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CP is a group of disorders of the development of movement and posture, which is attributed to non-progressive disturbances that occur in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, cognition, communication, perception, behavior and/or a seizure disorder.
Wyatt presents with abnormal patterns of posture and movement as well as increased muscle tone (spastic hyper tonus) in both lower limbs, right more than left. He also shows decreased variety and selectivity of his movements.
The spastic hyper tonus has resulted in non-neural changes in his muscles. Thus, the actual length (i.e. shortening) and structure of a variety of muscles (iliopsoas, hip adductors, hamstrings, astrocnemius) in his lower limbs has been altered. This has negatively affected his walking and he now complains of discomfort in his legs and especially his knees. He was recently assessed by his pediatric neurologist, Dr
Wilson (Practice number 032 001 0382183), to address the shortening of his muscles. To improve his gross motor function he received Botox injections and serial casting on the 7th March 2013. The use of Botulinum toxin type A (Botox) in the treatment of cerebral palsy and spasticity is growing and continues to be redefined. When injected into spastic muscles the tone will normalize and allow the muscle to lengthen with growth of the limbs. A combination of muscle weakening and strengthening of the agonist muscles minimizes or prevents contracture development with bone growth. This type of intervention is used when limited number of muscles are causing deformities, such as spasticity of the gastrocnemius muscle causing toe-heel gait or hamstring spasticity being responsible for a crouch gait. This Botox lasts for 4 to 6 months. During this time Wyatt went through extensive physiotherapy and a routine home exercise program. Wyatt will see Dr Wilson again in June to assess his improvement and if there is a need for more Botox at this time.
Due to the CP, Wyatt presents with global developmental delay. He has achieved sit to stand from the floor, walking, running and climbing stairs with assistance. All of the aforementioned are performed with some difficulty and are not energy efficient. His walking is not performed with ease and he frequently trips, falls and fatigues easily. In conjunction with Wyatt’s ability to achieve and maintain certain positions, a constant area of focus is his ability to transition from one position to another (e.g. Sitting to standing through half kneeling). Wyatt was unable to transition from sit to stand from the floor through half kneeling independently but since the Botox he has been able to get into that position a lot easier and only needs a little assistance at times.
His walking is not performed with plantar grade feet, but mostly on his toes. He struggles to stop and start running with ease and safely. He displays an associated reaction in his right arm when running (although this too has gotten a lot better and is more prominent now only when he is tired). He is starting to jump with 2 feet but cannot maintain this for long periods. He is unable to jump with 2 feet together from a small step. He is unable to balance or hop on 1 leg.
Neurodevelopment physiotherapy is indicated to address Wyatt’s development of movement and posture. Through therapy we aim to achieve Wyatt’s maximum functional potential and improve functional performance. Wyatt also goes to tumbling on Tuesdays and Thursday to help him gain his maximum functional potential.
At physio and home we have worked on sitting in a variety of positions (i.e. sitting on the floor with his feet in front (long sitting) or legs crossed). Time spent playing in prone is also vital, as it helps stretch out his hip flexors. We have worked in high kneeling, half kneeling, one legged standing, jumping with two feet, climbing stairs, hopping on one leg, balance and ball skills.
Wyatt has been wearing bilateral ankle foot orthoses (AFO’s/ splints) during the day. They have helped improve his general alignment, posture, gait and his static dynamic balance. His incidence of falling has reduced and his ability to climb (e.g. jungle gym) has improved. They have allowed for better alignment of his ankles and a good base support for walking, running and climbing. Wyatt also uses night ankle-foot orthoses as an adjunct to his AFO’s worn during the day. The aim of the AFO’s is to complement his Botox and physiotherapy treatment. In so doing improve the biomechanical alignment and range of movement of the joints in his lower limbs, maintain and hopefully increase the length of the muscles in his lower limbs.
Wyatt displays some disturbances of his speech (i.e. articulation, drooling). His speech is delayed, but has recently shown great improvement in articulation and vocabulary. Wyatt requires speech therapy to improve his communication and attends once a week at the moment with Heidi Babic.
Wyatt is busy with an Occupational Therapy at Lara Gunter assessment to see where he is lacking with regards to fine motor skills and will then start therapy to assist with that.
Wyatt is also seeing an Optometrist (Kate Howsley) and an eye specialist (Dr. Stoch) as his right eye has a very slight squint and is lazy. He currently wears eye patches in the morning to help make his right eye stronger.
Wyatt has come a long way and has improved in leaps and bounds. But to achieve and maintain his maximum functional potential he will require continued therapeutic intervention (physiotherapy, speech and Occupational Therapy). Overall we are aiming to reduce his activity limitations and improve his participation at play times, in family activities, at school and with friends in the broader community.
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