Kuwait University

Faculty of Allied Health Sciences

Occupational Therapy Department

Course: OT-318 Clinical Fieldwork II

(Semester 2 - 2025)

Course Coordinator: Mohammad Alshehab, PhD, OTR/L

Case Study of Cerebral Palsy

Noor Selwadi 2221189775

Renad Alharbi 2221138036

March 23, 2025

Case Background & Medical Information:

The patient is an 11-year-old wheelchair user with Spastic Quadriplegic Cerebral Palsy (CP),
characterized by muscle stiffness and weakness in all four limbs. This affects mobility, daily
activities, and school/social participation. The condition results from brain damage in motor
areas, often due to perinatal complications.

The child has some voluntary upper limb control but did not achieve early milestones like
rolling or crawling. Impairments limit tasks such as feeding, dressing, and grooming, while
cognitive challenges impact school performance.

Observations & Screening:

We assessed range of motion (ROM) and muscle tone. The child has generalized hypertonia
with increased tone in the upper limbs (especially forearm rotators) and tight hamstrings
restricting knee flexion to 90°. Hip tone is mild, while ankle movement is limited due to
moderate spasticity.

Other challenges include drooling from weak mouth closure, poor hand function with weak
grip strength, and cognitive-perceptual difficulties requiring frequent prompts. Reflex testing
showed mild ATNR (no rolling), a right-side spinal Galant reflex, and mild STNR (no
crawling).

For visual tracking, we assessed smooth pursuit eye movements. The child struggled to
track a moving pen, likely due to cognitive impairment and difficulty understanding the task
rather than a visual issue. Glasses may have also influenced tracking.

Activity Analysis:

The child sat cross-legged with poor posture. The therapist placed a basket in front and held
linking toys on the child’s right side, instructing them to pick up a toy and place it in the
basket. The child did not initiate movement, requiring verbal and physical cues. With
assistance, they slowly pulled one toy but had a weak, awkward grip, causing it to drop.
Despite repeated prompts, their response was slow and inconsistent. As the task continued,
they stopped responding altogether. After multiple trials, they managed to place some toys in
the basket, but movements remained slow and uncoordinated. When asked to help clean up,
they showed minimal engagement, leaving most of the task to the therapist.

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The child has voluntary arm movement but limited active ROM (AROM), while passive ROM
(PROM) is full. They show poor movement patterns, slow, weak reach, and low endurance.

Clinical & Scientific Reasoning of the Assessment Process:

Neuromuscular Function

The child has fair head control but does not use it functionally, no rotation or nodding. Trunk
control is fair but muscle weakness causes slouching. Fine motor skills are impaired, with
awkward grip in both hands.

Supine posture , wrist/elbow flexion, knee flexion with external rotation, and hip abduction,
while sitting posture shows posterior pelvic tilt, reducing stability.

Cognitive Skills

They can wave goodbye and smile but have low arousal, needing strong stimuli to respond.
Sustained attention is poor, and they struggle with problem-solving and following commands,
requiring multiple repetitions.

Motor Skills

Their reach is slow and limited, especially for objects outside their visual field. They lean
forward with poor alignment and have weak grip strength, making it difficult to grasp objects.
Bilateral coordination and in-hand manipulation are poor, and low endurance limits sustained
movement.

Process Skills

They struggle with task adjustments, material handling, and organizing actions. Pacing is
slow, attention is inconsistent, and they need frequent breaks.

Social Skills

The child has minimal engagement with the therapist, does not turn toward them, and has
limited speech. They struggle to express needs but sometimes respond with facial
expressions.

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Summary of Key Challenges

● Muscle tone issues, persistent reflexes (ATNR, STNR, spinal Galant), and cognitive
impairments limit daily activities.
● Limited endurance and poor motor control make tasks like grasping, eating, and
moving difficult.
● Poor problem-solving and attention impact school performance and self-care.
● Spasticity, weak grip, and muscle tightness hinder posture, movement, and
participation.

These findings highlight the need for targeted interventions, including sensory-motor
strategies and structured support, to improve engagement, mobility, and daily functioning

Standardized assessments

Assessments in the OT form

GMFCS (Gross Motor Function Classification System)
Level IV: the patient is transported in a wheelchair, and can sit with support but has poor
dynamic balance which limits his abilities to do any activity that requires midline crossing.
MACS (Manual Ability Classification System)
Level III: the patient faces difficulties in handling objects and his performance is slow due to
poor fine motor skills.
CFCS (Communication Function Classification System)
Level IV: inconsistent Sender and Receiver, relying on gestures and facial expressions.

Rationale for Using GMFCS, MACS, and CFCS Assessments

The GMFCS, MACS, and CFCS are three of the most commonly used assessments for
children with cerebral palsy (CP). These assessments are included in the hospital's
occupational therapy evaluation form.
They are standardized tools based on clinical observations by therapists, which makes them
easy to administer during task analyses and efficient in terms of time. These assessments
provide a general overview of the patient's capabilities, aiding in the selection of additional
assessments as needed.

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Other assessments
● The Gross Motor Function Measure (GMFM)

The GMFM is an assessment tool that evaluates gross motor function in children with
cerebral palsy (CP) and other motor impairments. It focuses on key areas such as lying,
sitting, crawling, standing, and walking.

Rationale: we can use it to track improvements in gross motor skills specifically sitting and
crawling and it can be used as an outcome measure.

● The Pediatric Evaluation of Disability Inventory (PEDI)

The evaluation measures the impact of motor impairments on a child's daily functioning in
self-care, mobility, and social participation. It assesses functional skills, caregiver assistance
needed, and any necessary adaptations like adaptive equipment.

Rationale: Using this assessment will give a better insight into the challenges that the
patient faces in everyday functions and the level of caregiver assistance required. From the
results we can direct the therapy to modify tasks, provide assistive devices, and educate the
caregivers about proper handling.

● Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)

The assessment measures fine and gross motor coordination, balance, and strength in
children. It evaluates domains such as fine motor precision, manual dexterity, bilateral
coordination, balance, strength, and agility.

Rationale: It's especially helpful for children with poor hand function and balance issues,
allowing for tracking improvements in coordination and postural control which was observed
in the patient during the activity analysis.

● Vineland Adaptive Behavior Scale (VABS)

The assessment aims to evaluate adaptive behavior in areas such as communication, daily
living skills, socialization, and motor skills. It focuses on expressive, receptive, and written
communication, self-care, domestic tasks, and community involvement.

Rationale: Using this assessment will give the therapist a better idea about how the patient
uses his acquired skills functionally and it can be an indicator for his cognitive abilities. It can

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be administered to parents, teachers and other caregivers through semi-structured
interviews.

Goals and intervention

Goal 1: Improve Sitting Balance

By the end of 6 weeks, the patient will enhance sitting balance by maintaining unsupported
sitting for at least 2 minutes without loss of posture in 4 out of 5 trials. This will be achieved
through balance exercises and core-strengthening activities during therapy sessions.

Intervention:

● Core strengthening activities using a therapy ball

● Dynamic sitting exercises (e.g., weight shifts, trunk rotations, reaching for objects)
● Facilitating protective and equilibrium reactions (e.g., catching and throwing a ball
while seated)

Rationale: for our case the main concern should be maintaining the current level of function
and trying to improve it and in order to have any gross motor improvement balance should
be addressed first. Working on balance will decrease the level of assistance needed in
everyday tasks and will prevent injuries due to falls.

Goal 2: Improve Hand Function for Daily Tasks

By the end of 6 weeks, the patient will demonstrate improved hand function by reaching for
and grasping objects with minimal assistance in 4 out of 5 trials. This will be achieved
through task-oriented therapy sessions focused on hand strengthening and coordination
exercises.

Intervention:

● Pegboard activities (placing and removing pegs to enhance finger dexterity)

● Stacking and grasping tasks (using different-sized objects to promote controlled
reaching and grasping)
● Bilateral coordination tasks (e.g., tearing paper, stringing beads, or using both hands
to manipulate objects)

Rationale: improving hand function will lead to improvement in most ADL’s such as feeding,
dressing, and self-care

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References

1. Russell, D. J., Rosenbaum, P. L., Avery, L. M., & Lane, M. (2002). Gross Motor
Function Measure (GMFM-66 & GMFM-88) User’s Manual. Mac Keith Press.
2. Haley, S. M., Coster, W. J., Ludlow, L. H., Haltiwanger, J. T., & Andrellos, P. J.
(1992). Pediatric Evaluation of Disability Inventory (PEDI) Development,
Standardization and Administration Manual.
3. Bruininks, R. H., & Bruininks, B. D. (2005). Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2): Manual. Pearson.
4. Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland Adaptive Behavior
Scales, Second Edition (Vineland-II): Survey Forms Manual. Pearson.
5. Novak, I., Morgan, C., & Badawi, N. (2013). A systematic review of interventions for
children with cerebral palsy: State of the evidence. Developmental Medicine & Child
Neurology, 55(10), 885-910. https://doi.org/10.1111/dmcn.12246
6. Rosenbaum, P., Paneth, N., Leviton, A., et al. (2007). A report: The definition and
classification of cerebral palsy April 2006. Developmental Medicine & Child
Neurology, 49(Suppl. 109), 8-14. https://doi.org/10.1111/j.1469-8749.2007.tb12610.x
7. Palisano, R. J., Rosenbaum, P., Bartlett, D. J., & Livingston, M. H. (2008). Gross
motor function classification system (GMFCS) expanded and revised. Developmental
Medicine & Child Neurology, 50(4), 249-252. https://doi.org/10.1111/j.1469-
8749.2008.02067.x