Cerebral Palsy

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Cerebral Palsy

• Course Development
• Alissa Backus
• Jessica Laurent

course outline, organization, and editing Paul
A. Hayden Ph.D
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Definition of Cerebral Palsy

• A group of chronic neurological disorders that
  appear in the first years of life.
• These disorders involve impaired control of
  movement that generally do not worsen over time.
• These disorders cause faulty development or
  damage to motor areas in the brain which causes
  the inability to control movement and posture.

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A Closer Look

• The word cerebral refers to the brain's two
  halves, or hemispheres.
• The word palsy refers to any disorder that
  impairs control of body movement.

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Incidences

• 1 in 500 people in the United States have
  Cerebral Palsy.
• United Cerebral Palsy Associations estimate that
  more than 500,000 Americans have cerebral palsy.
• Equally occurs among males and females.

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Etiology of Cerebral Palsy

• Caused by dysfunctions of parts in the brain that
  control body movement and posture.
• Dysfunction can occur when brain cells
• Fail to or abnormally grow
• Damage due to lack of blood, oxygen, or nutrients
• Damage caused by infection

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Prenatal Etiology of Cerebral Palsy

• Genetic or Chromosomal cause
• Parents age as related to sperm and egg
  viability
• Exposure to toxins
• Mother acquires infection during pregnancy
• Infections in the birth canal or uterus

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Natal Etiology of Cerebral Palsy

• Prolonged labor
• Placenta breaks down before infant is delivered
• Infection in the birth canal
• Poor health
• Multiple births

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Postnatal Etiology of Cerebral Palsy

• Serious illness
• Bleeding surrounding the brain (hemorrhages)
• Anoxia due to accidents (i.e. drowning)
• Traumatic Brain Injuries (i.e. car accidents,
  abuse, etc.)
• Low blood sugar

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Cramped Synchronized General Movements in
Preterm Infants as an Early Marker for Cerebral
PalsyFabrizio, F., Giovanni, C., et al (2002)

• Purpose To determine whether specific
  abnormalities (cramped synchronized general
  movements GM) can predict cerebral palsy and
  its severity in preterm infants affected by brain
  lesions.
• Method Traditional neurological exams were
  performed, and GMs were videotaped and blindly
  studied for 84 preterm infants with ultrasound
  abnormalities from birth to 56-60 weeks
  gestation. The developmental course of GM
  abnormalities was compared with brain ultrasound
  findings alone and with findings from the
  neurological exams. The results from these two
  tests were then compared to the patient outcome
  at age 2-3 years.

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Cramped Synchronized General Movements in
Preterm Infants as an Early Marker for Cerebral
PalsyFabrizio, F., Giovanni, C., et al (2002)

• Results Infants with consistent cramped
  synchronized GMs developed cerebral palsy. The
  earlier cramped synchronized character GMs, the
  most severe motor disorder, has been linked to
  the worse neurological impairment. Temporary
  cramped synchronized character GMs or normal GMs
  with poor repertoire GMs lead to mild CP or
  normal development.
• Conclusion Consistent and predominant cramped
  synchronized GMs predict CP. The earlier this
  characteristic appears, the worse the later
  impairment.

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Classification by Limb Involvement

• Quadriplegia All four limbs are involved
• Diplegia All four limbs many be involved, but
  two inferior limbs are more severely affected
  than the two superior limbs
• Hemiplegia One side of the body is affected.
  The arm is usually more affected then the leg.
• Triplegia Three limbs are involved, usually
  affecting both arms and one leg
• Paraplegia Two paired limbs are involved (i.e.
  both arms).
• Monoplegia Only one limb is involved, usually
  affecting an arm.

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Classification by Movement Disorder Location of
brain injury determines how movement is affected

• Spastic Cerebral Palsy Upper Motor Neuron
• Athetoid Palsy Basal Ganglion
• Ataxic Palsy - Cerebellar
• Mixed-Type Cerebral Palsy Any Combination

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Spastic Cerebral Palsy

• Most common type - accounts for about 80 of the
  cases
• Due to damage of the motor cortex
• Movement is limited due to spastic muscles (tight
  and stiff)
• Spasticity may range from very mild (affecting
  only a few muscles) to very severe (affecting the
  whole body)
• Spasticity can vary from day to day basis

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Athetoid Cerebral Palsy

• Accounts for 10 of the cases
• Due to damage of the basal ganglia
• Difficultly in controlling and coordinating
  movements (i.e. speech, reaching and grasping
  objects, etc.)
• Some movements may be involuntary

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Ataxic Palsy

• Rarest type - accounts for only 5-10 of the
  cases
• Due to damage of the cerebellum
• Low muscle tone and poor coordination of
  movements
• Affects balance and depth perception

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Mixed-Type Cerebral Palsy

• Accounts for about 10 of the cases
• Due to damage of the brain affecting both muscle
  tone and voluntary movement
• Spasticity is more apparent in the beginning
• Involuntary movement increase throughout the
  childs development

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Associated Problems Accompanying Cerebral Palsy

• Visual Difficulties
• Hearing Problems
• Seizures
• Social/Emotional

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Visual Difficulties

• Cerebral palsy frequently affects the visual
  system
• Categories of Visual Impairments
• Refractive errors
• Strabismus
• Amblyopia
• Cataracts
• Cortical Blindness

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Refractive Errors

• Most prevalent visual impairments
• Hyperopia (farsightedness)
• Myopia (nearsightedness)
• http//my.webmd.com/content/article/1680.53542
• Astigmatism (blurry vision) due to abnormal
  curvature of the cornea
• Treatment
• Glasses or contact lenses can help improve vision

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Strabismus

• Crossed eyes
• Affects half of all children with cerebral palsy
• Treatment
• Placing a patch over the stronger eye, which
  forces the muscle of the weaker eye into proper
  alignment
• Corrective glasses
• Surgery to assure development of good muscle
  coordination

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Amblyopia

• Lazy eye
• The brain purposely suppresses the weaker eye
  preventing the child from having blurred or
  double vision
• Caused by other underlying problems strabismus,
  impaired acuity, and cataracts
• Treatment
• If detected early the problem can be reversed

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Cataracts

• Clouding of the Lenses

• Causes
• Congenital
• Genetic
• Rubella

• Toxoplasmosis
• CMV
• Other infections in utero

• Treatment
• Surgery in early months of life to remove
  cataracts

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Cortical Blindness

• Injury to visual centers in the cerebral cortex
• Brain cannot interpret and process information
  correctly
• Total cortical blindness is rare, usually occurs
  with extensive brain injury (severe quadriplegia)
  
• Treatment
• Seek medical and educational treatment
• Enhance use of other senses

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Hearing Problems

• 5 to 15 of children with cerebral palsy have
  hearing impairments.
• Two types of hearing losses
• Sensorineural hearing loss
• Conductive hearing loss
• Most common hearing loss
• Due to middle ear infections, anatomic
  abnormalities (cleft lip and palate), or
  malformed ears.

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Sensorineural Hearing Loss

• 1 of children with cerebral palsy have this type
  of loss.
• Due to congenital or acquired factors
  (meningitis, high fever or medication).
• Treatment
• Hearing aids to amplify sounds

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Conductive Hearing Loss

• Most common type of hearing loss.
• Due to middle ear infections, anatomic
  abnormalities (cleft lip or palate, or malformed
  ears).
• Treatment
• Antibiotics
• Decongestants
• Myringotomy with P.E. tubes

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Acoustic-Phonetic Contrasts and Intelligibility
in the Dysarthria Associated with Mixed Cerebral
PalsyJournal of Speech and Hearing Research
(1992)

• Purpose The purpose of this study was to
  examine the relationship between several acoustic
  measures of speech features and perceptual
  judgments of word intelligibility of people with
  mixed cerebral palsy who possess dysarthric
  characteristics.
• Subjects SLPs from two large United Cerebral
  Palsy Association Centers were asked to select
  those male individuals with a diagnosis of mixed
  cerebral palsy who used verbal communication as
  their sole means of communication, and who in the
  opinion of the staff had some degree of
  intelligibility deficit. These subjects had IQ
  scores of at least 70, normal hearing, and a
  normal oral-peripheral structure. A sample of 16
  subjects ranging from 21 to 41 years with varying
  degrees of intelligibility deficit was used.

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Acoustic-Phonetic Contrasts and Intelligibility
in the Dysarthria Associated with Mixed Cerebral
PalsyJournal of Speech and Hearing Research
(1992)

• Study 1
• Method for Acoustic and Perceptual Analysis
  Speech material included monosyllabic CVC real
  word pairs. Stimulus words concentrated on seven
  phonemic contrasts syllable-initial voicing
  (back-pack), syllable-final voicing (cab-cap),
  stop-nasal (bad-mad), fricative-affricate
  (ship-chip), front-back vowel (bat-bought), high
  low vowel (hat-heat), and tense-lax vowel
  (feet-fit).
• Six minimal word pairs were constructed for each
  phonemic contrast.
• Each subject read a total of 112 stimulus words
  one time from printed cards.
• Word productions were tape-recorded and later
  digitalized at a sampling rate of 20 kHz for
  preparation of listener tapes.

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Acoustic-Phonetic Contrasts and Intelligibility
in the Dysarthria Associated with Mixed Cerebral
PalsyJournal of Speech and Hearing Research
(1992)

• Method for Speech Intelligibility Twelve
  potential listeners, who had varying degrees of
  familiarity with the speakers with dysarthria,
  were administered a training tape transcription
  task. Eight of these listeners who reached 73
  agreement were retained as listeners, thus
  increasing interjudge reliability.
• Each judge was seated in a quiet room with a
  quality headset for delivery of speech material.
  Words were presented at a rate of 1 every 5 sec.
  Listeners were asked to provide orthographic
  transcriptions of each stimulus word, and then
  indicate the degree of ease or difficulty they
  had recognizing the word heard on a 7-point
  scale.
• 3 ways transcriptions were scored
• Whether the entire word was transcribed correctly
  
• Whether the target phonemic segment was
  transcribed correctly
• If the contrast was incorrect, the transcribed
  error was coded to signify if the opposite
  contrast pair had been transcribed

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Acoustic-Phonetic Contrasts and Intelligibility
in the Dysarthria Associated with Mixed Cerebral
PalsyJournal of Speech and Hearing Research
(1992)

• Study 2
• Method The subjects and acoustic and perceptual
  data analyzed in this study consisted of the same
  data in Study1.
• Analysis All acoustic measures were included in
  a multiple regression framework to determine
  which acoustic measures or combination of
  measures accounted the most for the variance in
  the perceptual intelligibility measures. The
  potential predictor (independent) variables were
  the 7 acoustic measures (voice onset time, vowel
  duration). The predicted (dependent) variables
  were the intelligibility percentages.

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Acoustic-Phonetic Contrasts and Intelligibility
in the Dysarthria Associated with Mixed Cerebral
PalsyJournal of Speech and Hearing Research
(1992)

• Summary of Study 1 and Study 2 A large multiple
  correlation between speech intelligibility and
  four acoustic aspects of speech
  fricative-affricate, front-back vowel contrast,
  high-low vowel contrast, and tense-lax vowel
  contrast indicated that these 4 factors strongly
  influence intelligibility. A general conclusion
  of this research is that the vowel parameters of
  duration and F1 and F2 formant locations, and the
  fricative-affricative durational parameters are
  major predictors of the scored intelligibility.
• Clinical Implications The ability to explain
  intelligibility deficits in the way of specific
  acoustic correlates has definite clinical
  implications such as to use diagnostic tools to
  document deficits, to focus treatment, and to
  validate improvements in speech proficiency.

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Seizures

• Involuntary movements or changes in consciousness
  or behavior resulting from abnormal bursts of
  electrical activity in the brain.
• 1 out of 2 children with cerebral palsy develop
  seizures.
• Higher risks due to brain damage and scaring
  which can trigger abnormal brain activity.
• Classified by type and location of abnormal brain
  activity.

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Types of Seizures

• Partial Seizures
• Abnormal brain activity in one area of the brain.
• Generalized Seizures
• Abnormal brain activity is present in both sides
  of the brain.

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Social/Emotional Needs of Parents

• Accepting the disability
• Adjusting to the situation
• Overcoming shame, embarrassment, and social
  isolation
• Asking and accepting help
• Maintaining a positive relationship with the child

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Social/Emotional Needs of the Child

• Instill high self-esteem
• Sense of belonging
• Support and reassurance
• Prepare for social situations

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Physical Therapy Considerations

• Goal To recognize and treat problems involving
  movement and posture.
• Crucial that physical therapy (PT) begin at an
  early age because the central nervous system is
  more receptive to changes in the first five year
  of life.

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Areas that Require Physical Therapy

• Posture
• Difficulty with holding head, trunk, arms, or
  legs in proper alignment in the following
  positions
• Sitting
• Side-lying
• Kneeling
• Standing
• All need to be mastered in order to acquire
  gross motor skills

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Areas of Physical Therapy

• Transitional Movements
• Connects one posture to another (Roll from back
  to front)
• Persistent Primitive Reflexes
• Present at birth and fades away before 6 mo.
• Balance
• Ability to keep body upright
• Sensory Impairments
• Over or under responsive to senses
• Joint Mobility
• Movement and flexibility of joints

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Physical Therapy
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Occupational Therapy Considerations

• Goal Help people function as effectively as
  possible in their daily activities.
• Occupational Therapists (OT) assist with helping
  people overcome sensory, motor and perceptual
  problems that affect their learning and daily
  living skills.

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Areas of Occupational Therapy

• Fine Motor Skills
• Hand-eye Coordination
• Daily Living Skills
• Perceptional Skills
• Sensory Processing and Integration
• Basic Non-Verbal Communication Skills

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Occupational Therapy
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Recreational Therapy

• A health care and human service discipline that
  delivers treatment services designed to restore,
  remediate and/or rehabilitate functional
  capabilities for persons with injuries, chronic
  illnesses and all types of disabling conditions
  (ATRA).
• Goal Increase motivation and ease the feelings
  of idleness, loneliness, and depression, which
  can prevent progress in the healing process.

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Music Therapy

• Goal Use therapeutic music in rehabilitation,
  special education, and community settings.
• Music therapists assess emotional well-being,
  physical health, social functioning,
  communication abilities, and cognitive skills
  through musical responses.

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Medical Considerations

• Surgery Not always necessary, but may be
  recommended to improve muscle development and
  reduce spasticity in the legs. 
• Medication Your child's doctor may prescribe
  medication to prevent or control seizures
  associated with cerebral palsy. 

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Major Speech Problems Associated with Cerebral
Palsy

• Articulation
• Dysarthrias
• Voice Problems
• Dysphagia

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Articulation

• Moderate to profound vocal communication
  disorders (70-80). The muscles that control
  speech are often affected. Poor speech can
  complicate cognitive assessment.
• Considerations 
• Early intervention.
• Consult with a speech-language pathologist.
• Investigate augmented communication and assistive
  technology.

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Dysarthrias

• Most common
• Difficulty controlling muscles to coordinate
  speech movement.
• Hypernasal
• Hyponasal
• Speech may sound slow and slurred.

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Voice Problems

• Spastic Palsy Harsh vocal quality, increased
  intensity, and high pitch
• Athetoid Palsy Hoarse vocal quality,
  fluctuating intensity, and variable pitch
• Ataxic Palsy Hoarse vocal quality, fluctuating
  intensity, and variable pitch

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Dysphagia

• Related to muscular speech mechanism
• Due to muscles beginning spastic, athetosis,
  ataxic or flaccid
• People with cerebral palsy may cough, gag, or
  choke when eating.

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Language Delay

• Expressive language delay due to limits in speech
  production imposed by dysarthria
• Inability to express their level of language
  comprehension
• They are subjected to the same language disorders
  as children without CP

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Speech Therapy Considerations

• Goal Improve childs speech and language skills.
• Evaluate speech and language skills. Based upon
  results, develop therapy plan that helps child
  communicate more effectively.

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Areas of Speech Therapy

• Oral-Motor Skills
• Language Skills
• Augmentative Communication (AAC)

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Oral-Motor Skills

• Feeding
• A child with CP may have difficulty with sucking,
  chewing, or swallowing due to muscle tone or
  sensory integration.
• The SLP exercises the facial muscles and
  recommends certain foods (textures and amounts).
• Speech
• The SLP will teach the child to use their lips
  and tongue to produce sounds.
• The SLP will teach appropriate breathing postures
  and techniques required for speech production.
• Drooling
• Sensory Deficit SLP will massage childs face
  with a variety of textures to increase
  sensitivity.
• Motor Deficit SLP will position the child so
  muscle tone is as normal as possible.

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Language Skills

• Concepts
• The SLP will use real objects and pictures to
  teach concepts.
• Auditory Processing
• The SLP will begin by presenting instructions at
  the length and complexity at which the child can
  barely understand.
• Grammar/Syntax
• The SLP will work on each grammatical error. The
  SLP will begin with isolation and end with
  carry-over activities.
• Pragmatics
• The SLP will explain the importance of allowing
  the child to communicate on their own.

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Augmentative Communication

• The SLP will choose an appropriate AAC device for
  the child.
• The SLP will explain the importance of using the
  AAC in everyday activities.
• The SLP will facilitate the use of the AAC
  device.
• http//www.abilityhub.com/aac/aac-devices.htm

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Phonatory Control in Adults with Cerebral Palsy
and Severe DysarthriaAAC Augmentative and
Alternative Communication (March 2002)

• Purpose AAC users with severe dysarthria may
  benefit from using residual vocalizations to
  enhance their communication efficiency and
  naturalness.
• Hypothesis Despite severe degradation of
  segmental speech sounds, speakers signal
  information through the control of phonatory
  features such as pitch and duration.
• Participants Eight individuals with severe
  dysarthria caused by cerebral palsy and unable to
  communicate using only speech.

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Phonatory Control in Adults with Cerebral Palsy
and Severe DysarthriaAAC Augmentative and
Alternative Communication (March 2002)

• Method
• Each participant was asked to produce 20
  vocalizations at three different levels for both
  pitch and duration.
• Pitch High, Medium, and Low
• Duration Long, Medium, and Short
• The Praat System was used to visualize and
  calculate the average pitch and duration for each
  vocalization.
• The duration was measured in seconds.
• The pitch was calculated by the average
  fundamental frequency of each vocalization.

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Phonatory Control in Adults with Cerebral Palsy
and Severe DysarthriaAAC Augmentative and
Alternative Communication (March 2002)

• Results
• There was separate analysis done for each
  subject.
• All eight were able to produce at least three
  distinctive durations.
• The subjects were more varied in their production
  of pitches. However, at the vary least they were
  able to produce two distinct pitches.
• Conclusion
• Using distinct durations and pitches, the speaker
  with severe dysarthria due to CP will be able to
  vocalize information using their voice helping to
  improve communication efficiency and naturalness.
  

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Work Cited

• Books
• Finnie, N. (1974). Handling the Young Cerebral
  Palsied Child at Home. New York Dutton-Sunrise.
• Gerialis, E. (1991). Children with Cerebral
  Palsy A Parents Guide. Bethesda, MD Woodbine
  House.
• Shames, G., Wiig, E., Secord, W. (1998). Human
  Communication Disorders An introduction, Fifth
  Edition. Needham Heights, MA Allyn and Bacon

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Work Cited

• Journals
• Acoustic-Phonetic Contrasts and Intelligibility
  in the Dysarthria Associated with Mixed Cerebral
  Palsy. (1992). Journal of Speech and Hearing
  Research, 04(01).
• Ferrari, F., Cioni, G., Einspileler, C., Roversi,
  F., et. al. (2002). Cramped Syncronized General
  Movements in Preterm Infants as an Early Marker
  for Cerebral Palsy. Pediatrics and Adolescent
  Medicine, 156(5), 460-471.
• Patel, Rupal. (March 2002). Phonatory Control in
  Adults with Cerebral Palsy and Servere
  Dysarthria. AAC Augmentative and Alternative
  Communication, 18(1), 2-11.

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Work Cited

• Web sites
• www.about-cerebral-palsy.org
• www.webmd.com
• http//epilepsyontario.org
• http//www.abilitiescenter.com