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Case Study

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on 30 October 2013

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Transcript of Case Study

Case Study
Sean
By Ailsa Walker (student PT) 2013
Goal
Mums goals for the term were as follows:
increase Gross Motor development (standing and walking).
acquire new cut-out table and new AFOs.
to have more ideas for fine motor skills
Communication development.
Activities included:
sit-to-stand practice
crawling
reaching and rotation in standing
weight shift from one foot to the other
long sitting
resisted walking
independent standing
Session Outcomes
Gas goal will be assessed this week.
CPL will continue with ongoing assessment and therapy to increase Sean's independence with his mobility, to improve his participation in home and school activities and to increase his confidence (for further information see the FSP.)
Activities and exercises that Sean can do at home to help his development were discussed with mum and demonstrated during therapy.
A report could be made to provide the family with solid information for their own reference in the home.
Background
Birth History:
Born 32weeks, ventilated for 4hrs.
PMHx:
Encephally found on MRI at 6mnths, Squint operation to correct vision.
Diagnosed with CP at 13months old.
Irritable hip syndrome diagnosed at last hip x-ray.
Activity
Limitation with transitions and needs support
decreased swing phase in gait
can mobilise with walker on flat even surface
can perform ball rolling with support for regaining balance
can reach outside base of support in sitting and standing requiring minimal assistance to regain balance.
displays poor weight bearing when using walker.
can walk independently using walker
can sit independently
limited participation in weight bearing activities as he requires to hold on to something for balance.
able to use UL's in 'W' sitting for bi-manual play.
unable to use UL's for bi-manual tasks in standing/ walking.
unable to keep up with peers and socialise appropriately due to mobility restriction.
able to perform meaningful play in sitting and when supported in standing.
dependent for ADLs such as hygiene, toileting, dressing, eating and drinking.
Participation
Assessment findings
MAS Grade 2
Spasticity and increased tone in hamstrings, abductor and calves.
Decreased hip abduction ROM.
Decreased pelvic and trunk control.
Decreased awareness of body in space.
It was reported that he handles all consistencies of food well, only very ocaasionally coughing.
Body Structure and Function
3 yr old boy
Cerebral Palsy, Spastic Di-plegia.
Peri-ventricular leuko malacia
GMFCS: III
MACS: IV
Irritable hip syndrome.
Botox for adductors March 2014
Week 2
Week 4
Week 3
Week 5
Session Plans & Rationale
Included activities that allowed:
stretching
standing and reaching,
trunk rotation,
sit to stand practice,
walking against resistance,
long sitting,
obstacle avoidance.
These activities were selected to target;
increasing swing phase in gait,
increase independent standing time,
decrease trunk sway when walking,
increase control of gross motor movements,
improve standing balance following internal pertebation
improve weight transfer from one leg to the other in standing,
practice lower limb dissociation and half
halg kneeling
lower limb strength
Personal Factors
communication: bi-lingual English and French, uses sentence formation
cognition: appears good.
very cooperative & sociable
enjoys cars, building games and task orientated activities
Supportive family: Mo Virginie, Fa William, 2x older sisters.
Equipment:
Kaye Walker, articulated AFOs.
Schooling:
conductive education weekly
Other professional support and services:
Allied Health team at CPL
Mater Health Service
GP: Dr Joseph
Orthopaedic Sx: Dr Walsh
Neurologist: Dr Wallace
Opthamologist: Dr Yuen
Private Speech Pathologist.
Environmental Factors
Full transcript