Understanding Cerebral Palsy, Traumatic Brain Injury, and Stroke

1. chapter14 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 mild to severe • Other associated symptoms (e.g., speech and language, intellectual disability, 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 (rare) • Quadriplegia—total body involvement (all four limbs, neck, and trunk)

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

6. Functional Classification of Cerebral Palsy • Class l—poor range of motion, strength, and trunk control; motorized wheelchair • Class ll—poor strength and trunk control; propels wheelchair on level surface with legs only • Class lll—fair to normal strength in one extremity; propels chair independently; might walk short distances with assistance • Class lV—good strength and minimal control problems in arms and torso; uses assistive devices for distance; chair used for sport (continued)

7. Functional Classification of Cerebral Palsy (continued) • Class V—good strength and balance; moderate involvement in legs; no chair; might use assistive devices • Class Vl—fluctuating muscle tone; ambulates without aids; function varies; better mechanics running than walking • Class Vll—good functional ability on nonaffected side; walks and runs without aids; shows asymmetrical action • Class Vlll—good balance; minimal coordination problems; runs and jumps freely; little to no limp; might be slight loss of coordination in one leg

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

9. Traumatic Brain Injury • Insult to the brain—results in physical, cognitive, social, behavioral, and emotional functioning • Referred to as “silent epidemic” • Physical impairments—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—might result in short- or long-term memory deficits, poor attention and concentration, altered perception, communication disorders (reading and writing), poor judgment • Social / emotional / behavioral impairments—mood swings, lack of motivation, low self-esteem, inability to self-monitor, depression, sexual dysfunction, excessive laughing or crying, difficulty with impulse control, and difficulty in relating to others

11. Main Causes and Statistics of Brain Injury • Leading killer and cause of disability in children and young adults under 45 years of age in the United States. • About 5.3 million people in the U.S. have sustained a traumatic brain injury (TBI). • Males are twice as likely to sustain a TBI as females. • Motor vehicle accidents, violence, and falls are leading cause of injury. (continued)

12. Main Causes and Statistics of Brain Injury (continued) • Injury can also be caused by anoxia, cardiac arrest, near drowning, child abuse, and sports and recreation accidents. • Brain injury accounts for • 75% of all football deaths • 60% of all equestrian-related deaths

13. Classification and Degrees of Traumatic Brain Injury • Open head injury—might result from accident, gunshot wound, or blow to head resulting in a visible injury • Closed head injury—might be caused by severe shaking, lack of oxygen, cranial hemorrhage, blow to the head (e.g., such as occurs 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

14. Ranchos Los Amigos Hospital Scale (typically used in first few weeks or months following injury) • Level 1—no response (deep coma) • Level 2—inconsistent or nonspecific response to stimuli • Level 3—might follow simple commands; inconsistent or delayed manner; vague awareness of self • Level 4—severe decreased ability to process information; poor discrimination and attention (continued)

15. Ranchos Los Amigos Hospital Scale (continued) • Level 5—consistent response to simple commands; highly distractible; needs frequent redirection • Level 6—responses might be incorrect because of memory loss but appropriate to situation; exhibits retention of relearned tasks • Level 7—appropriate and oriented behavior; lacks insight; poor judgment and problem solving; requires minimal supervision • Level 8—ability to integrate recent and past events; requires no supervision once new activities are learned

16. Re-Entry 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 establish and 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.

17. 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 and instructions 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.

18. Stroke • Damage to brain resulting from faulty circulation • Can affect motor ability and control, sensation and perception, communication, emotions, consciousness, and other abilities • Varying degrees of disability—minimal loss to total dependency • Commonly causes partial or total paralysis to one side of the body • Most common form of adult disability • Rare in infants, children, and adolescents

19. Selected Risk Factors Associated With Stroke (controlled through appropriate lifestyle changes) • Hypertension • Smoking • Diabetes mellitus • Drug abuse • Obesity • Alcohol abuse • Diet

20. Stroke Symptoms (depend on location of damage; similar to CP and TBI) • Cognitive or perceptual deficits • Motor deficits • Seizure disorders • Communication problems

21. Stroke Classification • Cerebral hemorrhage (ruptured artery) • Ischemia (lack of appropriate blood supply to brain) • Transient ischemic attack (TIA)—very brief, sometimes unnoticed; might occur days, weeks or months prior to major stroke

22. Stroke — Educational Considerations • Teachers and coaches should be aware of these warning signs: • Sudden weakness or numbness of face, arm, or leg on one side of the body • Dimness or loss of vision • Loss of speech • Severe headache with no apparent cause • Unexplained dizziness, sudden falls (continued)

23. Stroke — Educational Considerations (continued) • Teachers and coaches should • Know medical history of students and players • Seek medical attention when needed

24. Safety Considerations • Teachers and coaches—closely monitor games and activities, especially for students prone to seizures or who lack good judgment. • Use special equipment for students with severe impairments (bolsters, crutches, standing platforms, orthotic devices). • Assist students with severe impairments who have difficulty moving voluntarily: • Into and out of activity positions • Physically support during activity • Actually help execute a specific skill or exercise

25. Brockport Physical Fitness Test • Incorporates the eight-level classification system used by NDSA 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)

26. Motor Development Considerations • Physical education and sport programs should encourage sequential development of fundamental patterns and skills • Emphasize authentic assessment and evaluation of functional skills • Goal is to achieve maximum motor control and development of functional recreation and leisure activities • Common standardized motor development tests • Denver Developmental Screening Test ll • Milani–Comparetti Developmental Chart • Peabody Developmental Motor Scale

27. Psychosocial Development Considerations • Lack of self-esteem • Low motivational levels • Problems with body image

28. Selected Physical Education and Sport-Specific Guidelines for CP • Strength—focus on strengthening extensor muscles; use moderate, not fast, movements. • Flexibility—perform regularly; relax target muscle groups; do static, not ballistic, movements. • Speed—activities are performed in a controlled, accurate, purposeful manner. • Motor coordination—allow time to plan movements; reduce loud noises and stressful situations; use relaxation and imagery techniques. • Perceptual–motor—reduce environmental distractions.

29. Selected Physical Education and Sport-Specific Guidelines for TBI and Stroke • Physical fitness—gradual introduction of exercises and activities; focus on relaxation and flexibility if spasticity (similar to CP) is present; use universal gym equipment rather than free weights when possible. • Motor control—break down complex skills and activities into simpler subskills; practice skills sequentially; provide sufficient time to process information; provide activity choices.

30. National Disability Sports Alliance (NDSA) • Provides competition and participation for athletes with CP, TBI , and stroke as well as a select group of sports for athletes with other physical disabilities (e.g., MD, MS, OI) • Three age divisions • Junior (up to 18 years of age) • Open (any age) • Masters (over 40 years of age) • Wheelchair and ambulatory sports for all three divisions (continued)

31. National Disability Sport Alliance (NDSA) (continued) • Sanctions regional and national championships • Offers coaching, training, and officiating clinics for professionals and volunteers • Publishes a variety of printed matter, including a sports rules manual and a newsletter

32. NDSA Events • Archery • Bocce • Bowling • Cross country • Cycling (bicycle and tricycle) • Equestrian • Power lifting (bench press) • Slalom (continued)

33. NDSA Events (continued) • Soccer (seven-a-side; indoor wheelchair) • Shooting • Swimming • Table tennis • Track (e.g., 60m weave; 100m; 1,500m; relays) • Field events (e.g., soft shot, medicine ball thrust, club throw, discus, long jump)