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Cerebral Palsy, Stroke, and Traumatic Brain Injury

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Title: Cerebral Palsy, Stroke, and Traumatic Brain Injury


1
Cerebral Palsy, Stroke, and Traumatic Brain Injury
  • Chapter 25

2
Introduction
  • Individuals have common needs
  • Primarily a motor disorder
  • Often in conjunction with sensory, perceptual,
    and cognitive disorders
  • Participation in physical activity varies

3
Introduction
  • CP-ISRA - Cerebral Palsy-International Sports and
    Recreation Association
  • NDSA - National Disability Sports Alliance
  • Special Olympics or INAS-FID if dual diagnosis
    with mental retardation
  • Programming is challenging

4
Definitions, Etiologies, and Incidence
  • Orthopedic Impairments - IDEA
  • Cerebral Palsy (CP)
  • Stroke
  • Separate category - IDEA
  • Traumatic Brain Injury (TBI)

5
Cerebral Palsy (CP)
  • Neurological disorder of movement and posture
  • Cause - damage to the immature brain
  • Not hereditary, contagious, or progressive
  • Varies from mild to severe

6
Cerebral Palsy (CP)
  • Prenatal causes - before or during birth
  • Maternal infection
  • Chemical toxins
  • Injuries to the mother
  • Difficult deliveries

7
Cerebral Palsy (CP)
  • Acquired causes - before age 2
  • Brain infections
  • Brain traumas
  • Chemical toxins
  • Oxygen deprivation
  • More common in males

8
Stroke
  • Sudden onset of neurological impairment that
    occurs when the flow of oxygen and nutrients to
    the brain is disrupted by blood clot blockage or
    bleeding
  • Most common over age 60

9
Types of Stroke
  • Ischemic strokes
  • Associated with heart disease
  • Associated with high cholesterol levels
  • Hemorrhagic strokes
  • Linked with high blood pressure
  • Weak or malformed arteries and veins within the
    brain
  • Leukemia

10
Types of Stroke
  • Left-brain strokes
  • Weakness or paralysis of the right side
  • Speech/language deficits
  • Behavioral style - slow, cautious
  • Memory deficits in language

11
Types of Stroke
  • Right-brain strokes
  • Weakness or paralysis of the left side
  • Spatial/perceptual deficits
  • Behavioral style - quick, impulsive
  • Memory deficits in performance

12
Types of Stroke
  • Transient ischemic attacks (TIAs)
  • Incomplete strokes
  • Occur in both children and adults
  • Characterized by total recovery
  • Cause several hours of dysfunction
  • Warning signs

13
Stroke
  • Progression of recovery
  • More common in males until age 75
  • Early childhood strokes - often mistaken for CP
    in the past
  • Resulting conditions include hemiparesis, seizure
    disorders, learning disabilities, visual
    perception problems, memory deficits, and speech
    deficits

14
Traumatic Brain Injury (TBI)
  • Acquired injury to the brain
  • Closed- or open-head injuries result in total or
    partial functional disability and/or psychosocial
    impairment
  • Various sequelae that alter sensation,
    perception, emotion, cognition, and motor function

15
Traumatic Brain Injury (TBI)
  • Occur most often in males
  • Prediction of recovery - Glasgow Coma Scale
  • Eye opening
  • Motor response
  • Verbal response
  • Attention, memory, and visuomotor difficulties
    most common in school-age persons

16
Soft Signs
  • Soft Signs - indicators of CNS dysfunction
  • Behavior indicators of brain damage
  • Attention deficits
  • Hyperexcitability
  • Perseveration
  • Conceptual rigidity
  • Emotional lability
  • Hyperactivity

17
Associated Dysfunctions
  • Mental retardation
  • Speech problems
  • Learning disabilities
  • Visual problems
  • Hearing problems
  • Perceptual deficits
  • Seizures
  • Reflex problems

18
Associated Dysfunctions
  • Determine appropriate sport placement
  • Special Olympics - mental retardation
  • NDSA - average or better intelligence
  • Caution - many misdiagnosed as MR because of
    communication and speech that cannot be understood

19
Associated Dysfunctions
  • Strabismus - inability to focus both eyes
    simultaneously on the same object
  • Seizures - do not contraindicate sport
    participation
  • Reflex problems - interfere with learning to sit,
    stand, and walk

20
Number of Limbs Involved
  • Diplegia - lower extremities much more involved
    than upper
  • Quadriplegia - all four extremities involved
  • Hemiplegia - entire right or left side involved
  • Triplegia - three extremities involved, usually
    both legs and one arm

21
Types of Motor Disorders
  • Motor disorder described in terms of abnormal
    muscle tone and postures
  • Three types of CP are recognized
  • Spasticity
  • Athetosis
  • Ataxia
  • Hypotonia

22
Spasticity o Cerebral Origin
  • Abnormal muscle tightness and stiffness
  • Hypertonic muscle tone during movement
  • Hypertonic state - muscles feel and look stiff
  • Cocontraction - no relaxation of muscles
  • Interferes with release of objects
  • Interferes with precise movements

23
Spasticity of Cerebral Origin
  • Exaggerated stretch reflex - exaggerated response
    to stretch receptor input
  • Associated gaits
  • Scissors gait - both legs involved
  • Hemiplegic gait - arm and leg on same side
    involved
  • Abnormal postures

24
Athetosis
  • CUP - constant, unpredictable, purposeless
    movement as a result of fluctuating muscle tone
  • Interferes with facial expression, eating,
    speaking, visual pursuit and focus, handwriting
    and other fine motor skills
  • Walking is unsteady or staggering

25
Ataxia
  • Disturbance of balance and coordination
  • Hypotonia or low postural tone
  • Cerebellar-vestibular origin
  • Voluntary movements are clumsy and uncoordinated
  • Varies from mild to severe

26
Flaccidity/Hypotonia
  • Low muscle tone
  • Problems in persons with hypotonia
  • Poor head and trunk control
  • Absent postural and protective reactions
  • Shallow breathing
  • Joint laxity or hypermobility

27
Profiles to Guide Assessment and Programming
  • Sport classifications can be used to develop IEPs
    and IFSPs
  • Determine nonambulatory versus ambulatory
  • Use sport specific classifications

28
Profiles to Guide Assessment and Programming
  • Track and field classifications
  • Class 1 - Motorized Chair
  • Class 2 - Athetosis 2L or 2U
  • Class 3 - Moderate triplegic or quadriplegic
  • Class 4 - Diplegic
  • Class 5 - With or without assistive devices
  • Class 6 - Athetosis, ambulatory
  • Class 7 - Hemiplegic
  • Class 8 - Minimal involvement

29
Class 1 - Motorized Chair
  • Uses motorized wheelchair
  • Severe involvement in all four limbs
  • Limited head and trunk control
  • Limited range of motion
  • Difficulty in grasp and release
  • May need one-on-one assistance

30
Class 2 - Athetosis 2L or 2U
  • Propels chair with feet and/or very slowly with
    arms
  • Severe to moderate involvement in all four limbs
  • Uneven profile - subclassifications
  • 2 Upper - (2U) - upper limbs have greater ability
  • 2 Lower - (2L) - lower limbs have greater ability
  • Severe control problems in accuracy tasks

31
Class 3 - Moderate Triplegic or Quadriplegic
  • Propels chair with short, choppy arm pushes but
    generates fairly good speed
  • Moderate involvement in three or four limbs and
    trunk
  • Can take a few steps with assistive devices
  • Not functionally ambulatory

32
Class 4 - Diplegic
  • Propels chair with forceful, continuous arm
    pushes
  • Demonstrates excellent functional ability for
    wheelchair sports
  • Involvement primarily in lower limbs
  • Good strength in trunk and upper extremities
  • Minimal control problems

33
Class 5 - With or Without Assistive Devices
  • Typically uses assistive devices
  • Moderate to severe spasticity of either arm and
    leg on same side (hemiplegia) or both lower limbs
    (paraplegia)
  • May choose to participate as a Class 4 in the
    Paralympics system

34
Class 6 - Athetosis, Ambulatory
  • Ambulates without assistive devices
  • Severe balance and coordination difficulties
  • Moderate to severe involvement of three or four
    limbs
  • Problems less prominent when running than walking

35
Class 7 - Hemiplegic
  • Includes only those with hemiplegia
  • Ambulates well, but with a slight limp
  • Moderate to mild spasticity in arm and leg on
    same side
  • Work well in an integrated setting

36
Class 8 - Minimal Involvement
  • Runs and jumps freely without noticeable limp
  • Demonstrates good balance and symmetric form but
    has obvious (although minimal) coordination
    problems
  • Has normal range of motion

37
Coping With Special Problems
  • Delayed motor development
  • Postural reactions
  • Reflexes and abnormal postures
  • Spasticity problems
  • Athetosis problems
  • Surgery and braces
  • Hip dislocation, scoliosis, and foot deformities
  • Attitudinal barriers

38
Delayed Motor Development
  • Delays in all aspects of motor development
  • Limits physical, mental, and emotional
    stimulation
  • Early intervention is essential
  • Emphasis on integration of reflexes (0-7)
  • Instruction in sports, dance, and aquatics after
    age seven
  • Teach to compensate and/or use reflexes

39
Postural Reactions
  • Emphasis on protective extension to protect
    during falls
  • Development of equilibrium
  • Sports to work on weaknesses
  • Sports to develop strengths and enhance peer
    interactions to prevent social rejection

40
Reflexes and Abnormal Postures
  • Holding and carrying
  • Help with transfers may be needed
  • Extensor tone - hold close in tucked positions
  • Flexor tone - hold in positions that maintain
    head and limbs in extension
  • Use Velcro, padding, and cushioning to achieve
    proper alignment when using apparatus

41
Reflexes and Abnormal Postures
  • Strapping and positioning
  • Good alignment in sitting
  • Hips are at 90 flexion and in contact with back
    of the chair
  • Thighs are slightly abducted and in contact with
    the seat
  • Knees, ankles, and elbows are positioned at 90
    flexion
  • Strapping may be required to maintain proper
    position

42
Reflexes and Abnormal Postures
  • Strapping and positioning
  • Essential in sports for safety
  • Extensor pattern will pull body down and out of
    chair
  • A bolster will help inhibit the crossed extension
    reflex

43
Reflexes and Abnormal Postures
  • Contraindicated activities
  • Creeping on all-fours - may increase flexor
    spasticity
  • Frog or W sitting position - worsens hip joint
    adduction-inward rotation-flexion pattern
  • Bridging in supine - worsens abnormal neck
    extension and scapulae retraction
  • Walking on tiptoes or pointing the toes - if
    already have tight calf muscles

44
Spasticity Problems
  • Handling techniques
  • Correcting common problems
  • Rotation of the trunk decreases spasticity
  • Active exercises and stretching

45
Handling Techniques
  • Maintain symmetry - keep body parts in midline
  • Use inhibitory actions that are the opposite of
    the undesired pattern
  • Work from designated key points to central
    control - grasp body parts as close to the joint
    as possible

46
Correcting Common Problems
  • Fisted hand
  • Scissoring in supine position
  • Abnormal arm position

47
Rotation of the Trunk
  • Decreased overall spasticity
  • Rhythmic rolling activities
  • Gentle rocking movements
  • Also develop equilibrium reactions

48
Active Exercises and Stretching
  • Active exercises - utilize correct handling
  • Rotatory and rocking - utilize for warm-up and
    relaxation
  • Water play and exercises in a warm pool
  • Daily stretching helps prevent contractures

49
Athetosis Problems
  • CUP movements may cause a hindrance in aiming
    activities but can also excel in bowling and
    boccia
  • Promote proper warm-up
  • Main goal in early childhood is head and trunk
    control which serves to decrease undesired limb
    movement
  • Upright activities versus prone are stressed

50
Surgery and Braces
  • Various surgical procedures to correct or relieve
    problems caused by severe spasticity
  • Tenotomy
  • Myotomy
  • Arthrodesis
  • Braces are used to control spasticity and provide
    needed stability

51
Hip Dislocation, Scoliosis,and Foot Deformities
  • Nonambulatory children high risk for hip
    dislocations
  • Corrected with surgery
  • Scoliosis is associated with abnormal muscle
    tone, reflex problems and improper positioning
  • Foot deformities are associated with lack of
    attention to stretching tight calf muscles and
    Achilles tendon

52
Attitudinal Barriers
  • Multidisabled profiles
  • Ranked last or next to last as friendship choices
  • Affects success in mainstream activities,
    self-concept, and motivation

53
Fitness and CP
  • Difficulty making comparisons across
    classifications
  • Research reports significant differences on most
    measures
  • Body build differences may affect comparisons
  • Mechanical inefficiency increases energy used
  • Strength training should be supplemented with
    flexibility training

54
Sports and Aquatics
  • Team sports
  • Individual sports - generally more success
  • Paralympics and international issues

55
Team Sports
  • Soccer
  • Generally same as AB soccer
  • Coed, with seven players on a team
  • Classes 6, 7, and 8 participate
  • Two periods, 25 minutes each

56
Team Sports
  • Indoor wheelchair soccer
  • Classes 1 to 9, and all physical disabilities
    participate
  • Six-person teams
  • One motorized chair on the floor at all times
  • Uses a 10-inch playground ball
  • Played on a basketball court

57
Team Sports
  • Boccia
  • Played as team or individual sport
  • Uses baseball size leather balls
  • Balls are thrown, rolled, kicked, or can be
    propelled using an assistive device
  • Object is to get the ball as close as possible to
    the target ball

58
Individual Sports
  • Archery,
  • Bowling
  • Cycling
  • Track and field
  • Horseback riding
  • Swimming
  • Rifle shooting
  • Slalom
  • Table tennis
  • Powerlifting

59
Teaching Individual Sports
  • Use PFDs for swimming if necessary
  • Freedom can be gained using bicycles, tricycles,
    and horses
  • Slalom emphasizes wheelchair skills
  • Throwing activities are very popular
  • Bowling allows for many adaptations

60
Paralympics and International Issues
  • Segregated events
  • Paralympics participation limited
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