “Hindi siya makatayo at makalakad”

PT Translation: “Informant c/o pt’s inability to stand and
ambulate”
 HPI
Pt’s present condition when px was a year old when informant noticed that
px cannot assume sitting independently and is having a head lag upon pull to
sit from supine position. Px was also described to be dragging (B) LE on
propped forearms position. This prompted the parents to consult Dr. A, px’s
pediatrician/neonatology of Our Lady of Lourdes Hospital, t/c c CP since px
was premature at 7mos. Px was then referred to Dra. B, a
neurodevelopmental specialist. Dra. B administered physical exam and some
cognitive tests(unrecalled) for the px. No ancillary procedures were requested
and px was diagnosed with CP Spastic diplegia. Dra. B referred px to Dr. C,
rehab MD at OLLH for further evaluation and treatments. Px underwent PT
treatments 3x a week for 2 years c the following management; (1) FES on (B)
quads and back extensors x 5min., (2) US on (B) hams x 1.0W/cm2 x 5min.,
(3) GPS on hams, adductors and gastrocs, (4) cross sitting x 5min., (5)
PROMEs on (B) UE/LE, (6) vestibular ball exercises, (7) sit ups x 10 reps x 1
HPI
At 2 yrs old, px received botox injection on (B) gastrocnemius for spasticity
and continued PT mx at OLLH as ordered by rehab MD, Dr. C. Informant stated
no significant changes noted after the injection of botox to the px. Some
improvements were observed on the same year as px was then able to cruise,
sit (assume), and ambulate with maximal support. However, informant noticed
that the progression was slow and eventually discontinued PT treatments.
At 3 yrs old, informant decided to stop PT treatments. Px stayed at home for
2 years s any PT interventions and treatments. Informant stated carrying out
home exercises instructed at OLLH such as PROMEs on (B)UE/LE, cross
sitting and GPS on hams, adductors and gastrocs at home. There is no
progression and regression of problems occured but informant noticed that px
was delayed in motor development.
HPI
At 5 yrs old, informant noticed that px was still unable to stand and walk
independently at his age and this prompted px’s mother to bring px to PCPI,
through referral by a neighbor and then underwent a medical checkup at Fort
Med Makati by Dr. M. (Rehab MD). No ancillary procedures or examinations
was done. Px was then diagnosed c CP Spastic Diplegia.Dr. M also prescribed
the use of rigid AFO and to undergo PT/OT/SLP treatments. (lagay nalang kayo
pedeng mx)
At present, px is able to creep, crawl, and assume sitting with an abnormal
pattern and able to assume standing by pulling himself up by holding unto a
stable object and maintains it by holding on the object for ~1-2mins. Px is also
able to transfer from bed to floor, vice versa. Px is unable to stand and walk
independently.
OBSTETRIC SCORE: Prenatal Hx
Informant stated that she didn’t have any hx of
FULL TERM:1 illnesses,trauma/accident,hospitalizations and any
PRE-MATURE: 1 medical problems during her gestation. She also took
medicines such as folic acid, vitamins, and Anmum
ABORITVE: 0 (powdered milk).
LIVING: 2
Perinatal Hx:
GRAVIDA: 2 Informant was brought to OLLH and the labor was
PARITY: 2 conducted by Dr. S s any delivery precautions. No
prolonged hours of labor noted.
(-) accidents, hospitalizations,
medical problems Postnatal history
(-) smoker, alcoholic drinker Informant stated that she didn’t have any
hospitalization, trauma, accident and hx of illness;
(-) use of contraindicated drugs still had medical consultation for 4 months and took
(-) prolonged labor Folic acid for 6 months.
BIRTH HISTORY
APGAR
- at 1min. = 8
- at 5min. = 9
Age of Gestation: Preterm at 7mos. (31 weeks AOG)
Nature of Delivery: Normal spontaneous vaginal delivery
Manner of Presentation: Cephalic presentation

NUTRITIONAL HISTORY
Breastfed from 0-1mo.
Bottle feeding from 1mo.-present
Semi-solid and Solid food started at 6mos. (e.g. rice, fish, mashed fruits)
(-) feeding problems

IMMUNIZATION HISTORY
Complete immunization as stated by mother.
DEVELOPMENTAL MILESTONES

Ø Chronological age: 5yo & 2mos.

Ø Developmental age: 18mos
Ø Age of delay: 3yo & 8mos.
PAST MEDICAL HISTORY
(+) previous hospitalizations (d/t prematurity; March 17, 2015;
OLLH; Dra. S)
(+) pneumonia (2016)
(-) current medications
(-) trauma
(-) asthma
(-) surgery
(-) seizures

Past Medications
PSEHx:
Pt has a sedentary lifestyle c any other form of activity other than playing with
his brother, watching cartoons at youtube ,and scribbling. Pt. Lives in a
bungalow type of house together c his parents and older brother. Pt also loves

Pt’s Goal
C/c : “Syempre yung pinaka goal namin eh yung maglakad siya mag isa”.
PT Translation: Informant aims px to be able to ambulate independently
OBJECTIVE
VS a IE p IE
PR (taken using pulse oximeter) 96 bpm 98 bpm
RR 15 cpm 16 cpm
Temperature (taken using digital thermometer on L 36. 1 oC 36. 3 oC
axilla)

OCULAR INSPECTION
Ø mother borne
Ø Alert, coherent, sometimes uncooperative
Ø One word communication (e.g. Yea, No); able to imitate one to two words
with difficulty on pronouncing some consonants (ex. teacher, thank you, bye-
bye, go away)
Ø Nonverbal communication (e.g. nods for approval)
Ø Well nourished
Ø Short attentions span (px consistently proceeds to explore his immediate
environment after ~10sec. of attending to PT or after following command)
Ø Normocephalic at 52cm (N range: 48.72cm – 54.72cm)
Ø (+) mild drooling (prone, sitting, & standing)
Ø (+) postural deviations (see PA)
Ø (+) gait deviation (see GA)
Ø (+) “W” sitting
Ø (+) bunny hopping, occasionally
Ø (-) fisted hands
Ø (-) cortical thumb
Ø (-) scoliosis
Ø (-) scars on (B) UE/LE
(-) flexor/extensor synergy on (B) UE/LE
PALPATION
Normothermic on all exposed body parts
Hypertonic on (B) UE/LE (see Tone
Assessment)
(+) Spasticity on (B) UE/LE (see Spasticity
Assessment)
(+) tightness on (B) hamstrings, (B)
iliopsoas, (B) rectus femoris, and (B)
gastrocnemius mm.
(+) contracture on (B) LE
(-) subluxations on (B) shoulders
(-) dislocations on all joints of (B) UE/LE
(-) crepitus on (B) UE/LE
(-) tenderness on (B) UE/LE
NEUROLOGIC ASSESSMENT
A.Sensory Testing • b.Auditory Testing
a.Tactile Testing • STD: examiner’s voice calling out px’s name
Light touch • Findings: px looks at caller of name (3/3)
STD: brush on neurohammer • Significance: px will be able to respond to verbal
Findings: px looks and turns head towards stimulated cues and follow verbal commands during treatment;
part will be responsive to auditory stimulus (e.g. audio-
Deep Pressure visual toys, rattle) to entertain px and won’t be easily
bored
STD: examiner’s thumb
• c.Visual Testing
Findings: px looks at stimulated part
• Tracking
Pain
• STD: toy
STD: pointed tip of neurohammer
• Findings: px looks and follows toy (3/3)
Findings: px withdraws or looks at stimulated part
• Threat
Significance: Pt will be able to respond and perceive
tactile cues during treatment (e.g. guiding transitional
• STD: examiner’s hand directed in front of px’s eyes
movements); will be able to respond to potentially painful • Findings: px blinks upon abrupt stimuli (3/3)
stimuli (e.g. during GPS); pt can also differentiate • Significance: px will be able to respond to, follow, and
stimulus and be able to tell PT/guardian if something imitate visual cues given by PT or guardian and
harmed him protect eyes from objects that might come in contact
with his eyes.
a.DTRs a. Pathologic Reflexes
(R) (L) Ø (+) Clonus on (B) feet
Ø (-) Babinski on (B) feet
Legend:
0 – areflexia
Babinski like reflexes:
+ – hyporeflexia Ø (-) Oppenheim’s
++ – normoreflexia
+++ – hyperreflexia Ø (-) Chaddock’s
++++ – clonus
Ø (-) Gordon’s
Ø (-) Strandsky
Ø (-) Schaeffer’s
b. Primitive Reflexes
Ø (+) Parachute reaction
Ø (-) ATNR
Ø (-) STNR
Ø (-) Moro
Note: (B) UE were not assessed d/t px being Ø (-) Neck righting
unable to relax UEs. Ø (-) Extensor Thrust
Findings: Hyperreflexia on (B) knees and clonus Ø (-) Foot placement
on (B) ankles.
Sig.: 2o to increased gamma motor firing
TONE ASSESSMENT
Findings:
Grade 3 on (B) UE/LE
Sig.:2o to ↑ gamma motor neuron firing
Grading:
0 – No response (Flaccid)
1 – Decreased response (Hypotonia)
SPASTICITY ASSESSMENT 2 – Normal response (Normotonia)
3 – Exaggerated response (Mild to moderate hypertonia)
4 – Sustained response (Severe hypertonia)
Findings:
Grade 1 on (B) UE
Grade 1+ on (B) LE
Sig.: 2o to probable affectation of BA 6
***UMNL
ROM Assessment
All major joints of head, neck, trunk, (B) UE/LE were tested actively and passively c normal end feel were
found to be WNL except for the ff:
Motion PROM Normal Difference End-feel
Right Left Right Left
Ankle DF 0-6o 0-10o 0-20o 14o 10o Mushy

Ø Findings: LOM on (B) ankle DF d/t (+) tightness on (B) gastrocs with knees extended
Ø Significance: px will have difficulty assuming and maintaining half-kneeling and standing
positions independently d/t inability to position feet in proper position. Px will also have
decreased BOS compromising balance, and px will exhibit toe walking.
Grading:
FMT
0 – no ability
1 – beginning ability, partially achieved,
unreliable, insecure, momentary
2 – reliable with abnormal pattern
3 – reliably achieved, efficient, reliable
with good pattern
Balance
1 – cannot assume or maintain
2 – can assume but not maintain or vice
versa
3 – can assume and maintain
4 – can assume and maintain, weight
shift and be challenged
Tolerance
Poor – 0-15min.
Fair – 16-30min.
Good – 31-45min.
Normal – 46-60min.
Grading:
FMT
0 – no ability
1 – beginning ability, partially achieved,
unreliable, insecure, momentary
2 – reliable with abnormal pattern
3 – reliably achieved, efficient, reliable
with good pattern
Balance
1 – cannot assume or maintain
2 – can assume but not maintain or vice
versa
3 – can assume and maintain
4 – can assume and maintain, weight
shift and be challenged
Tolerance
Poor – 0-15min.
Fair – 16-30min.
Good – 31-45min.
Normal – 46-60min.
REACH, GRASP, RELEASE Grading:
RGR
Right Left
Poor – (-) RGR; (+) Reach, (-)
REACH + +
GRASP + + Grasp and release
RELEASE + + Fair – (+) Reach with
difficulty grasping and
Ø Findings: complete RGR on (B) hands. Px always releasing; (+) Reach and grasp
use his (L) hand and reach a bit slowly using his ® with difficulty releasing
hand. Good – Complete RGR; (+)
Ø Significance: px will be able to manipulate toys RGR
during the treatments; will be able to reach and
grasp pull-up bars during kneeling and standing
exercises and parallel bars/walker during
ambulation exercises as well as in ADLs such as
feeding and dressing
Leg Length Measurement

Reference Point Right Left Difference

Umbilicus-ASIS 9cm 8.5cm 0.5cm
ASIS-Greater 8cm 8cm 0
trochanter
Greater 23cm 23cm 0
trochanter-
Lateral femoral
condyle
Medial joint line- 23cm 23.5cm 0.5cm
Medial malleolus

Ø Findings: (-) LLD

Ø Significance: Serves as a good contributing factor for the px to stand properly.
SPECIAL TESTS
Response Indications
1. (+) (+) APT but thigh cannot be Iliopsoas tightness
Thomas pushed down on (B) LE
test
2. (+) Pt is unable to fully extend (B) Hamstring
popliteal knee tightness
angle test

3. (+) 6 deg. (extended knee) 20 deg. Gastrocnemius

silfverskiold (flexed knee)® 10 deg (extended tightness
knee)30 deg (flexed knee)

4. (+) (+) APT on B LE Adductor

phelp’s spasticity
5. (+) (+) APT on (B) LE before 90 deg. Iliopsoas
staheli’s (L: 10 deg; R: 12 deg.) contracture

6. (+) ely’s (+) APT and hip flexion on I/L side Rectus Femoris
tightness

7. (-) (-) LLD

galleazi
Postural Analysis
Anterior Posterior Lateral
Head midline midline midline
Neck --- --- ---
Shoulders (B)Slightly adducted; IR --- Ear is not in midline c the tip of
shoulder
Elbows Slightly flexed --- (B) Slightly flexed
trunk ------ ----- Increased thoracic flexion, decrease
lumbar extension (sitting)
Hips (B) add and IR (B) add and IR (B) slightly flexed (standing)
Knee ® knee more ant. & ® knee more ant. & (B) flexed in standing, but ® knees
higher than (L) in higer than (L) more flexed than (L)
standing (standing)
Ankles Add and inverted --- Plantarflexed (R)>(L)
(R)>(L)

Ø Findings: Pt presents kyphosis d/t ms imbalance; slightly flex elbow d/t Grade 1 spasticity on B UE;
Scissoring posture on (B) LE; equinovarus on (B) ankles d/t tightness on (B) gastrocs
Ø Significance: px exhibit postural deviations in standing and sitting that will lead to compromised balance
leading to difficulty in standing B/T; maintenance of postural deviations may also exacerbate or promote
tightness of some soft tissues causing greater difficulty in standing, kneeling and ambulation.
GAIT ANALYSIS
Assessed inside parallel bars with px supporting himself by holding onto the parallel bars with
close guard standby assist of one. However, phases of Gait were N/A d/t presence of AD and/or
inability to ambulate independently.
Note: Px’s trunk is flexed throughout ambulation s armswing d/t px holding on parallel bars.
Findings: Pt presents Scissoring gait pattern; decreased step length and stride length;
demonstrates toe walking c narrowed BOS
Significance: d/t tightness of muscles (hams, iliopsoas, rectus femoris, gastrocnemius)

ADL ANALYSIS
Px is able to roll on bed from supine to prone and vice versa with abnormal pattern; able to sit
up from supine and go back to supine
Px can move in and out of bed/plinth(low and medium), moving in by crawling then climbing
and moving out by positioning himself with stomach against the edge of the bed then lowers
himself through the UEs.
Px is able to sit to stand and vice versa, cruise and ambulate by holding on to a stable object
ASSESSMENT
PT IMPRESSION:
A.B. is a 5 year old male clinically diagnosed c CP Spastic Diplegia; GDD with c/o inability to
ambulate independently further defined by Grade 2 FMT in rolling over, POE, creep, crawl,
sitting(assume), kneel (assume); 2/Poor kneeling B/T and 1/Poor half-kneeling B/T;Postural and
Gait deviations, LOM on (B) ankle DF 2º to Tightness on (B) hamsrings, (B) iliopsoas, (B) rectus
femoris, (B) gastrocnemius mm.; Gr. 1 spasticity (B) UE and gr. 1+ (B) LE. and clonus on B
achilles tendon.

PROCEDURAL INTERVENTION:
Pt proposes rehabilitative to preventative intervention scenario to address her condition
because problems could be addressed by PT interventions effectively.

REHAB POTENTIAL
Px has good rehab potential given that adjuncts to treatment such as medications, orthosis, or
surgical procedures will be added to physical therapy management. Px is very likely to
ambulate but with an assistive device as px already has beginning ability on ambulation but
able to do so with maximal support.
Problem List LTG (3x a wk; 6 mos) STG (3x a wk; 3 mos)
Tightness on (B) hamstrings, (B) Pt wiill demonstrate absence of Pt wiill demonstrate decrease in
iliopsoas, (B) rectus femoris, (B) tightness of (B) hamstrings, (B) tightness of (B) hamstrings, (B)
gastrocnemius mm. iliopsoas, (B) rectus femoris, (B) iliopsoas, (B) rectus femoris, (B)
gastrocnemius mm. As manifested gastrocnemius mm. As manifested
in Special Test p 6 mos of tx session in Special Test p 3 mos of tx session

2/P kneeling B/T and 1/P half-kneeling Pt will be seen to assume,maintain, wt Pt will be seen to assume and maintain
B/T;3/F Sitting B/T and 3/P Standing shift and challenge Balance in kneeling, Balance in kneeling, assume half
B/T sitting and standing and kneeling; Tolerance in kneeling, half
assume/maintain half kneeling; kneeling and standing from poor to fair
Tolerance in kneeling, half kneeling and and sitting from fair to good p 3 mos of
standing from fair to good and sitting tx session
from good to normal p 6 mos of tx
session

LOM on (B) ankle DF Pt will demonstrate near normal ROM Pt will demonstrte increase in ROM in
in (B) ankle DF p 6 mos of tx session (B) ankle DF c 5-10 deg increments p 3
mos of tx session
Scissoring Gait Pt will be able to ambulate using AD s Pt will be seen to ambulate using AD c
assist mod assist
Gr. 2 FMT in rolling over, POE, creep Pt will achieve rolling over, POE, creep Pt will demonstrate improvement in
and crawl and crawl efficiently and with good rolling over, POE, creep and crawl p 3
pattern p 6 mos of tx session mos of tx session
Kyphosis,(B) elboows slightly flexed, Pt will be able to demonstrate proper Pt will be able to demonstrate proper
Scissoring posture, Equinovalgus on body mechanics and proper body body mechanics and proper body
(B) ankles posture p 6 mos of tx session posture every tx sessions
PLAN
PT Mx:
1.Play Therapy
a)GPS on (B) hamstrings, (B) iliopsoas, (B) rectus femoris, (B) HIP:
gastrocnemius mm. X 30 secs x 3 sets to maintain soft tissue
1.Adherence to exercises integrated at home to be taught
extensibility and prevent further tightness
by PT and for return demo by caregivers
b)Cross sitting in thera ball c wt shifting from side to side to
improve sitting posture 2.Px to be discouraged from “W” sitting by
c)Kneeling x 5 mins c verbal and tactile cues commanding/reminding px
d)Kneeling to Half kneeling x 10 reps x 1 set to To facilitate 3.When px is sitting in a chair or on the floor, px is to be
kneeling (assume) and B/T, and half-kneeling (assume) to allow encouraged to erect his back particularly on the low back
for proper transition into standing (assume) area
e)Half kneeling to standing x 10 reps x 1 set; c 5 mins standing at
last rep and incorporation of perturbations to facilitate wt shifting
f)Gait training using posterior rollating walker
RECOMMENDATIONS:
1.Referral to orthotist for possible use of flexible
supramalleolar DAFO on (R) foot
HEP: 2.Referral to OT for px’s short attention span
1.Play therapy 3.Referral to SLP for improvement of px’s phonation of
a)GPS on (B) hamstrings, (B) iliopsoas, (B) rectus femoris, (B) consonants
gastrocnemius mm. X 30 secs x 3 sets 4.Recommending use of night splints on (B) feet to
b)Encouraged for certain periods of the day to play his iPad while prevent plantar flexion contracture
in kneeling or half-kneeling position in front of a table/surface
about below the armpit level 5.To have a prescription for posterior rolling walker.
2.Family education regarding the components for proper
transition into standing position.