Chapter 14 Cerebral Palsy, Traumatic Brain Injury, and Stroke

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Chapter 14 Cerebral Palsy, Traumatic Brain
Injury, and Stroke
C H A P T E R
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Cerebral Palsy, Traumatic Brain Injury, and Stroke
David L. Porretta
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Cerebral Palsy

• A group of permanently disabling conditions
• Damage to motor control areas of the brain
• Symptoms vary from mild (only slight speech
  impairment) to severe (total inability to control
  body)
• Other symptoms associated with cerebral palsy
  (e.g., speech and language, mental retardation,
  sensory impairments) 
• Premature infant five times more likely to be
  born with CP than full-term baby

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Three Classification Schemes of Cerebral Palsy

• Topographical (anatomical)
• Neuromotor (medical)
• Functional (movement related)

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Topographical Classification of Cerebral Palsy

• Monoplegiaany one body part
• Diplegiamajor involvement of both lower limbs or
  minor involvement of both upper limbs 
• Hemiplegiaone complete side of the body (arm and
  leg)
• Paraplegiaboth lower limbs only
• Triplegiaany three limbs involved (rare)
• Quadriplegiatotal body involvement (all four
  limbs, neck, and trunk)

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Neuromotor Classification of Cerebral Palsy

• Spasticityincreased muscle tone
• Athetosislow uncoordinated movements,
  involuntary movements
• Ataxiaabnormal hyptonicity, balance problems,
  clumsiness, awkwardness

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Functional Classification of Cerebral Palsy

• Class Ipoor range of motion, strength, and trunk
  control motorized wheelchair
• Class IIpoor strength and trunk control propels
  wheelchair on level surfaces with legs only
• Class IIIfair to normal strength in one
  extremity propels wheelchair independently may
  walk short distances with assistance 
• Class IVgood strength and minimal control
  problems in arms and torso uses assistive
  devices for distance chair used for sport
• (continued)
• Adapted by permission from National Disability
  Sport Alliance, 2008.

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Functional Classification of Cerebral Palsy
(continued)

• Class Vgood strength and balance moderate
  involvement in legs no chair, may use assistive
  devices
• Class VIfluctuating muscle tone ambulates
  without aids function varies better mechanics
  running than walking
• Class VIIgood functional ability on unaffected
  side walks or runs without aids shows
  asymmetrical action
• Class VIIIgood balance minimal coordination
  problems runs and jumps freely little to no
  limp maybe slight loss of coordination in one
  leg
• Adapted by permission from National Disability
  Sport Alliance, 2008.

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Cerebral PalsyEducational Considerations

• Managed, not treated
• Alleviating symptoms caused by brain damage 
• Managing motor functionimproving muscle control,
  muscle relaxation, functional skills 
• Abnormal reflex developmentinterferes with
  development of functional skills (e.g., kicking
  and throwing balls) 
• Physical therapy
• Primary concernto develop total person (use of
  collaboration or team approach)

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Traumatic Brain Injury

• Insult to the brain affecting physical,
  cognitive, social, behavioral, and emotional
  functioning.
• Referred to as silent epidemic.
• Physical impairments include lack of
  coordination, planning and sequencing movements,
  muscle spasticity, headaches, speech disorders,
  paralysis, and sensory impairments (vision
  problems).
• (continued)

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Traumatic Brain Injury (continued)

• Cognitive impairments may result in short- or
  long-term memory deficits, poor concentration,
  altered perception, communication disorders
  (reading, writing), and poor judgment.
• Social, emotional, and behavioral impairments
  include mood swings, lack of motivation, low
  self-esteem, inability to self-monitor,
  depression, sexual dysfunction, excessive
  laughing or crying, and difficulty with impulse
  control and relating to others.

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Brain Injury Statistics

• Leading killer and cause of disability in
  children and young adults under 45 years of age
  in U.S.
• About 5.3 million Americans have sustained a
  traumatic brain injury (TBI).
• Males 1.5 times more likely to sustain a TBI than
  females.
• Motor vehicle accidents, violence, and falls are
  leading causes of injury.
• Can also be caused from anoxia, cardiac arrest,
  near drowning, child abuse, and sport and
  recreation accidents.

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Classification and Degrees of Traumatic Brain
Injury

• Open head injurymay result from accident,
  gunshot wound, or blow to head resulting in a
  visible injury.
• Closed head injurymay be caused by severe
  shaking, lack of oxygen, cranial hemorrhage, or
  blow to the head as in boxing.
• Can range from very mild to severe.
• Severe degree of injury characterized by
  prolonged state of unconsciousness and many
  functional limitations remaining after
  rehabilitation.

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Rancho Los Amigos Scale

• Level Ino response (deep coma) 
• Level IIinconsistent or nonspecific response to
  stimuli
• Level IIImay follow simple commands
  inconsistent or delayed manner vague awareness
  of self
• Level IVseverely decreased ability to process
  information poor discrimination and attention
• (continued)

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Rancho Los Amigos Scale (continued)

• Level Vconsistent response to simple commands
  highly distractible needs frequent redirection
• Level VIresponses may be incorrect due to memory
  but appropriate to situation exhibits retention
  of relearned tasks 
• Level VIIappropriate and oriented behavior
  lacks insight poor judgment and problem solving
  requires minimal supervision
• Level VIIIability to integrate recent and past
  events requires no supervision once new
  activities are learned

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Reentry Programs Educators and Parents Working
Together (Walker, 1997)

• Collaboration means sharing control with parents
  in educational planning.
• Value parents as primary decision makers in
  determining quality of life and interventions.
• Strive to maintain rapport and trust in
  relationships with parents.
• Strive for educational programs that include
  equal proportions of parent and professional
  goals.
• Work to resolve disagreements and interpersonal
  tension between teachers and parents.

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Selected Instructional Strategies for Teachers
of Students With TBI

• Use the top-down approach to instruction.
• Use frequent reminders.
• Provide additional time for review.
• Present information in simple steps.
• Help student organize information and use special
  techniques to remember material.
• Use task analysis. 
• Use cooperative learning activities. 
• Color-code written materials.

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Stroke

• Damage to brain resulting from faulty
  circulation 
• Can affect motor ability and control, sensation
  and perception, communication, emotions,
  consciousness, and so on
• Varying degrees of disabilityminimal loss to
  total dependency
• Most commonly causes partial or total paralysis
  to one side of body 
• Most common form of adult disability 
• Rare in infants, children, and adolescents

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Selected Risk Factors Associated With Stroke

• Hypertension 
• Smoking 
• Diabetes mellitus 
• Drug abuse
• Obesity 
• Alcohol abuse 
• Diet

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Stroke Symptoms

• Cognitive or perceptual deficits 
• Motor deficits 
• Seizure disorders
• Communication problems

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Stroke Classification

• Cerebral hemorrhage (ruptured artery)
• Ischemia (lack of appropriate blood supply to
  brain)
• Transient ischemic attack (TIA) 
• Very brief sometimes unnoticed 
• May occur days, weeks, or months prior to major
  stroke

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Stroke Educational Considerations

• Be aware of warning signs
• Sudden weakness or numbness of face or arm or leg
  on one side of body
• Dimness or loss of vision
• Loss of speech
• Severe headache with no apparent cause
• Unexplained dizziness and sudden falls
• Teachers and coaches should 
• know medical history of students, and
• seek medical attention when needed.

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Safety Considerations

• Teachers and coaches closely monitor activities,
  especially for students who are prone to seizures
  or who lack good judgment.
• Use special equipment for students with severe
  impairments, such as bolsters, crutches, standing
  platforms, and orthotic devices.
• Assist students with severe impairments who have
  difficulty moving voluntarily.
• In and out of activity positions
• Physical support during activity
• Help in executing a specific skill

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Brockport Physical Fitness Test

• Incorporates 8-level classification system used
  by BNDSA and CPISRA
• Test components
• Aerobic functioning (e.g., target aerobic
  movement test)
• Body composition (e.g., skinfold measures)
• Musculoskeletal function
• Flexibility (e.g., modified Apley test)
• Muscular strength and endurance (e.g., seated
  push-up)

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Motor Development Considerations

• Physical education and sport programs that
  encourage sequential development of fundamental
  patterns and skills
• Authentic assessment of functional skills
• Goal to achieve maximum motor control and
  development of functional recreation and leisure
  activities
• Common standardized motor development tests
• Denver Developmental Screening Test
• Milani-Comparetti
• Peabody Developmental Motor Scales

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BlazeSports National Disability Sports Alliance
(BNDSA)

• Provides competition and participation for
  athletes with CP, stroke, and TBI.
• Three age divisions 
• Junior (up to 18 years of age)
• Open (any age)
• Masters (over 40 years of age)
• Offers wheelchair and ambulatory sports for all
  three divisions.
• (continued)

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BlazeSports National Disability Sports Alliance
(BNDSA) (continued)

• Sanctions regional and national competitions.
• Offers coaching, training, and officiating
  clinics for professionals and volunteers.
• Publishes a variety of printed matters, including
  a sport rules manual and a newsletter.

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BNDSA Events

• Archery 
• Boccia
• Bowling 
• Cross country
• Cycling (bicycle and tricycle)
• Equestrian
• Powerlifting (bench press)
• Slalom 
• Soccer (seven a side indoor wheelchair) 
• (continued)

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BNDSA Events (continued)

• Shooting
• Table tennis
• Track (e.g., 60 m weave 100 m 1500 m relays)
• Field events (e.g., soft shot medicine ball
  thrust club throw discus long jump)