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