Chapter 14 Cerebral Palsy, Traumatic Brain Injury, and Stroke

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

2. 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

3. Three Classification Schemes of Cerebral Palsy • Topographical (anatomical) • Neuromotor (medical) • Functional (movement related)

4. Topographical Classification of Cerebral Palsy • Monoplegia—any one body part • Diplegia—major involvement of both lower limbs or minor involvement of both upper limbs  • Hemiplegia—one complete side of the body (arm and leg) • Paraplegia—both lower limbs only • Triplegia—any three limbs involved (rare) • Quadriplegia—total body involvement (all four limbs, neck, and trunk)

5. Neuromotor Classification of Cerebral Palsy • Spasticity—increased muscle tone • Athetosis—low uncoordinated movements, involuntary movements • Ataxia—abnormal hyptonicity, balance problems, clumsiness, awkwardness

6. Functional Classification of Cerebral Palsy • Class I—poor range of motion, strength, and trunk control; motorized wheelchair • Class II—poor strength and trunk control; propels wheelchair on level surfaces with legs only • Class III—fair to normal strength in one extremity; propels wheelchair independently; may walk short distances with assistance  • Class IV—good 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.

7. Functional Classification of Cerebral Palsy (continued) • Class V—good strength and balance; moderate involvement in legs; no chair, may use assistive devices • Class VI—fluctuating muscle tone; ambulates without aids; function varies; better mechanics running than walking • Class VII—good functional ability on unaffected side; walks or runs without aids; shows asymmetrical action • Class VIII—good 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.

8. Cerebral Palsy:Educational Considerations • Managed, not treated • Alleviating symptoms caused by brain damage  • Managing motor function—improving muscle control, muscle relaxation, functional skills  • Abnormal reflex development—interferes with development of functional skills (e.g., kicking and throwing balls)  • Physical therapy • Primary concern—to develop total person (use of collaboration or team approach)

9. 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)

10. 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.

11. 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.

12. Classification and Degrees of Traumatic Brain Injury • Open head injury—may result from accident, gunshot wound, or blow to head resulting in a visible injury. • Closed head injury—may 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.

13. Rancho Los Amigos Scale • Level I—no response (deep coma)  • Level II—inconsistent or nonspecific response to stimuli • Level III—may follow simple commands; inconsistent or delayed manner; vague awareness of self • Level IV—severely decreased ability to process information; poor discrimination and attention (continued)

14. Rancho Los Amigos Scale(continued) • Level V—consistent response to simple commands; highly distractible; needs frequent redirection • Level VI—responses may be incorrect due to memory but appropriate to situation; exhibits retention of relearned tasks  • Level VII—appropriate and oriented behavior; lacks insight; poor judgment and problem solving; requires minimal supervision • Level VIII—ability to integrate recent and past events; requires no supervision once new activities are learned

15. 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.

16. 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.

17. 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 disability—minimal 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

18. Selected Risk Factors Associated With Stroke • Hypertension  • Smoking  • Diabetes mellitus  • Drug abuse • Obesity  • Alcohol abuse  • Diet

19. Stroke Symptoms • Cognitive or perceptual deficits  • Motor deficits  • Seizure disorders • Communication problems

20. 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

21. 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.

22. 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

23. 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)

24. 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

25. 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)

26. 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.

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

28. 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)