Cerebral Palsy, Stroke, and Traumatic Brain Injury

1
Cerebral Palsy, Stroke, and Traumatic Brain Injury

• Chapter 25

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Introduction

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

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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

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Definitions, Etiologies, and Incidence

• Orthopedic Impairments - IDEA
• Cerebral Palsy (CP)
• Stroke
• Separate category - IDEA
• Traumatic Brain Injury (TBI)

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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

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Cerebral Palsy (CP)

• Prenatal causes - before or during birth
• Maternal infection
• Chemical toxins
• Injuries to the mother
• Difficult deliveries

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Cerebral Palsy (CP)

• Acquired causes - before age 2
• Brain infections
• Brain traumas
• Chemical toxins
• Oxygen deprivation
• More common in males

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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

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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

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Types of Stroke

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

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Types of Stroke

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

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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

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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

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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

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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

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Soft Signs

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

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Associated Dysfunctions

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Profiles to Guide Assessment and Programming

• Sport classifications can be used to develop IEPs
  and IFSPs
• Determine nonambulatory versus ambulatory
• Use sport specific classifications

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Spasticity Problems

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

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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

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Correcting Common Problems

• Fisted hand
• Scissoring in supine position
• Abnormal arm position

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Rotation of the Trunk

• Decreased overall spasticity
• Rhythmic rolling activities
• Gentle rocking movements
• Also develop equilibrium reactions

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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

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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

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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

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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

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Attitudinal Barriers

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

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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

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Sports and Aquatics

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

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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

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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

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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

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Individual Sports

• Archery,
• Bowling
• Cycling
• Track and field
• Horseback riding

• Swimming
• Rifle shooting
• Slalom
• Table tennis
• Powerlifting

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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

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Paralympics and International Issues

• Segregated events
• Paralympics participation limited