A Case Study About a 13-Year Old Male Diagnosed with Cerebral Palsy

This patient is a thirteen-year-old male diagnosed with Cerebral Palsy birth. His female therapist, physical therapist assistance (PTA) at Andalusia Regional Hospital has been seeing him since he was three months old. This patient is an outpatient along with a homehealth patient. He has had surgeries for muscle releases of contractures. Since the PTA has been seeing him of his entire life, I will only discuss his most recent surgery.

In April 2002, he had surgery bilaterally for the lengthening of his hamstrings (HS).

He was prescribed bilateral knee immobilizers along with a short leg cast on his right ankle. Following surgery, he was cleared to weight bear as tolerated. His prior level of functioning was dependent for most activities of daily living (ADLs) and gait, in which he did use a rolling walker. The patient required maximum assistance for standing, also. The strength of his quadriceps bilaterally was 2+/5 to 3/5; left dorsi flexion (DF) and plantar flexion (PF) was a 2/5; bilateral upper extremities were 3+15.

Plan of care: Immediately following surgery, the patients plan was therapeutic goals were to wear knee immobilizers full-time (except when bathing) for 2 weeks, then essentially full time for 2 more weeks to encourage healing with his hamstrings stretched. After four weeks he was to wear them all night. Also, he needed to be able to stand on his right foot in four to five days with his only limit being pain. His short-term goals (STGs) included: 1.) Moderate assistance with sit to stand; 2.) Moderate assistance with gait using a rolling walker ambulating 39 feet; 3.

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) Family independent with home exercise plan (HEP). These goals were to be reached in six weeks. His long-term goals (LTGs) included: 1.) Minimum assistance with sit to stand; 2.) Minimum assistance with gait using a rolling walker ambulating 100 feet; 3.) Independent and compliant with home exercise plan (HEP). The patient and family goals were to improve gait and overall functional status. His treatment plan included therapeutic exercises, gait training, functional activities (FAS), safety awareness/precaution training, and patient/caregiver education.

Description of care given: A lot of care has been given, and continues to be given to this patient. Gait training has been a major concern for this patient, getting him ready to start back to school. When he began therapy, shortly after surgery, he was able to ambulate 20 feet with moderate assistance of a rolling walker and the therapist. Now, he can ambulate 200 feet with moderate assistance of a walker and therapist. His distance of ambulation would increase and decrease due to his endurance throughout the treatment. He was able to perform sit to stand progressing from two times independently to five times independently, bicep curls with two pounds progressing to three pounds, shoulder flexion with cane slowly increasing from two pounds to two and a half pounds in three months. He would perform 30 repetitions (reps) of retraction exercises increasing from the green theraband for one week to red for three and a half weeks, to blue for one and a half weeks, and he is currently using yellow. The patient performed HS stretches manually in the prone position beginning at five reps holding for ten seconds progressing to five reps holding 30 seconds, HS sets of five reps holding ten seconds increasing to 20 reps holding five seconds within one month, then he decreased to 15 repetitions holding five seconds, and HS curls with moderate assistance five reps at beginning, within one week increased to ten reps, and one and a half weeks later increased to 30 reps. Trunk strengthening exercises were performed, and posture corrections were taught along with that. The patient performed dips exercises in his wheelchair increasing and decreasing depending on endurance, and he required minimum assistance at times. Also, scar massage was performed on his scars. A month after his surgery, a few more exercises were added to his treatment. Bilateral ankle range of motion (ROM) was performed, along with ankle stretches of DF and PF for ten reps holding 15 seconds.

A restorator was added, which is a peddler he can do while seated in his wheelchair. He performed this for 15 minutes. He performed exercises with the rope and pulley for five minutes, premod and moist heat to both his hamstrings for 15 minutes was added, also. Within the last month a few more exercises were added. Thirty reps of short arc quadriceps were performed with a bolster and towels. Single knee extensions and abduction exercises of 30 reps each were added. The last exercise to be added was straight leg raises performing five reps holding ten seconds with moderate assistance. On each visit not all of the therapeutic exercises were performed bye this patient due to tardiness, endurance, or cooperation. Some days were better than others were. His overall cooperation was good, with my experience. Three months later a reassessment was made on him. Established goals included increasing ROM, increasing strength, increasing endurance, and improving capacity in ADLs and education, which all improved. There was exceptionally goo progress with endurance. He was walking with his legs straighter and for 200 feet with moderate assistance of walker and PTA. He can now independently transfer. His active ROM of his knees increased on the left from 20 to 50 and right 10 to 40. Passive ROM of the knees increased on the left from 12 to 20 and right 5 to 15. All his STGs were met. All his LTGs were met except for compliance with the HEP. It is fair. The patient and family goals were reviewed. He is now transferring independently and ambulating 200 feet, in immobilizers, with rolling walker. The family was thoroughly instructed in HEP.

Discharge: N/A. He went to see his doctor in Texas this past week. My opinion: The PTA has been seeing him all his life, and she reports progress after surgeries, but compliance with the HEP, dynaplints, and immobilizers hinder further progression. There is only so much that can be doe to educate the family of the importance of these things. I believe the overall care of this patient to be good. I wouldnt change anything, except for maybe more motivation from the therapist.