VELEZ COLLEGE INC.

COLLEGE OF OCCUPATIONAL THERAPY AND PHYSICAL THERAPY

DEPARTMENT OF OCCUPATIONAL THERAPY

A Case Conference on Seminar 1

S.Y. 2022-2023

Prepared by:
Bacay, Kyron Gay A.
Chang, Yu-ling R.
Clemente, Leigh Erin L.
del Mar, George Nicole C.
Lim, Lenina G.
Manigque, Rose Anne G.
Palionay, Marielle L.

September 2022
 TABLE OF CONTENTS

I. BACKGROUND INFORMATION...……………….………………………………...……...02
Introduction………………………………...…….……………….……………….…..02
Medical Literature………………………………....….…………………...…….……03
Models, FORs, & Approaches………………………………....….….……...….…..07

II. EVALUATION…………………………………………...…………………...……….…….…10
Occupational Profile…………………………………....…….…...………….………10
Occupational Performance………………………………………..………..……….14
Strengths and Limitations………………………………………...…………….……23
OT Diagnosis……………………………………………………..…………….........24
Classical Picture vs Clinical Picture……………….……………...……......….…...25
Potential for Participation in Occupation……………………………...…………….26

III. INTERVENTION PLANNING………………………………….…..…………………..……26

Problem List Prioritization……………………………..…….….……………….......26
Targeted Outcomes……………………………………………...…….....................27
Goals/Objectives and Management………………………………………………...27

IV. TREATMENT SESSIONS…………………………………….………..………………..….33

V. PROGNOSIS OF TREATMENT…………………………………….….…………..……...38

VI. RECOMMENDATIONS………………………………….………..……………….….…..…38

VII. APPENDICES…………………………………….…………………..…...……….…...…....39

VIII. REFERENCES……………………………….……………………..…..…....….…..……....4

1
I. BACKGROUND INFORMATION

A. Introduction

This is the case of S.R., a 3-year old

male resident of Lahug, Cebu City, who
has difficulties in functional mobility,
self-feeding, play participation due to
problems in neuromusculoskeletal and
movement-related functions specifically,
muscle strength, muscle tone, balance
reactions, reflexes, movement functions
specifically, control of voluntary
reactions, specific mental functions
specifically, attention and sensory
functions specifically, proprioception
vestibular, and oral-seeking behavior.

All are caused by Cerebral Palsy of the

Spastic Diplegia Type.

2
B. Medical Literature

Cerebral Palsy

Definition
Cerebral Palsy (CP) is a group of disorders of the development of movement and
posture, causing activity limitations that are attributed to nonprogressive disturbances
that occurred in the developing fetal or infant brain. The three major criteria for diagnosis
of cerebral palsy are the neuromotor control deficit that alters movement or posture, a
static brain lesion, and acquisition of the brain injury either before birth or in the first
years of life. Due to the broadness of these criteria, cerebral palsy is considered as an
extremely heterogeneous diagnosis in terms of clinical presentation, etiology, and
pathology. Although the brain lesions that result in cerebral palsy are not progressive,
the clinical picture of CP may change with time as the affected individual grows and
develops.

Types of Cerebral Palsy

1. Spastic Cerebral Palsy also known as Hypertonic Cerebral Palsy, is the most
common type of Cerebral Palsy. Individuals with this type experience high muscle
tone and exaggerated, jerky movements (spasticity). Common manifestations
include: abnormal walking, awkward reflexes, contractures, and stiffness of the
body.
2. Athetoid Cerebral Palsy also known as “Non Spastic” or Dyskinetic Cerebral
Palsy, causes issues with involuntary movement in the face, torso, and limbs. It is
characterized by a combination of hypotonia (loosened muscles) and hypertonia
(stiffened muscles) which causes muscle tone to fluctuate. Common
manifestations include: floppiness of the limbs, problems in posture, feeding
issues, and stiff or rigid body.
3. Ataxic Cerebral Palsy affects balance, coordination, and voluntary movement.
Common manifestations include: poor coordination, problems with depth
perception, shakiness and tremors, speech difficulties, and spreading feet apart
when walking.
4. Hypotonic Cerebral Palsy also known as Atonic Cerebral Palsy, is classified by a
low muscle tone that causes loss of strength and firmness, resulting in floppy
muscles. Instability and floppiness in muscles caused by this type causes the
child to miss developmental milestones such as crawling, standing, or walking.
Common manifestations include: flexible joints and ligaments, lack of head
control, loose muscles, and poor balance and stability.
5. Mixed-type Cerebral Palsy occurs when the child shows symptoms of two or
more types of Cerebral Palsy. The most common mixed cerebral palsy diagnosis
is a combination of spastic and athetoid cerebral palsy, since both of these types
are characterized by issues with involuntary movement.

Types of Movement Problems

■ Monoplegia is a very rare type of movement problem that occurs when only one
arm or leg is affected.
■ Diplegia affects two limbs, commonly on the legs. Children with diplegia may
have mild movement issues in the upper body. Diplegia is a commonly a result of
premature birth that results in Cerebral Palsy
■ Triplegia occurs when all four limbs are affected. This may occur if both legs and
one arm cannot move freely.
■ Quadriplegia occurs when all four limbs are affected. The legs are generally
impacted more than the arms. Quadriplegia may cause limited control over facial
muscles.
■ Double hemiplegia occurs when all four limbs are affected, but one side is
affected more than the other.

Levels of Cerebral Palsy

Cerebral Palsy is classified according to the Gross Motor Function Classification System
(GMFCS).

3
Level I - Children in Level I walk indoors and outdoors without limitations. Performs
gross motor skills like running and jumping but speed, balance, and coordination may be
impaired.

Level II - Children who are in GMFCS II walk indoors and outdoors and climb stairs
holding onto a railing but experience limitations walking on uneven surfaces and inclines.
Walks with limitations. This includes uneven surface, inclines, stairs, long distances, or in
crowds or confined spaces.

Level III - Children who are in GMFCS III walk indoors or outdoors on a level surface
with an assistive mobility device. Children may climb stairs with a railing or propel a
manual wheelchair. Walks using a hand-held mobility device. Walks on even surfaces,
indoors, and outdoors with an assistive device. Children may use a manual wheelchair
for long distances.

Level IV - Children who are in GMFCS IV may walk short distances with a device, but
rely more on wheeled mobility at home and in the community. Self-mobility with
limitations. Children may use powered mobility or require more assistance from a
caregiver. May walk short distances with a mobility device but relies primarily on wheeled
mobility.

Level V - Child has no means of independent mobility and relies on a caregiver for all
transportation needs. Transported in a manual wheelchair.

Epidemiology

CP is the most common motor disability of childhood, affecting approximately 3.6 per
1,000 school-age children with at least 8,000 new cases each year in the United States.
The proportion of CP that is most severe is increasing, with as much as a third of all
children with CP having both severe motor impairments and mental retardation. The
population of children with CP may be increasing due to:
● Premature infants who are surviving in greater numbers
● Higher incidence in normal-weight term infants
● Longer survival overall

Etiology/Pathophysiology

Etiology
The etiology of CP is often not well understood and majority of the cases in term infants
do not have an identifiable etiology. Factors that may contribute to brain injury and CP
include:
● Prematurity - Premature infants (born earlier than 37 weeks gestation) are much
more likely to develop the condition than term infants, and incidence rates are
highest in the very earliest infants.
● Inflammation - Infant infections that cause inflammation in or around the brain.
Traumatic head injury to an infant, such as from a motor vehicle accident,
fall or physical abuse.
● Kernicterus - caused by severe jaundice that is untreated for too long.
● Methylmercury exposure - Methylmercury can pass through the blood-brain and
placental barrier, causing serious damage in the central nervous system.
● Genetic causes - gene mutations that result in genetic disorders or differences in
brain development.

Maternal Risk Factors Postnatal Risk Factors

● Chorioamnionitis or fever ● Trauma in developed nations

during labor ● Infection in developing nations

4
 ● Coagulopathy or bleeding
● Placental infarction
● Thyroid disease
● Birth Asphyxia
● Infections including viruses
such as chickenpox, rubella
(german measles), and
cytomegalovirus (CMV),
and bacterial infections
such as infections of the
placenta or fetal
membranes, or maternal
pelvic infections.

Signs and Symptoms

Signs and Symptoms of Cerebral Palsy typically vary from person to person. Some
people may present with a whole body affectation, others might have problems with one
or two-limbs, or even on one side of the body.

● Abnormalities in tone and reflexes during early infancy

● Early hand preference or asymmetric use of extremities
● Bunny hopping
● Combat crawling
● Bottom scooting
● Involuntary limb movements
● Continuous muscle spasms and contractions
● Abnormal walking, marked by knees crossing in scissor-like movement
● Joint contractures
● Flexion at the elbows, wrists and fingers
● Poor coordination and control of muscle movements

They may also develop other nervous system-related symptoms, such as:
● Hearing difficulties
● Vision abnormalities
● Speech difficulties
● Cognitive, learning and behavioral disabilities
● Seizures

Related problems may include:

● Drooling
● Breathing irregularities
● Gastric reflux
● Difficulty with chewing or swallowing
● Constipation and bladder incontinence

Course and Prognosis

Children with cerebral palsy often change over time, due either to growth and
development or as a result of treatment. Because it is a condition that can affect a
person in so many ways and because there can be related conditions, the prognosis can
vary significantly. Children with CP experience limitations in mobility and are at risk for
lower participation in leisure and social activities, and therefore, there is a perception that
they have a lower quality of life (QOL). QOL is defined as “an individual’s perception of
their position in life in the context of the culture and value systems in which they live, and
in relation to their goals, expectations, standards and concerns”. However, reports have
been made that despite their condition, many children with CP were noted to have a
social and emotional quality of life that is on par with their peers who aren’t disabled.

5
 Many studies have been published regarding the prognosis for ambulation of
children with CP, and the best predictors of eventual ambulation appear to be
persistence of primitive reflexes, gross motor development, and type of cerebral palsy.
The persistence of primitive reflexes or the absence of postural reactions at age 2 years
is associated with a poor prognosis for ambulation. Prognosis for eventual ambulation is
also closely related to the type of CP. Children with spastic hemiparesis have the best
prognosis for ambulation, with nearly 100% achievement. More than 85% of children
with spastic diparesis will eventually ambulate. The likelihood for ambulation is much
less with spastic quadriparesis. The presence of severe intellectual impairment also is a
poor predictor for walking. If one takes into account all of these potential predictors, it’s
possible to make a relatively accurate prognosis for ambulation by the age of 2 to 3
years.

In cases of moderate to severe CP or when there are other related conditions

affecting the prognosis, the child’s life expectancy may be lower. Seizures, trouble eating
or breathing, mobility limitations, intellectual impairment, and other factors can all affect a
child’s life expectancy. However, careful monitoring and an effective treatment plan can
help improve a poor life expectancy. A study published by the National Institutes of
Health explains that people exhibiting severe cerebral palsy symptoms that check “all
four functional disability categories” have a 50% chance of making it to the age of 13 and
a 25% chance of living to celebrate their 30th birthday.

6
C. Models, FORs, & Approaches

Motor Learning Approach

The Motor learning Approach posits that emphasizes that skills are acquired using
specific strategies and are refined through a great deal of repetition and the transfer of
skills to other tasks

Evaluation
The client's performance was evaluated by observations up until what aspect of the
activity he can do spontaneously. Notable areas for improvement are noted to be
targeted.

Intervention
The therapists utilized different practice levels such as massed/blocked, variable
practice, mental practice, etc. and feedback techniques such as verbal feedback,
knowledge of results, etc. based on the capabilities of the client.

Biomechanical Frame of Reference

The Biomechanical Frame of Reference (FOR) is a theoretical foundation for a remedial
strategy that focuses on impairments that hinder occupational performance. With the use
of this FOR we can determine and remediate the child’s problems in her motor skills,
muscle tone, muscle endurance, muscle strength, ROM, and structural stability.

Evaluation
The range of motion (ROM) was evaluated utilizing a goniometer and functional
observation. There was limitation of motion due to spasticity, no limb isolation, and
muscle weakness. For the child’s muscle power, the left and right shoulder flexors,
extensors, abductors, internal rotators, and external rotators are graded 3+ while the left
and right elbow extensors are graded 4.

Intervention
The therapists utilized a different range of motion exercises as an intervention to support
occupations for the child.

Neurodevelopmental Frame of Reference

The Neuro-Developmental Treatment FOR is used to analyze and treat posture and
movement abnormalities with basis on kinesiology and biomechanics. Planes of
movement, alignment, range of motion, base of support, muscle strength, postural
control, weight shifts, and mobility are all elements to consider in NDT while identifying
problems and planning interventions. NDT assumes that posture and mobility problems
may be improved.

Evaluation / Assessment
Evaluating the child’s:
● Planes of movement
● Alignment
● Range of motion
● Base of support
● Muscle strength
● Postural control
● Mobility

Intervention
● Handling
○ Graded application of manual forces to the client's body through the
therapist's hand, combined with directional cues for the client to feel and
learn new movement patterns. The therapist then provided verbal and
physical prompts, and facilitation of motor skills to help the child enhance
coordination and timing of movement patterns.

7
 ● Reflex Inhibiting Patterns
○ Used to inhibit spasticity of the child’s lower extremities by lengthening
the shortened muscles through passive stretching. This pattern was used
to break the synergies that made the child’s muscles stiff. Key points of
control in the legs were used to stabilize and input tactile control.

Sensory Integration Frame of Reference

The Sensory Integration (SI) frame of reference focuses on how the interaction between
the sensory systems including auditory, vestibular, proprioceptive, tactile, and visual
systems, provides integrated information that contributes to a child’s learning and
adaptive behaviors. The key consideration is that children have the abilities to make
adaptive responses to constantly changing sensory environments. The sensory
integrative abilities include sensory modulation, sensory discrimination, postural-ocular
control, praxis, bilateral integration, and sequencing.

Evaluation
During a functional observation, the therapists can determine sensory seeking or
avoidant behaviors. The child was noted to have a sensory seeking behavior specifically
on the oral areas as he was observed to constantly place objects in his mouth and
cannot determine if it was edible or not. The Short Sensory Profile was also administered
and it resulted with a 137/195, meaning there is probable difference.

Intervention
The therapists can assist the child in his ability to modulate, discriminate, and integrate
sensory information from the body and environment, provide self-regulation to maintain
his arousal on a task, maintain postural control, bilateral coordination, and laterality,
praxis and organizing behavior for tasks and activities, and development of self-esteem
and self-efficacy. Desensitization may also be utilized to address the child’s actions.

Developmental Frame of Reference

The Developmental Frame of Reference views clients as dynamic, developing, and
going through stages of growth and decline, requiring them to adapt. According to this
FOR, development is sequential and that an individual’s behaviors are primarily
influenced by how well they have mastered and integrated the preceding phases.
Dysfunction is present when the individual’s developmental level is unequal to
age-related demands. A disruption in one specific skill can also impact other areas of
development.

Evaluation
Under this FOR, evaluation is done through interviews, observations, review of medical
records, tests, and the collaboration of the caregivers of the child in order to assess the
current developmental level of the child. It was found out that the child lacked the
age-appropriate skills that would’ve enabled him to independently engage in several
areas of occupation, such as functional mobility, self-feeding, and play participation.

Intervention
The therapists adjusted the interventions to focus working on the identified skills that the
child wasn’t able to meet considering his age. Play activities were used during the
sessions so that the child can attain an age-appropriate level of adaptive skill that would
enable him to meet the demands of his environment.

Rood Approach
This approach focuses on the activation or deactivation of sensory receptors to evoke a
motor response, promote changes in muscle tone and developmental posture. The Rood
approach utilizes inhibitory techniques to help normalize the child's muscular tone or
lessen spasticity by applying tactile, thermal, or proprioceptive stimulation to the muscle
or its antagonists. These techniques are applicable as the child has a spastic muscle
tone and the use of inhibitory techniques can help her in doing her occupations.

Evaluation

8
The ontogenetic patterns under this approach can also be used in evaluating the child’s
motor developmental milestones.

Intervention
To address the child’s spasticity, inhibitory techniques such as slow rolling or light joint
compression may be utilized to alleviate pain and offset muscle imbalance.

9
 II. EVALUATION

Velez College
Department of Occupational Therapy
F. Ramos St., Cebu City

OCCUPATIONAL THERAPY PEDIATRIC INITIAL EVALUATION

GENERAL INFORMATION
NAME: Simon Rizal REFERRED BY: Dra. Michelle Sy, M.D.
AGE: 3 years and 11 months old SEX: Male
BIRTHDATE: September 8, 2019 DATE OF EVALUATION: August 9, 2022
DIAGNOSIS: Cerebral Palsy (Spastic Diplegia) OT-INTERN-IN-CHARGE:
Kyron Gay A. Bacay
Yu-ling R. Chang
Leigh Erin L. Clemente
George Nicole C. del Mar
Lenina G. Lim
Rose Anne G. Manigque
Marielle L. Palionay
CLINICAL IMPRESSION: Cerebral Palsy OT CLINICAL SUPERVISOR:
ADDRESS: Lahug, Cebu City SCHEDULE: Monday 10:00-11:00 am, Thursday
9:00-10:00 am
CONTACT NUMBER: 09283446735 INFORMANT:
Maria Teresa Rizal, Mother

The Occupational Profile

CHIEF COMPLAINT
“According sa doctor, need niya ang PT ug OT. Three years old naman gud siya and lain kaayo puro ra PT
niya wala sad engagement pud. If mo lakaw, gunitan jud nako siya kay di man siya maka step nga siya ra.
Isa ka problem sad kay sometimes ra siya mo pick (food). If naay ma-kuptan, i-direct dayon sa baba. If
makig play iyang brother, di mo play si Simon Rizal; iyang i-direct sa iyang mouth ang toy.”

According to the mother, “ di siya kibaw mu lakaw.. Kuptan jud nako sya kung mu tindog kay di sya
matumba siya. Sa balay, kung naa siyay makita, iyaha i punit nya isulod sa baba, nya di sya makig dula sa
iya brother.”
REFERRAL DETAILS
The child encountered delays with his motor functions, primarily gross motor skills, and is currently
experiencing problems fulfilling age-appropriate activities. The child was referred to Physical Therapy at
the age of 2 by his neurologist, Dra. Michelle Sy, to address his motor limitations and was later referred
to Occupational Therapy that year to address his concerns in functional mobility, feeding, and play
participation.
GOALS
According to the Mother:
“Ang akong goal ma’am kay maka kibaw na siya mo lakaw, kibaw na siya mo kaon sa iyaha lang, ug maka
social communication. Ang ako lang sad kay mo play sad siya sa iyang kauban.”
PRECAUTIONS/CONTRAINDICATIONS
● The child may be prone to falls due to problems with balance and mobility.
● The child may feel pain in the lower extremities due to the spasticity and is prone to muscle
contractures and pressure sores.

10
MEDICATIONS/SUPPLEMENTS
● CENTRUM KIDS (MULTIVITAMINS)
- Strawberry flavored chewable multivitamin tablets
- For children 2 and 3 years of age, approximately ½ tablet is chewed daily with food.
● BACLOFEN TABLET
- ¼ tablet, 3x a day after meals
- A muscle relaxer and antispasmodic drug used to muscle spasticity, especially on the child’s
lower extremities.
Side effects should be noted including constipation, tiredness, difficulty falling asleep or staying
asleep

HISTORY OF PRESENT CONDITION

Patient was born 30 weeks: pre-term to a G2 P2 (F1 P1 A0 L2) 25-year-old mother via normal
spontaneous vaginal delivery in cephalic presentation inside a taxi parked outside the hospital with
assistance from nurses.
PRENATAL HISTORY
Accidents/Illnesses: During the mother’s third trimester of pregnancy, she was still working as a manager
in a fast-food chain wherein she happened to reprimand someone at work. At that moment, the mother
noticed she had a vaginal bleeding which was around 8 o'clock in the morning. She was then rushed to
the hospital right away to have medical assistance. It was alarming for the mother since she was already
30 weeks pregnant. At the hospital, the doctor had the mother undergo a prenatal ultrasound
examination to check for any pregnancy complications. Her bleeding lasted for 10 hours that day since it
was noted to have stopped around 6 o’clock in the evening.

Hospitalizations: The mother did not mention any history of hospital admission during the pregnancy
except for being brought to the hospital right after the bleeding she experienced at work during her third
trimester specifically on her 30th week of pregnancy.

Interventions made: On the same day during the accident, the mother had a prenatal ultrasound
examination for the doctor to check on the baby’s health and development. Even after the mother got
the result of the examination, it was noted that the bleeding hadn’t stopped yet.

Vices/Other Risk Factors: N/A

Check-up: The mother had a regular prenatal checkup during the pregnancy based on the typical
schedule given by her doctor.

Medications/Prenatal Vitamins: The mother was prescribed normal prenatal vitamins and milk. She did
not take any medication for a certain disease or illness.

Employed/Unemployed/On-Leave: The mother was employed as a manager of a fast-food chain

restaurant during her pregnancy wherein she was in charge with the management or the daily
operations of the store and handling employees at work.
PERINATAL HISTORY
Labor Details: The mother went through a normal vaginal delivery during her 30th week of pregnancy.
Due to excessively strong contractions, she delivered the baby as she was still inside the taxi parked
outside the hospital while waiting for her sister to get a wheelchair in order to take her to the emergency
room. It was also noted how the mother experienced frequent contractions while she and her sister
were still on the way to the hospital. The mother indicated that she was assisted by nurses from the
hospital.

Complications and interventions done: There were no complications noted during the labor. The baby
was brought directly to the neonatal intensive care unit since the baby was born preterm.

Birth Weight: The child’s birth weight was not noted by the mother.

11
APGAR: According to the mother, the child was normal upon delivery and the baby was able to cry when
she placed him in her chest. The child’s appearance was pink in skin color all over his body after birth as
indicated by the mother and was noted to have a black color on his forehead. According to the doctor,
the black color that appeared on the child’s forehead was a result of the prolonged constraint of the
mother while she was traveling to the hospital. It was noted to fade after a month when the baby was
admitted to the hospital.

Discharge Condition and Details: The baby was discharged from the hospital after two months of being
admitted to the neonatal intensive care unit.
POSTNATAL HISTORY and RELEVANT MEDICAL HISTORY
The child and his mother stayed at the NICU for 2 weeks following the doctors’ order of further
monitoring of the child due to being born premature and undergoing incubation to allow the child to
catch up with full normal development before discharge. The mother started noticing development
delays of the child at the age of 1 such as not being able to balance, hold things, cannot stand up, and
constant drooling which she can compare from the previous experiences that she had babysitting her
nephews and from searching it up on the internet. Upon having these observations, she then decided to
have her child checked by his doctor. The child’s first diagnosis was Global Developmental Delay (GDD)
and was prescribed medications for muscle spasticity. At 2 years old, the child began to receive PT
services to address the child’s mobility problems. At 3 years old, a medical certificate was given by the
doctor and diagnosed the child with Cerebral Palsy (Spastic Diplegia) to perinatal insult. The child was
also referred to OT services and continued PT services.
EDUCATIONAL BACKGROUND
N/A. The child is not enrolled in any educational program.
PREVIOUS THERAPY RECEIVED: (PT, OT, SLP, and Others)
At 2 years old, the child received Physical Therapy services to address his mobility problems and head
control.
CURRENT THERAPY RECEIVED: (PT, OT, SLP, and Others)
The child is currently receiving physical therapy sessions daily and face-to-face sessions every Thursday
and Friday from 9:00-10:00 AM at FUNdamentals Pediatric Therapy Center in Axis Entertainment
Avenue, Escario St., Cebu City. He has had physical therapy sessions since he was 2 years old. After a year
of sessions, he is able to shift into a prone position independently. He is also able to creep and cruise.
According to the mother, the physical therapist massages the child’s legs.

Context and Environment

CONTEXT
Personal: S.R. is a 3-year-old boy whose family belongs to the middle socioeconomic class. He is the
youngest of the two siblings. He is currently not attending school now due to limitations in movement,
developmental delays, and diagnosed with cerebral palsy. He loves to play with Lego blocks, balls, and
loves listening to nursery rhymes.

Temporal: S.R. is aged 3 years and 11 months and is expected to turn 4 years old this September 8, which
makes the child in his early childhood. At this stage, the child is learning many things in his environment
necessary for growth and development. It is important that the child has a supportive learning
environment to cater to his needs. The child has physical therapy face-to-face sessions every Friday from
9:00-10:00 AM and occupational therapy sessions on Mondays, 10:00-11:00 AM. He has co-treatment
sessions with his OT and PT during Thursdays from 9:00-10:00 AM.

Cultural: The child belongs to a very supportive family, and they value the child despite his condition.
During the session, the mother stated that she was very supportive no matter what for her child and it
was shown that other members of the family were very cooperative when given interventions and made
sure to help the child.

12
Virtual: The child has access to an iPad which is placed at least 2 feet away from the child. The mother
plays nursery rhymes during playtime. His mother stated that the child has an average of 1 hour of
screen time every day with pre-selected videos.
ENVIRONMENT
PHYSICAL ENVIRONMENT
Home: The child currently resides in Lahug Cebu City with his parents and older brother in a one storey
house. Inside the child’s bedroom, it consists of a cemented floor with a flat surface to decrease the risk
of injury. There was also a padded mat on the floor to which there are no instances that the child would
fall as he has difficulty ambulating and still requires the assistance of his mother. In the child’s kitchen,
there is also no chair that would stabilize the child when sitting, instead, a monoblock chair is used.
Inside the kitchen where the child eats, there is a television situated about 10 meters away from the
dining table. When feeding, the child uses a standard small metal spoon instead of a silicone spoon.

School: The child is not enrolled in any educational program.

Community: The mother stated that their house is located near their barangay and that they would need
to commute to go to other places, especially when accompanying the child for check-ups at the hospital.

Transportation: The mother stated that they usually ride a taxi in going to his physical therapy sessions
at FUNdamentals Pediatric Therapy Center.

Play Area Details: The child has a room that he stays in that consists of a standard 54” x 75” double bed,
small table, and toys such as Lego blocks which are placed around the area for the child to play with.

SOCIAL ENVIRONMENT
Play: The child plays with his mom and other kids at home such as his older brother and cousins, he also
gets to play with his dad during weekends and during days off. He also has toys available at home such as
Legos, toy animals, small cars, and balls. The child shows interest in toys that produce sound which was
noted to elevate his mood. The child was observed to enjoy listening to his mother singing nursery
rhymes whenever they play.
Family Background: The child lives together with his parents and brother. The mother expressed how
very supportive she was of her child wherein she decided to take a leave from work in order to give
full-time care and assistance. The child’s mother is also very compliant with the different management
given to address the difficulties of her son. The child also has a brother who he usually plays with and
some of his cousins at home.

Primary Caregiver: The parents of the child are the primary caregivers.

Home: At home, the child usually interacts more with his mother and his older brother as his father is
currently working. In addition, there are other kids interacting with the child at home such as his cousins
and his older brother. His mother is the one taking care of and communicating with the child at home.
His mother is also currently on leave from her work, so she is always present at home.

School: The child is not enrolled in any educational program.

Performance Patterns
Habits: The child has a habit of putting objects in his mouth.

Routines: The child starts his day by waking up at 5:00 or 6:00 in the morning. Once breakfast is set at
7:00 am, the mother would assist the child during feeding since he has difficulty with postural balance
and in controlling the utensils. After having his breakfast, the child is then assisted by his mother in
taking a bath.

On Fridays, the child is scheduled to have his daily physical therapy sessions for 30 minutes to help with
his mobility problems.

13
On Mondays, the child also has his occupational therapy sessions scheduled from 10:00-11:00 am. If the
child doesn’t have any sessions in the morning, he will sleep until 12:00 pm.

On Thursdays. the child has co-treatment sessions with his OT and PT for about an hour from 9:00-10:00
AM.

He would then have his lunch afterward, still with his mother’s assistance. At 2:00 or 3:00 pm, the child
would have his PT sessions again. Sometimes, the mother would engage the child in physical activity at
home to make up for the time when the child doesn’t have PT sessions in the afternoon. The child would
then have his dinner at 5:00 or 6:00 pm and sleep at around 8:00 or 9:00 pm.

Rituals: The child is born from a family of protestants. They go to church every Sunday and attend mass
during mornings. They celebrate important events such as christmas, new year, and birthdays with the
family.

A. Occupational Profile and Occupational Performance

Analysis of Occupational Performance

Occupations

LEVEL OF INDEPENDENCE IN OCCUPATIONS (FIMS-BASED EVALUATION)

LEVEL OF PERFORMANCE SKILLS CLIENT FACTORS AFFECTED
INDEPENDENCE IN
OCCUPATIONS
Maximal Dependence The child is able to shift to prone The child has problems in
in Functional Mobility independently. He is able to creep and neuromusculoskeletal &
cruise independently. movement-related functions
specifically, limitations in ROM &
The child exhibits limited range of motion MMT, spastic muscle tone, absent
in both of his lower extremities. balance reactions, impaired gross
Assistance is given by the child’s mother motor skills, disturbance in gait
hoisting him under his axilla when patterns, and coordination.
walking & giving him back support with
her forearm around the child’s chest
when sitting.

The child is able to move through the

clinic through crawling but requires
maximal assistance by the therapist to do
different positions such as sitting,
standing or walking since he has
problems stabilizing and aligning his body
as he would lose balance and would
often prop himself against task objects
(e.g. walls of the ball pit) to support
himself. He also has difficulty
coordinating, moving, calibrating his legs
when standing or walking due to
spasticity in the lower extremities. The
child also has problems in enduring
upright position as he is observed to
experience fatigue.

14
Moderate Dependence The child is able to reach the spoon and The child has problems with
in Self-feeding bring it to his mouth. He is also able to neuromusculoskeletal and
release the spoon from his hand. movement-related functions
However, the child has difficulty in specifically, muscle strength,
picking up the right amount of food from muscle tone, balance reactions,
the plate resulting in moderate spillages. coordination, and reflexes. The
child also has problems with
He is able to continue, and endure during movement functions specifically,
a feeding activity. However, the child has control of voluntary reactions.
difficulty in stabilizing, aligning, and Lastly, the child has problems with
positioning his body in an upright specific mental functions
position during feeding. specifically, attention and sensory
functions specifically,
He also has difficulty during paces and proprioception vestibular, and
flows during the duration of the activity, oral-seeking behavior.
in attends as he loses attention when he
hears external sounds during feeding,
and in uses, chooses, and terminates
when selecting food or items to place in
his mouth.
Total Dependence in The child has difficulty in coordinating his The child has problems with
Play Participation movements as evidenced by being unable neuromusculoskeletal and
to smoothly control his arms on his own movement-related functions
in stacking the blocks as well as being specifically, muscle strength,
unable to imitate the therapist when she muscle tone, balance reactions,
started to build a tower out of Lego coordination, and reflexes. The
blocks. Instead, the child grabbed a Lego child also has problems with
block and placed it inside his mouth. He movement functions specifically,
was also unable to ask the therapist for control of voluntary reactions.
the Lego block using language or Lastly, the child has problems with
gestures. awareness/orientation, specific
mental functions in attention
Throughout the table-top activities, it functions, specifically in
was also noted that the child has sustaining, shifting, distractibility,
problems in stabilizing, aligning, and and concentration; impulse
positioning his body in an upright control; and sensory functions
position without the therapist’s specifically, proprioception,
assistance. He constantly leans towards vestibular, and oral-seeking
the therapist. The child is also unable to behavior.
stand and walk around the room to
retrieve toys independently due to
problems with his muscle functions and
difficulty with balance.

LEVEL OF INDEPENDENCE
DEFINITION
BASED ON FIMS
Complete independence Fully independent (timely and safely)
Modified independence Requiring the use of a device but no physical help, performs safely but needing more time
Supervision Requiring only standby assistance or verbal prompting or help with set-up
Minimal dependence Requiring incidental hands-on help only (subject performs > 75% of the task)
Moderate dependence Subject still performs 50–75% of the task
Maximal dependence Subject provides less than half of the effort (25–49%)
Total dependence Subject contributes < 25% of the effort or is unable to do the task
N/A (Not Applicable) When an occupation does not apply to the client

15
 Client Factors

MENTAL FUNCTIONS
PIAGET’S STAGE OF COGNITIVE DEVELOPMENT
The child’s developmental age is currently at Piaget’s sensorimotor stage wherein there is coordination
of sense with motor responses and sensory curiosity about his surroundings. In this stage, language is
used for demands and cataloging and object permanence is developed.

Upon observation, the child was noted to be non-verbal and demonstrates non-verbal gestures such as
moving his head away or crying when he does not like the activity given. The child’s object permanence
is also developing as he becomes upset whenever the Lego blocks are being taken away from him. It was
also noted that when the child grabs ahold of an object, he brings it to his mouth to feed his senses.
Upon these observations, his chronological age does not seemingly match and fit with his developmental
age which is preoperational stage.
CONSCIOUSNESS
During the session, the child was observed to be conscious and awake throughout the session as
evidenced by actively participating in the different activities and engaging in free play during breaks.
AWARENESS/ORIENTATION
During the therapy session, the child was observed to have impaired awareness and orientation as he
would stare blankly at the therapist when presented with toys. When given the Lego blocks, the child
brought it towards his mouth. The child does not turn his head when his name is called.
CONCEPTS
Colors: AGE-INAPPROPRIATE. During the stacking of Legos activity, the child wasn’t able to point to the
red Lego block when asked by the therapists.
Shapes: AGE-INAPPROPRIATE. The child is unable to match the shape of the circle plate with the picture
of the circle.
Body Parts: AGE-INAPPROPRIATE. When the therapist and his mother sang and acted the nursery rhyme
“My toes, my knees, my shoulders, my head” the child could move the body parts being asked.
Quantitative: AGE-INAPPROPRIATE. The child is unable to nod his head when asked if the carrot has
been fully painted or not during the carrot painting activity.
Positional/Directional: AGE-INAPPROPRIATE. When the paintbrush was placed in front of the child and
was asked to look at it, he was unable to do so.
Letters: N/A. Not applicable for the child’s age.
Numbers: AGE-INAPPROPRIATE. The child wasn’t able to count the number of blocks along with the
therapist's cues during the Legos stacking activity.
Temporal: AGE-APPROPRIATE. The child doesn’t show any problems when waking up on time to get
ready for the day.
TEMPERAMENT
Slow-to-warm-up child. The child’s activity level was observed to be moderate. The child was uneasy
during the Lego stacking activity. The child’s rhythmicity is regular as he is able to follow a routine at
home. The child showed to be open to the therapist as he smiled when she sang him songs. At the start
of the session, he was pleasant as he smiled at his mother and the therapist as the therapist applied
deep pressure massage and sang him nursery rhymes. However, the child showed an unpleasant mood
by crying in the next activity which was sitting control exercises, wherein his extremities are moved in
different positions. The child showed slow adaptability as the therapists introduced new activities. The
child showed high distractibility as he is easily sidetracked when hearing songs being played or of the
other kids moving around the center. His attention span and persistence are low as he appeared to be
looking around the room while doing the painting activity.
GLOBAL AND SPECIFIC MENTAL FUNCTIONS
ATTENTION FUNCTIONS
Selecting: ABLE. The child was able to pay attention to his mother every time he hears her singing some
nursery rhymes, disregarding other people who was also in the room.
Sustaining: ABLE WITH DIFFICULTY. When given an activity by the therapists, the child was unable to
sustain his attention to the activity as evidenced by showing signs of discomfort and distractibility with
sounds. He is only able to sustain his attention for 1-2 minutes when doing activities. Maximal physical

16
and verbal prompts were given including hand-over-hand assistance by his mother to complete the
activity.
Shifting: UNABLE. While playing with his Legos, the therapists called his attention, and the child was not
able to answer as he was only focused on mouthing the toy.
Dividing: ABLE. The child was able to jam along to his mother’s singing while engaging in the deep
pressure massage activity.
Sharing: ABLE. The child was able to share his focus on the Lego stacking activity with his mother as
observed by when his mother guided him in stacking the blocks and how he went along with doing it.
Distractibility: ABLE WITH DIFFICULTY. The child was able to listen and cooperate 70% of the time during
activities. However, he gets easily distracted whenever he hears music or sees other children playing,
resulting in not following the tasks given to him.
Concentration: ABLE WITH DIFFICULTY. The child was able to start but not finish the carrot painting
activity. As observed, after a couple of seconds, he is distracted as seen when he looks at different places
in the room and how he shows some discomfort as evidenced by crying.
Impulse Control: UNABLE. The child was unable to control himself from bringing objects towards his
mouth every time he held an object despite being told by the therapist not to bite or mouth the objects.
MEMORY
Visual: INTACT. The child was also able to successfully interact with the objects used in the different
activities and was also able to see his preferred toys as evidenced by him often reaching for them during
activities.
Auditory: INTACT. During the painting activity, a nursery rhyme was played by a phone next to the
painting. The child immediately stopped crying and was focused on the song instead.
Kinesthetic: IMPAIRED. The child wasn’t able to touch the body parts during the nursery rhyme “My
Toes, My Knees”. When the therapist clapped her hands and asked the child to do the same, he was
unable to do so.
Short-term: INTACT. The child was able to grab his cup that he left in the small room after the session.
Long-term: INTACT. When the child hears his mother singing his favorite nursery rhyme, he is able to
recall the sound of the song and smile.
EMOTIONAL REGULATION
Throughout the session, the child showed signs of frustration such as crying. Although there are times
where he would pleasantly smile at the therapist and his mother, especially when the mother actively
sang nursery rhymes in an attempt to soothe him, he was able to stop himself from crying and was able
to get back to the activity.
HIGHER LEVEL COGNITIVE FUNCTIONS (N/A for 6 years and below)
Problem Solving: N/A
Concept Formation: N/A
Time Management: N/A
Judgment: N/A
Cognitive Flexibility: N/A
Praxis: N/A
COMMUNICATIONS
Reception: ABLE. The child was able to smile and laugh when being sung to by his mother.
Expression: ABLE WITH DIFFICULTY. The child isn’t able to verbally communicate but he was able to cry
to express his irritability in response when he was given a cracker.
Comprehension: UNABLE. The child was unable to follow the instructions of the therapist after multiple
repetitions and required maximal physical and verbal prompts including hand-over-hand prompts to
finish the activity.
Speech Level: ABLE WITH DIFFICULTY. The child was unable to answer yes/no or simple phrases to the
therapist as to whether he already ate or not. However, he would exclaim “wah” and “wiee” if he is
excited and/or happy.
CALCULATIVE ABILITIES
UNABLE. When the therapist asked the child to count along with her while piling the Lego blocks during
the block stacking activity, the child couldn’t count the number of blocks.
SENSORY FUNCTIONS
VISUAL: INTACT. Using the spoon, the child was able to scoop the food from the plate which was right in
front of him and placed it into his mouth during the feeding simulation.
AUDITORY: INTACT. The child was able to listen and respond accordingly to his mother’s singing as
observed by when he would express laughter after hearing the sound.

17
TACTILE: INTACT. The child was able to touch the Lego blocks inside the macaroni sensory bin during the
block stacking activity without displaying any unusual behavior.
PROPRIOCEPTIVE: IMPAIRED. The child is able to only creep and cruise at his age. He was also able to use
the spoon to scoop the food from the plate and feed himself without directly looking at his hand;
however, this wasn’t observed all the time due to problems with coordination.
VESTIBULAR: IMPAIRED. The child isn’t able to stand, maintain balance, and ambulate independently
when asked to get the toy 1 meter away from him as he exhibits problems with controlling his legs which
will result in him losing his balance if left unassisted.
SENSORY INTEGRATION
During the activities done, the child displays presence of sensory seeking behaviors as he tends to place
objects inside of his mouth and is not aware if it is edible or not. The child would turn his head to the
sound of the therapist singing; he would then smile and laugh. He was also noted to like the sound of the
maracas and loud voices. The child would also cry during stretching exercises such as passive ROM, but
when provided with hand-over-hand assistance, we would not mind nor push the therapist away.

Section Score Interpretation

Tactile Sensitivity 30/35 Typical Performance
Taste/Smell Sensitivity 20/25 Typical Performance
Movement Sensitivity 10/15 Probable Difference
Under Responsive/Seeks Sensation 24/35 Probable Difference
Auditory Filtering 23/30 Typical Performance
Low Energy/Weak 11/30 Definite Difference
Visual/Auditory Sensitivity 21/25 Typical Performance
TOTAL 139/195 Probable Difference

In the Sensory Profile, the mother indicated that the child frequently had trouble standing in line or
standing close to people. The child does not show any taste/smell sensitivity. For movement, it was
indicated that the child occasionally showed distress when his feet left the ground and when there were
activities where his head was upside down. This behavior can also be seen as the child often cries during
his exercises. The Sensory Profile also indicated that the child is sensory seeking as he frequently enjoys
strange noises, seeks all kinds of movements, and touches people and objects. He also frequently leaves
his clothing twisted. The child also frequently appears to not hear what the therapist says and has
difficulty paying attention. This behavior can be seen as the child’s gaze flicks towards the object in front
of him and then around the room.

The mother indicated that the child always props himself for support. Additionally, he frequently seems
to have weak muscles, tires easily, weak grasp, can’t lift heavy objects, and tires easily. Lastly, the child is
frequently bothered by bright lights and watches everyone when they move around the room.
=
NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS
JOINT MOBILITY FUNCTIONS
□ All joints of all extremities are within functional limits.
✔ All joints of both UE are within functional limits EXCEPT (specify laterality, movement, and
cause of LOM per joint)
✔ All joints of both LE are within functional limits EXCEPT (specify laterality, movement, and
cause of LOM per joint)

AROM PROM CAUSE OF LIMITATION

OF MOTION
RANGE OF LEFT RIGHT LEFT RIGHT
MOTION
Shoulder Flexors 0-83 0-83 WFL WFL due to no limb isolation

18
 Shoulder Extensors 0-39 0-39 WFL WFL due to no limb isolation
Shoulder 0-79 0-79 WFL WFL due to no limb isolation
Abductors
Shoulder Internal 0-69 0-69 WFL WFL due to no limb isolation
Rotators
Shoulder External 0-89 0-89 WFL WFL due to no limb isolation
Rotators
Elbow Flexors 0-79 0-79 WFL WFL due to no limb isolation
Elbow Extensors 0-39 0-39 WFL WFL due to no limb isolation
Cervical Flexion 0-44 WNL due to muscle weakness
Cervical Extension 0-44 WNL due to muscle weakness
Cervical Lateral 0-44 0-44 WNL WNL due to muscle weakness
Flexion
Cervical Rotation 0-59 0-59 WNL WNL due to muscle weakness
Thoraco-Lumbar 9 cm WNL due to muscle weakness
Flexion
Thoraco-Lumbar 5 cm WNL due to muscle weakness
Extension
Thoraco-Lumbar 0-44 0-44 WNL WNL due to muscle weakness
Rotation
Hip Flexors 0-108 0-108 WNL WNL due to spasticity
Hip Extensors 0-16 0-16 WNL WNL due to spasticity
Hip Abductors 0-25 0-25 WNL WNL due to spasticity
Hip Adductors 0-18 0-18 WNL WNL due to spasticity
Hip Internal 0-25 0-25 WNL WNL due to spasticity
Rotators
Hip External 0-26 0-26 WNL WNL due to spasticity
Rotators
Knee Flexors 0-120 0-120 WNL WNL due to spasticity
Knee Extensors 125-0 125-0 WNL WNL due to spasticity
Ankle Dorsiflexors 0-3 0-3 WNL WNL due to spasticity
Ankle Plantar 0-43 0-43 WNL WNL due to spasticity
Flexors
Ankle Evertors 0-3 0-3 WNL WNL due to spasticity
Ankle Invertors 0-6 0-6 WNL WNL due to spasticity
Toe Flexors 0-23 0-23 WNL WNL due to spasticity
Toe Extensors 0-38 0-38 WNL WNL due to spasticity
JOINT STABILITY FUNCTIONS
(-) Joint dislocation: No pertinent findings.
(-) Shoulder subluxation: No pertinent findings.

MUSCLE POWER
□ All major muscle groups of both upper and lower extremities are grossly graded 5.
✔ All major muscle groups of both UE are grossly graded 5 EXCEPT (specify grade and laterality per
muscle group)
□ All major muscle groups of both LE are grossly graded 5 EXCEPT (specify grade and laterality per
muscle group)
□ Cannot be reliably assessed secondary to (indicate cause)
Laterality & Muscle Group Grading
Left and Right Shoulder Flexors Grade 3+
Left and Right Shoulder Extensors Grade 3+
Left and Right Shoulder Abductors Grade 3+
Left and Right Shoulder Internal Rotators Grade 3+
Left and Right Shoulder External Rotators Grade 3+

19
 Left and Right Elbow Extensors Grade 4

Legend:
Zero (0) – No muscle contraction can be seen or felt
Trace (1) – Contraction can be observed or felt, but no movement
Poor minus (2- ) – Part moves through incomplete ROM with gravity minimized
Poor (2) – Part moves through complete ROM with gravity minimized
Poor plus (2+) – Part moves less than 50% of available ROM against gravity/ through complete ROM with gravity minimized against slight
resistance
Fair minus (3- ) – Part moves through more than 50% of available ROM against gravity
Fair (3) – Part moves through complete ROM against gravity
Fair plus (3+) – Part moves through complete ROM against gravity and slight resistance
Good minus (4-) - Part moves through complete ROM against gravity and slight moderate resistance
Good (4) – Part moves through complete ROM against gravity and moderate resistance
Normal (5) – Part moves through complete ROM against gravity and maximal resistance

MUSCLE TONE
□ Normotonic

□ Flaccid

□ Fluctuations
✔ Spastic:

Laterality & Muscle Group Grading

Left and Right Hip Abductors Grade 2
Left and Right Hip Adductors Grade 2
Left and Right Hip Flexors Grade 2
Left and Right Extensors Grade 2
Left and Right Hip Internal Rotators Grade 2
Left and Right Hip External Rotators Grade 2
Left and Right Knee Flexors Grade 2
Left and Right Knee Extensors Grade 2
Left and Right Ankle Dorsiflexors Grade 2
Left and Right Ankle Plantar Flexors Grade 2
Left and Right Evertors Grade 2
Left and Right Invertors Grade 2
Left and Right Toe Flexors Grade 2
Left and Right Toe Extensors Grade 2

Legend:
Grade 0 – No increase in muscle tone
Grade 1 – Slight increase in tone, manifested by catch and release or minimal resistance
Grade 1+ - Slight increase in tone, manifested by catch, followed by minimal resistance in the remaining ROM
Grade 2 – More marked increase in tone through most of the ROM but affected parts easily moved
Grade 3 – Considerable increase in tone, passive movement difficult
Grade 4 – Affected part rigid in flexion and extension

REFLEXES
Primitive Reflexes (MASSPEN, identify if integrated or present)
✔ All developmental reflexes are well integrated
□ Primitive Reflexes: No pertinent findings

Balance Reactions
(-) Righting: The child was unable to maintain an upright head position as observed during a tabletop
activity. It was observed that the child would lean his neck or body forward and sideward. In the
vestibular ball exercise, it was observed that when the therapist pushed the ball side to side, the child
was unable to keep his head upright and go to the same side of the ball.
(+) Protective: The child was able to use his arms when he fell while he was crawling as well as when he
was trying to stand up in the ball pit.
(-) Equilibrium: The child has difficulty balancing on his own as seen when trying to stand on his own.
When he was asked to stand up on the mat without assistance, he fell down.

20
CONTROL OF VOLUNTARY REACTIONS
Gross Motor Control
Standing: AGE-INAPPROPRIATE. When assisted in standing, the child was unable to keep an upright
position and his upper body kept leaning forward and had to be corrected. The child’s lower extremities
are also spastic and was unable to widen his base of support which made standing difficult. The child
also needed to grab/hold onto the therapist from a sit-to-stand position.

Walking: AGE-INAPPROPRIATE. The child was unable to independently keep his balance when standing
and needed maximal assistance which made walking difficult for the child. He was unable to put one foot
in front of the other and the therapist would carry him to move from one place to another. However,
when given assistance by the therapist, the child exhibited scissoring gait.

Stair Climbing: AGE-INAPPROPRIATE. The child is unable to climb stairs as observed by difficulties in
standing and walking. During the chair climbing activity, the therapist was behind the child, holding her
trunk in order to keep him upright.

Running: AGE-INAPPROPRIATE. The child was instructed to run as far as he could, however, due to
difficulty in balance, standing, and walking, he required maximal assistance from the therapist and was
unable to run independently.

Jumping: AGE-INAPPROPRIATE. It was observed that the child finds it difficult as he is still unable to
properly stand and keep his balance when he tries to do so. When the therapist instructed the child to
jump, he was unable to do so.

Jumping Over: AGE-INAPPROPRIATE. It was observed that the child finds it difficult as he is still unable to
properly stand and keep his balance when he tries to do so. When the therapist instructed the child to
jump over, he was unable to do so.

Hopping: AGE-INAPPROPRIATE. It was observed that the child finds it difficult as he is still unable to
properly stand and keep his balance when he tries to do so. When the therapist instructed the child to
hop, he was unable to do so.

Kicking: AGE-INAPPROPRIATE. The therapist held him up during the kick the ball activity. When the
therapist instructed the child to kick the ball in front of him, he was unable to do so.

Balance Beam: AGE-INAPPROPRIATE. The child isn’t able to balance himself since he couldn’t control his
legs and maintain an upright position as observed when the therapist held him in an upright position.

Catching: AGE-INAPPROPRIATE. During the catch the ball activity, the therapist threw a ball to the child
and he was unable to catch it given moderate to maximal physical prompts. The therapist then
demonstrated how to catch the ball through play with the other therapist, for the child to imitate the
motion, however was still not able to do so.

Throwing: AGE-INAPPROPRIATE. During the throwing ball activity, the child was observed to be unable
to throw the ball to the appropriate basket and was unable to throw a big red vestibular ball during free
play despite demonstrations from the therapist. He was also observed to hold the ball throughout an
extended duration.

Fine Motor Control

Handedness (PDH, 247): Throughout the session, the child was observed to frequently use his right hand
such as in picking or grasping objects or toys. Upon painting activity, the child was observed to utilize the
right hand to pick, grip, and paint using the paint brush, however did not use the left hand to stabilize
the paper. Thus, the child exhibits right-hand preference.
Pattern of Grasp:
● Spherical Grip: The child was able to get each ball inside the basket using a spherical grasp.
Spherical grasp was also noted when the child was engaging in free play.
● Lumbrical Grip: The child was observed to use a lumbrical grasp as evidenced when he held the
book from the cabinet shelf and placed it on the floor using his thumb and four fingers.

21
 ● Palmar Supinate Grasp: The child was observed to use this grasp as he was holding the marker to
make scribbles and pushing the marker on the paper to create circle marks. In addition, he was
also able to use this grasp as he was given with the large tongs during the sensory bin activity.
● Digital Pronate Grasp: The child was observed to use the digital pronate grasp as evidenced by
scribbling on a page from the coloring book.
● Static Tripod Grasp: Given with a small crayon, the child was able to use a static tripod grasp as
he was trying to make scribbles on the paper.
● Pincer Grasp: During the stacking Lego block activity, the child was noticed to grasp the lego
block using a pincer grasp as he was trying to pick up the lego blocks from the table.

Prehensile Patterns:
(+) Dexterity: The child was able to manipulate and release objects such as legos and foam blocks during
free play. In addition, he was also able to use and manipulate the crayon and marker to make random
scribbles during the tracing activity.
(+) In-Hand Manipulation:
● (+) Translation: During the painting activity, the child was able to move the paintbrush from his
palm to his fingertips when the therapist placed the paintbrush on his palm.
● (+) Shifting: The child is able to adjust the paintbrush between his fingers. He was also able to
move his fingers down the marker as he was making scribbles.
● (+) Rotation: The child was able to turn the paintbrush as he started to paint on the carrot.
During the “Match the two-piece puzzle activity”, he was also able to do a simple rotation of the
circular tip of the puzzle using his thumb and finger.
(-) Eye-Hand Coordination: The child was able to scoop food and place the spoon into his mouth but has
problems with picking up the right amount of food from the plate which results in spillages.
(-) Eye-Foot Coordination: The child exhibits difficulty in maintaining balance, specifically in standing
independently to which it affects the child’s ability to walk independently or move on one foot alone
when asked to walk towards the table and needs the assistance of the therapist. Due to spasticity in the
lower extremity, this cannot be reliably assessed.
(-) Bilateral Coordination: In the coloring activity, the child was unable to stabilize the paper using his left
hand while using the colored pencil to scribble on his right hand given maximal assistance from the
therapist.
(+) Crossing the Midline: During the lego block stacking activity, the child was able to get the lego blocks
on the left side of the table using his right hand.
GAIT PATTERNS
(+) Gait disturbance: The child showed scissoring of the lower extremities and plantar flexion of the
ankles as he and the therapist walked towards the table.
OTHER PERTINENT FINDINGS (Specify for CP and Down Syndrome)
Muscle Bulk: □ Atrophy □ Hypertrophy (No pertinent findings)
Body Functions: No pertinent findings.
Body Structures:
(-) Edema: No pertinent findings.
(-) Inflammation: No pertinent findings.
(-) Facial asymmetry: No pertinent findings.
(-) Assistive device: No pertinent findings.
(-) Adaptive device: No pertinent findings.
(-) Drooling: No pertinent findings.
(+) Strabismus: Exotropia of the left eye.

22
B. Strengths and Limitations

I.

STRENGTHS LIMITATIONS
Context and Environment: Analysis of Occupational Performance:
● The child’s family belongs to the ● Maximal Dependence in Functional
middle socioeconomic class. The Mobility
parents are very supportive and ● Moderate Dependence in Self-feeding
appear to show great concern for ● Moderate Dependence in Play
the condition of their child. They Participation
are very cooperative as well during Concepts:
treatment sessions and made sure ● Colors: Age-inappropriate
to help the child with the tasks ● Shapes: Age-inappropriate
during activities. ● Body Parts: Age-inappropriate
Concepts: ● Quantitative: Age-inappropriate
● Temporal: Age-appropriate ● Positional/Directional:
Global and Specific Mental functions: Age-inappropriate
● Selecting: Able ● Numbers: Age-inappropriate
● Dividing: Able Global and Specific Mental Functions:
● Sharing: Able ● Sustaining: Able with difficulty
Memory: ● Shifting: Unable
● Visual: Intact ● Distractibility: Able with difficulty
● Auditory: Intact ● Concentration: Able with difficulty
● Long-term: Intact ● Impulse Control: Unable
● Short-term: Intact Memory:
Communication: ● Kinesthetic: Impaired
● Reception: Able (-) Emotional Regulation
Sensory Functions: Communication:
● Visual: Intact ● Expression: Able with difficulty
● Auditory: Intact ● Comprehension: Unable
● Tactile: Intact ● Speech Level: Able with difficulty
Reflexes Calculative Abilities: Unable
● Protective Sensory Functions:
Control of Voluntary Reactions ● Proprioceptive: Impaired
1. (+) Fine Motor Control: ● Vestibular: Impaired
● Pattern of Grasp Sensory Integration:
● Dexterity ● Sensory Seeking Behavior
● In-Hand Manipulation Neuromusculoskeletal and
● Crossing the midline Movement-Related Functions
Joint Mobility Functions: Due to no limb
isolation and spasticity
● SH flexors
● SH extensors
● SH abductors
● SH internal rotators
● SH external rotators
● Elbow flexors
● Elbow extensors
● Cervical flexion
● Cervical extension
● Cervical lateral flexion
● Cervical rotation
● Thoraco-lumbar flexion
● Thoraco-lumbar extension
● Thoraco-lumbar rotation
● Hip flexors
● Hip extensors

23
 ● Hip abductors
● Hip adductors
● Hip internal rotators
● Hip external rotators
● Knee flexors
● Knee extensors
● Ankle dorsiflexors
● Ankle plantar flexors
● Ankle evertors
● Ankle inverters
● Toe flexors
● Toe extensors
Muscle Power:
● Left and Right Shoulder Flexors (3+)
● Left and Right Shoulder Extensors
(3+)
● Left and Right Shoulder Abductors
(3+)
● Left and Right Shoulder Internal
Rotators (3+)
● Left and Right Shoulder External
Rotators (3+)
● Left and Right Elbow Extensors (4)
Muscle Tone: Spastic
Balance Reactions:
● (-) Righting
● (-) Equilibrium
Control of Voluntary Reactions:
1. Gross Motor Control:
● Standing: Age-inappropriate
● Walking: Age-inappropriate
● Stair Climbing: Age-inappropriate
● Running: Age-inappropriate
● Jumping: Age-inappropriate
● Jumping Over: Age-inappropriate
● Hopping: Age-inappropriate
● Kicking: Age-inappropriate
● Balance Beam: Age-inappropriate
● Catching: Age-inappropriate
● Throwing: Age-inappropriate
2. Fine Motor Control:
● (-) Eye-hand Coordination
● (-) Eye-Foot Coordination
● (-) Bilateral Coordination
Gait Patterns:
● (+) Gait disturbance
Other Pertinent Findings: Strabismus;
Extropia on the child’s left eye

C. OT Diagnosis

The child has maximal difficulty in functional mobility due to problems in neuromusculoskeletal
and movement-related functions specifically, limitations in ROM and MMT, spastic muscle tone,
absent balance reactions, impaired gross motor skills, coordination, and a disturbance in gait
patterns as evidenced by exhibiting minimal head control and head lag, requiring maximal
assistance from his mother when in sitting position and maintaining posture, lose his balance
and lean to either side as well as propping himself towards the therapist to stabilize himself.

24
 The child has moderate difficulty in self-feeding due to problems in neuromusculoskeletal and
movement-related functions specifically, muscle strength, muscle tone, balance reactions, and
reflexes. The child also has problems with movement functions specifically, control of voluntary
reactions. Lastly, the child has problems with specific mental functions specifically, attention and
sensory functions specifically, proprioception vestibular, and oral-seeking behavior as evidenced
by mouthing and putting objects inside his mouth.

The child has difficulty in play participation due to problems in neuromusculoskeletal and
movement-related functions specifically, muscle strength, muscle tone, balance reactions,
reflexes, control of voluntary reactions, specific mental functions in sustaining and shifting
attentions, distractibility, concentration, impulse control, proprioceptive and vestibular sensory
functions as evidenced by being unable to smoothly control his arms when stacking the blocks
on his own, imitate the therapist in building a tower out of lego blocks, and use language or
gestures in asking the therapist for the lego blocks.

All are caused by Cerebral Palsy of the Spastic Diplegia Type.

D. Classical Picture versus Clinical Picture

Classical Picture Clinical Picture

Etiology
Cerebral Palsy can either be congenital CP (+) The child’s cerebral palsy is
or acquired CP. The majority of cases in congenital due to premature birth born at
terms of infants do not have an identifiable the 30th week of pregnancy.
etiology. Factors that may contribute to
brain injury and CP include prematurity,
infection, inflammation, and coagulopathy.

Congenital CP is attributable to congenital

infections such as rubella, herpes,
cytomegalovirus, herpes, etc. It can also be
due to genetics, placental insufficiency, and
hypoxia. Acquired CP, on the other hand, is
usually associated with an infection, such
as bacterial meningitis, stroke, or head
trauma.

Diagnostic Criteria
Symptoms are usually recognized when the
child is missing some developmental
milestones. For Spastic Cerebral Palsy, the
child would first tend to exhibit some jerky
reflexes or involuntary limb movements.
(+) The child was first diagnosed with
Global Developmental Delay (GDD) at 8
months old following a checkup from his
pediatric neurologist. At this time, it was
observed that the child was unable to
perform skills that are supposed to be
seen in his age, such as being able to
keep his head upright and independently
crawl. He was later referred to PT to
address his motor deficits. It was only at
3 years old when he was given the
diagnosis of Cerebral Palsy, Spastic
Diplegia Type where he was
subsequently brought to OT to address
his missing developmental milestones.

Symptoms of Spastic Cerebral Palsy may

also include:
● Involuntary limb movements

25
 ● Continuous muscle spasms and (+) The child exhibits scissoring gait.
contractions
● Abnormal walking, marked by
knees crossing in a scissor-like (+) The child exhibits poor coordination
movement and control of muscle movements due to
● Joint contractures spasticity and muscle weakness.
● Limited stretching abilities
● Flexion at the elbows, wrists, and
fingers
● Poor coordination and control of
muscle movements

The following nervous system-related

symptoms may also be present: (+)The child has speech difficulties and
● Speech difficulties cannot respond with yes/no or simple
● Hearing problems phrases when asked by the therapist. He
● Vision abnormalities also has problems in cognitive and
● Cognitive, learning, and behavioral learning functions.
disabilities
● Seizures

Lastly, related problems may include:

● Drooling
● Difficulties with chewing and (-) There are no other related problems
swallowing present within the child.
● Hoarse voice or speech problems
● Breathing irregularities
● Failure to thrive or poor weight
gain
● Gastric reflux
● Constipation and bladder
incontinence
● Spinal and joint deformities

E. Potential for Participation in Occupation

The child has high potential in improving his muscle power, muscle tone, gait pattern, balance
reactions, vestibular and proprioception sensory functions, and control of voluntary reactions,
which are necessary for improving performance in functional mobility.

The child has high potential in improving his muscle power, muscle tone, balance reactions,
reflexes, vestibular and proprioception sensory functions, control of voluntary reactions and
attention, which are necessary for improving performance in self-feeding.

The child has high potential in improving his muscle power, muscle tone, balance reactions,
reflexes, vestibular and proprioception sensory functions, control of voluntary reactions,
attention functions specifically in sustaining, shifting, distractibility, and concentration, and
impulse control, which are necessary for improving performance in play participation.

III. INTERVENTION PLANNING

A. Problem List Prioritization

1. Child needs maximal assistance in functional mobility secondary to problems in muscle

power, muscle tone, gait pattern, balance reactions, vestibular and proprioception
sensory functions, and control of voluntary reactions.

26
 2. Child needs moderate assistance in self-feeding secondary to problems in muscle power,
muscle tone, balance reactions, reflexes, vestibular and proprioception sensory
functions, control of voluntary reactions and attention.
3. Child needs total assistance in play participation secondary to problems in muscle
power, muscle tone, balance reactions, reflexes, attention functions specifically in
sustaining, shifting, distractibility, and concentration, vestibular and proprioception
sensory functions, control of voluntary reactions, impulse control, concepts, and
memory.

B. Targeted Outcomes
Occupational Performance
● To improve the child’s skills necessary in performing activities of daily living particularly
in functional mobility and feeding, such that he will be able to move around the house
safely and easily without showing signs of losing balance and effectively transport
objects to the desired location and properly utilize feeding utensils and control his
movement as he brings food to his mouth.
● To improve the child’s skills necessary in play participation, such that he will be able to
move around the play area safely, effectively manipulate toys and other objects that will
be used in the activity, and initiate play with his siblings.

Prevention
● To prevent the worsening of the child’s condition and performance in his occupations by
implementing appropriate strategies to reduce the possible risks that may lead to
self-harm and other unwanted accidents within his home

Participation
● To promote the child’s participation in functional mobility, self-feeding, and play
participation.

Quality of Life
● To promote the child’s quality of life by increasing his participation in activities of daily
living, particularly in functional mobility and feeding, such that he will be able to engage
in other occupations that will require him to move around his environment and
effectively perform self-feeding tasks independently.

Occupational Justice
● To promote awareness about children with Cerebral Palsy and educate the child’s family
regarding his condition, as well as the importance of early intervention and further
rehabilitation and treatment.

C. Goals/Objectives and Management

LTG1: The child will be able to shift his body from supine to sitting position with moderate assistance
within 1 month of OT sessions.
Short Term Goals Intervention Type of Intervention
STG1: The child will be able to ● Performing reflex ● Interventions to Support
perform supine to sit with inhibiting pattern before Occupations
moderate assistance using the start of the sessions
physical prompts in at least 3
- to reduce spasticity ● Activity
opportunities within 8 OT
sessions. ● Balancing activities
where the child will be
asked to balance on a
pillow
● Passive range of motion
exercise and deep

27
 pressure massage ● Interventions to Support
before the start of the Occupations
session to inhibit muscle
spasticity
o Shoulder, elbow,
and finger
stretching
o Side to side
rolling
o Leg stretching
● Applying deep pressure
massage before the
start of the session ● Interventions to Support
● Educating and training Occupations
the mother in utilizing
joint protection ● Education & Training
techniques such as
balancing activity & rest
and maintaining good
joint alignment and
range of motion
exercises

● The child will sit up

appropriately to do
tabletop activities. ● Occupation

STG2: The child will be able to ● Performing reflex ● Interventions to Support

balance himself in an Indian inhibiting pattern before Occupations
sitting position for 10-15 the start of the sessions
minutes with moderate
● Balancing activities ● Activity
physical prompts within 8 OT
sessions. where the child will be
asked to balance on a
pillow
● Passive range of motion ● Interventions to Support
exercise and deep Occupations
pressure massage
before the start of the
session to inhibit muscle
spasticity
o Shoulder, elbow,
and finger
stretching
o Side to side
rolling
o Leg stretching
● Educating the mother ● Education & Training
and utilizing joint
protection techniques
such as balancing
activity & rest and

28
 maintaining good joint
alignment
● Righting exercises and ● Interventions to Support
tummy time activities to Occupations
strengthen trunk

● Provision of adaptive ● Interventions to Support

table/small table Occupations

● The child will be able to ● Occupation

sit up during tabletop
activities.

LTG2: The child will be able to participate in self-feeding activities with minimal assistance within 1
month of OT sessions.
Short Term Goals Intervention Type of Intervention

STG1: The child will be able to ● Provision of plate guard ● Assistive device
successfully scoop food using a ● Participating in a carrot ● Activity
plate guard with minimal painting activity
spillage with minimal physical
● Practice target shooting ● Training
assistance within 8 OT sessions.
with a ball and hoop
● Playing “Simon Says” ● Activity
with the therapist
incorporating touching
hand to nose
● Practice handling ● Training
utensils and getting
food from the plate
● Educate the family in ● Education
performing appropriate
feeding techniques
(e.g.: favorite food,
favorite utensils)
● Slow firm rubbing inside ● Activity
mouth on upper and
lower gums, both sides

● Playing scooping ● Activity

sensory bin activities

● Training the child to

● Education and Training
utilize “asking hands”
prior to giving the food

● Practice maintaining ● Training

postural control for
meal time

● The child will eat with ● Occupation

manageable spillage
during mealtimes.

29
STG2: The child will be able to ● Finger Feeding activity ● Activity
bring the spoon filled with food
from the plate to the mouth ● Bringing spoon filled ● Occupation
with minimal physical
with food to the mouth
assistance within 8 OT sessions.

● Voluntarily releasing ● Occupation

spoon after self-feeding

● Educate the child’s ● Education

family in performing
appropriate techniques
(e.g. favorite food,
favorite utensils)

● Slow firm rubbing inside ● Interventions to Support

mouth on upper and Occupations
lower gums, both sides

● Using or applying z-vibe ● Interventions to Support

inside the child’s mouth Occupations
(upper and lower lips,
inner cheeks)

● Using chewy tube inside

● Interventions to Support
the child’s mouth and
Occupations
ask him to bite the tube
● Interventions to Support
● Sensory play activities
Occupation
such as water play, corn
flour or edible finger
paints to target oral
sensory seeking
problems.
● Interventions to Support
● Movement-related
Occupation
activities such as
swinging, sand pits,
messy play to target
oral sensory seeking
problems.

STG3: The child will be able to ● Engage in self-feeding ● Occupation

feed himself with full attention within an appropriate
with minimal physical time frame
assistance within 8 OT sessions.
● Utilize nursery rhymes ● Self-regulation
to catch the child’s
attention
● Eliminate visual ● Environmental
distractions such as modifications
turning off the TV and
changing the position of
the child’s chair

30
LTG3: The child will be able to successfully participate in solitary play with minimal assistance within 1
month of OT sessions.

Short Term Goals Intervention Type of Intervention

STG1: The child will be able to ● Free play at the start of ● Interventions to
initiate play using faded the session and Support Occupation
hand-over-hand assistance in-between breaks to
with maximal prompts within 8
increase child’s
OT sessions.
participation in the
session.
● Engaging the child in ● Interventions to
sing and dance activity Support Occupation
with the therapist
● Activity
● Engaging the child in
pretend play activities ● Activity
● Floor time
● Playing the “Imitate Me ● Activity
Game” with the
therapist
● The child will be able ● Occupation
initiate play by using
nonverbal
communication
● Educating and training ● Education and Training
the caregivers on
language facilitation
techniques to be
applied at home
● Utilizing reinforcements ● Self-regulation
to reward target
behaviors and increase
desirable behaviors
during task
performance

STG2: The child will be able to ● Engaging in a Lego ● Activity

use toys according to their stacking activity
intended use with maximal ● Engaging in a painting ● Activity
prompts within 8 OT sessions.
activity ● Interventions to
● Introducing concepts to Support Occupations
the child during play
activities ● Interventions to
● Utilizing reinforcements support occupations
to reward target
behaviors and increase
desirable behaviors
during task
performance

● Using or applying z-vibe ● Interventions to

inside the child’s mouth Support Occupations
(upper and lower lips,

31
 inner cheeks) while
playing.

● Sensory play activities ● Interventions to

such as sensory bins Support Occupation
● Occupation
● The child will hold and
use the toys
purposefully during play
time.

STG3: The child will be able to ● Behavioral ● Interventions to

use the asking hand gestures to management Support Occupations
signify wanting to borrow toys techniques such as
with maximal prompts within 8
positive reinforcements
OT sessions.
and contingency
methods.
● Utilizing Language ● Interventions to
Facilitation Techniques Support Occupations
such as Information
Talk, Filling in and
Repetition to encourage
the child to respond to
interaction.
● Playing the “Imitate Me ● Activity
Game” with the
therapist
● Education and Training
● Educate and training
the caregivers on
language facilitation
techniques to be
applied at home
● The child will be able to ● Occupation
express emotions and
gesticulate preference
during play.

32
IV. TREATMENT SESSIONS

Date Objective Data Analysis of Treatment Done

Session 1 Interview with Caregiver The following client factors are

The interview was done to gather intact:
Initial information about the child’s ● Context & Environment
Evaluation occupational profile and the mother’s ● Concepts – Temporal
July 4, 2022 goal. The caregiver contributed to ● Global & specific mental
giving information. functions – selecting,
dividing, sharing
The child’s ROM & MMT were also ● Memory – visual, auditory,
observed as the therapist played long-term, short-term
with him. The results are as follows: ● Communication – reception
● Sensory Functions – visual,
ROM auditory, tactile
➢ SH flexors – 0-83 degrees ● Protective reflexes
➢ SH extensors – 0-39 degrees ● Fine Motor Control – pattern
➢ SH abductors – 0-79 degrees of grasp, dexterity, in-hand
➢ SH internal rotator – 0-69 manipulation, crossing the
degrees midline
➢ SH external rotator – 0-89 The following client factors have
degrees limitations:
➢ Elbow flexors – 0-79 degrees ● Concepts – colors, shapes,
➢ Elbow extensors – 0-39 body parts, quantitative,
degrees positional/directional,
➢ Cervical flexion – 0-44 numbers
degrees ● Global & Specific Mental
➢ Cervical extension – 0-44 Functions – sustaining,
degrees shifting, distractibility,
➢ Cervical lateral flexion – 0-44 concentration, impulse
degrees control
➢ Cervical rotation – 0-59 ● Memory – kinesthetic
degrees ● Emotional regulation
➢ Thoraco-lumbar flexion – 9 ● Communication –
cm expression, comprehension,
➢ Thoraco-lumbar extension – speech level
5 cm ● Calculative abilities
➢ Thoraco-lumbar rotation – ● Sensory functions –
0-44 degrees proprioceptive, vestibular
➢ Hip flexors – 0-108 degrees ● Sensory integration –
➢ Hip extensors – 0-16 degrees sensory-seeking behavior
➢ Hip abductors – 0-25 ● Joint mobility due to no limb
degrees isolation & spasticity
➢ Hip adductors – 0-18 ● Muscle power
degrees ● Spastic muscle tone
➢ Hip internal rotator – 0-25 ● Balance reactions – righting
degrees ● Gross motor control –
➢ Hip external rotator – 0-26 standing, walking, stair
degrees climbing, running, jumping,
➢ Knee flexors – 0-120 degrees jumping over, hopping over,
➢ Knee extensors – 125-0 kicking, balance beam,
degrees catching, throwing
➢ Ankle dorsiflexors – 0-3 ● Fine motor control
degrees ○ Gait patterns
➢ Ankle plantar flexors – 0-43 ○ Strabismus &
degrees exotropia on the
➢ Ankle evertors – 0-3 degrees child’s left eye
➢ Ankle inverters – 0-6 degrees
➢ Toe flexors – 0-23 degrees

33
 ➢ Toe extensors – 0-38
degrees ● The results of the Short
MMT Sensory profile indicate that
➢ 3+ grade of left & right there is a probable difference
shoulder flexors in the child’s movement
➢ 3+ grade of left & right sensitivity, is under
shoulder extensors responsive, auditory filtering,
➢ 3+ left & right shoulder and there is visual/auditory
abductors sensitivity. There is also a
➢ 3+ left & right shoulder definite difference in his
internal rotators energy level (low
➢ 3+ left & right shoulder energy/weak).
external rotators
➢ 4 left & right elbow extensors

Short Sensory Profile

The Short Sensory Profile was
answered by the caregiver while the
therapist presented different
opportunities for the child to play.
The child gravitated towards Lego
blocks, a paintbrush, and singing of
nursery rhymes done by the
therapist. Meal time was also done.

Session 2 General Appearance General Appearance

July 7, 2022 The child was noted to be The child was well-taken care of by
well-groomed, clean and wore his family/
appropriate clothing. No neglect in
personal grooming and hygiene was
seen as the appearance of the child
looked clean and neat.

General Behavior General Behavior

The child was observed to be Exhibits a fluctuating mood.
interactive towards the therapist
upon entering the gym. However,
during the lego stacking activity it
was noted that the child was uneasy.
He was also observed to have an
unpleasant mood during the
exercises.

Functional Mobility
● During the reflex inhibiting
pattern exercises, the child
was able to perform the
exercises given maximal
assistance by the therapist.
However, he was noted to
have disengagements to
which he was also given
moderate prompts.
Interventions
Functional Mobility
Child has lower extremity spasticity
to which during the exercises, the
child was given maximal assistance
by the therapist in order to complete
the activity.

Self-Feeding Self-Feeding
● During the food play activity, The child was noted to have poor
the child was able to slice the initiation and eye-hand coordination,

34
 fruits and vegetables with as evidenced by hand-over-hand
hand-over-hand assistance assistance from the therapist.
from the therapist.

Play Participation Play Participation

● During the lego-stacking
activity, the child was unable
to stack the lego blocks.
The child was noted to have an
oral-sensory seeking behavior as
evidenced by mouthing the lego toys
to which he was given moderate to
maximal verbal prompts in order for
the child to terminate his mouthing
behavior.

Session 3 General Appearance General Appearance

July 11, 2022 Well-groomed, clean, and wore Spasticity in the lower extremity was
appropriate clothing. No presence of evident.
wounds or bruises.

General Behavior General Behavior

Seems to be enjoying the activities
all throughout the session. More
interactive compared to the previous
sessions.
Exhibits low frustration tolerance.
Intact awareness and orientation
throughout the session. Showed
heightened distractibility due to
surroundings or preferred toys.

Interventions Interventions
Functional Mobility Functional Mobility
The child was relaxed when doing Exercise was effective in decreasing
the reflex inhibiting pattern as he the child’s spasticity in the lower
was holding a toy and the therapist extremities.
singing nursery rhymes to the child.

Self-Feeding
The child was observed to enjoy the
activity. He did not seem to lose
attention to the task at hand and was
able to initiate scooping
Self-Feeding
The child has difficulty initiating
voluntary movement as well as poor
eye-hand coordination.

Play Participation Play Participation

The child was able to stack the three The child showed interest in the
leggo parts with hand-over-hand activities provided by the therapist.
assistance from the therapist.
Moreover, the child was able to finish
the imitate me activity together with
the therapist given maximal physical
prompts.

Session 4 General Appearance General Appearance

July 14, 2022 Well-groomed, clean, and wore The child is well-taken and cared for
appropriate clothing. No presence of by his family.
wounds or bruises.

General Behavior General Behavior

The child was doing well and he was The child is in a good mood.
also seen to be all smiles during the
session.

Specific Activity
Specific Activity
Functional Mobility
Functional Mobility
The child was able to complete 1
The child was relaxed when doing

35
 round of the exercise. the stretching and massage.

Self-Feeding Self-Feeding
The child was able to get all 5 foam The child needs maximal assistance
fishes inside the small pool filled with when doing sensorimotor activities.
water with hand-over-hand This may be due to difficulty with
assistance and verbal and physical initiation of similar activities.
prompts from the therapist.

Play Participation Play Participation

The child was able to stack the three The child explores through oral
leggo parts with hand-over-hand stimulation.
assistance from the therapist. He
first mouthed the toys before being
stopped by the therapist.

Session 5 General Appearance General Appearance

July 18, 2022 The child wears appropriate clothing The child was well taken care of by
for the session, well-groomed and the family.
clean. No wounds or bruises were
noted.

General Behavior General Behavior

The child was active and participates The child is able to express
in all activities given. He gets excited emotions through gestures.
and smiles when interested in the
activities.

Interventions Interventions
Functional Mobility Functional Mobility
He seemed relaxed during passive The child has low frustration
exercises given assistance by the tolerance.
therapist. A few minutes later, he
started to become uneasy and
unhappy.

Self-Feeding Self-Feeding
The child was able to initiate The child has problems in
scooping, but spills the food as he coordination and grip.
scoops and brings it towards his
mouth.

Play Participation Play Participation

The child seemed to smile and laugh The child has impaired cognitive
when on top of the activity ball while skills and exhibits age inappropriate
playing legos with hand-over-hand play. His current level is
assistance. He plays with it for about sensorimotor stage.
15-20 minutes before seeking a new
activity. He also puts the legos into
his mouth.

Session 6 General Appearance General Appearance

July 21, 2022 The child wears appropriate clothing The child was well taken care of by
for the session, well-groomed and the family.
clean. No wounds or bruises were
noted.

General Behavior General Behavior

The child was generally compliant The child was in a good mood.
throughout the therapy session. He
was active and participated in all

36
 activities given by the therapist.

Interventions
Functional Mobility
The child was laughing while
engaging in the tummy time activity.
His name was often called by the
therapist while holding a toy to
encourage him to look up
Interventions
Functional Mobility
The child was able to tolerate the
tummy time and required moderate
physical and verbal prompts from
the therapist to focus and look up as
his name was called.

Self-Feeding
During the water play activity, he was
able to scoop the animals from the
water and transfer them to a Self-Feeding
separate container given HOHA and The child has problems in
moderate physical and verbal coordination and grip.
prompts from the therapist.

Play Participation
The child engaged with free play at
the start of the session. He was
noted to enjoy the different toy
animals. He was asked to do the
asking hands for him to receive a toy
animal.
Play Participation
The child still exhibits age
inappropriate behavior and needed
HOHA from the therapist as well as
moderate physical and verbal
prompts for him to place his palms
up and do the asking hands.

Session 7 General Appearance General Appearance

July 25, 2022 The child wears appropriate clothing The child is well-taken and cared for
for the session, well-groomed and by his family.
clean. No wounds or bruises were
noted,

General Behavior General Behavior

The child was noted to have an
irritable mood at the start of the
session, however, once the therapist
started talking and introduced him to
the room, he became interested.
The child was in an irritable mood
but lightened up throughout the
session.

Interventions
The child was able to normalize
Functional Mobility
muscle tone and reach full range of
The child was given passive and
motion.
active exercises as well as reflex
inhibiting patterns to normalize
muscle tone.

Self-Feeding
The child has difficulty with initiation,
The child was still having difficulty
coordination, and grip, however, was
with initiating during the self-feeding
able to follow instructions given by
activity, however, with verbal
the therapist.
prompts, the child was able scoop
the food but with spillage.

Play Participation
The child still exhibits age
Throwing and catching the ball and
inappropriate behavior and did not
playing with legos were the toys of
catch any of the balls thrown by the
choice for the child and he was
therapist, however, was able to
noted to laugh and smile throughout
throw 3 balls to the therapist and

37
 the activity. was able to stack 5 legos.

V. PROGNOSIS OF TREATMENT

Noted problems with motor skills, process skills, and social skills in the child’s case
interferes with his participation in meaningful occupations. But since he is receiving early
intervention targeted on improving his potential in establishing and maintaining different skills for
him to be able to engage in activities of daily living particularly in functional mobility, self-feeding,
and play participation, the child presents a good prognosis if given continuous therapy sessions.
Furthermore, the child has a supportive family, has access to proper healthcare and makes sure
that he attends his scheduled therapy sessions.

VI. RECOMMENDATIONS

It is recommended that physical therapy treatments should be continued to assist with

the growth of her motor abilities. Regular check-up with the child’s ophthalmologist is also
referred to as a precautionary measure if ever the child experiences issues with her eyes and
vision. For the child’s family, it is recommended to check on the child from time to time due to
spasticity of her lower extremity. Any possible precautions and physical changes must be noted
by carers.

Moreover, it is recommended for the child to explore the use of an ankle foot orthosis as
this can help in the child’s ambulation, providing both support and assistance and allowing the
patient to move through the various stages of gait.

38
VII. APPENDICES

APPENDIX A
SHORT SENSORY PROFILE

Short Sensory Profile

Child’s Name: Simon Rizal
Birth Date: September 8, 2019 Date: July 4, 2022
Completed by: Maria Teresa Rizal
Relationship to Child: Mother
Service Provider’s
Name:________________________Discipline:___________________________________

39
40
41
VIII. REFERENCES

Brown Trial Firm. (2019, November 8). Prognosis and life expectancy for cerebral palsy. https://
browntrialfirm.com/blog/cerebral-palsy/prognosis-and-life-expectancy-for-cerebral-palsy/

Cariccio, V., et al. (2018, May 18). Mercury involvement in neuronal damage and in neurodegen
erative diseases. https://pubmed.ncbi.nlm.nih.gov/29777524/

Centers for Disease Control and Prevention (CDC). (n.d.). Cerebral Palsy (CP). https://www.cdc

.gov/ncbddd/cp/causes.html#:~:text=Some%20types%20of%infection%20that.membran

e20that,membranes%2C%20or%20maternal%20pelvic%20infections.

Cerebral palsy - Symptoms and causes. (2021, September 1). Mayo Clinic. https://www.mayocl

inic.org/diseases-conditions/cerebral-palsy/symptoms-causes/syc-20353999#:%7E:text

=Infant%20infections%20that%20cause%20inflammation,a%20cause%20than%20histo

rically%20thought

Proctor, K. (2022, April 12). Cerebral palsy prognosis. Cerebral Palsy Guide. https://www.cerebr

alpalsyguide.com/cerebral-palsy/prognosis/

default - Stanford Medicine Children’s Health. (n.d.). Retrieved September 6, 2022, from

https://www.stanfordchildrens.org/en/topic/default?id=age-appropriate-speech-and-langu

age-milestones-90-P02170

42