Unit2: Cerebral Palsy

2.1 Concept and definition of Cerebral Palsy and Multi-sensory impairment

2.2 Assessment, Curriculum and teaching techniques- positioning, lifting and carrying, balance voluntary control, communication

2.3 Sensory impairments –curriculum and teaching techniques – ADL, orientation and mobility, communication, safety and security

2.4 Sensory motor stimulation

2.5 Adaptive and Assistive devices.

 

 

 

 

 

 

 

2.1 Concept and definition of Cerebral Palsy and Multi-sensory impairment

Cerebral palsy (commonly referred to as CP) affects normal movement in different parts of the body and has many degrees of severity.

CP causes problems with posture, gait, muscle tone and coordination of movement.

The word “cerebral” refers to the brain’s cerebrum, which is the part of the brain that regulates motor function. “Palsy” describes the paralysis of voluntary movement in certain parts of the body.

Definition

Cerebral Palsy is a group of conditions that are characterized by chronic disorders of movement or postures; it is cortical in origin, manifests itself early in life and is not the outcome of a progressive disease.

Cerebral Palsy is a syndrome as the following a combination of characteristics can be seen:

·        Motor Disorder.

·        Medical Conditions.

·        Sensory Impairments.

·        Hearing Disabilities.

·        Attention Deficits.

·        Language & Perceptual Deficits.

·        Behavioral Problems.

·        Mental Retardation.

Affected Areas of the Brain

The kinds of abnormal muscle tone and movement problems that a person with cerebral palsy experiences depend upon which area of the brain is injured.

Image result for affected area of the brain of cp

Characteristics of CP

Spastic

Athetoid/dyskinetic

Ataxic

These developmental movement disorders can be limited to: one side of the body, the legs, the arms, all four limbs or just one limb.

Conditions associated with cerebral palsy

Cerebral palsy is caused by damage to or malformation of the areas of the brain that control motor function during fetal development. Children with CP often have coexisting conditions, which are health conditions that a person has in addition to cerebral palsy. These other conditions may be the result of having cerebral palsy or an unrelated, but common co-occurrence.

 

Oral Motor Impairment (Problems with Feeding, Swallowing and Drooling)

Children with cerebral palsy often have impaired oral motor control, which means they have difficulty controlling the muscles in their mouth and throat. This can lead to problems with feeding (sucking, chewing, etc.) and dysphagia, or difficulty swallowing. In some cases, those with dysphagia may experience pain when swallowing or be unable to swallow at all.

Gastroesophageal reflux disease (GERD) is common among those with cerebral palsy. GERD is a digestive disease in which stomach acid is regurgitated into the esophagus.

Children who have difficulty swallowing and/or GERD are at risk for aspiration, which is when food, liquids, saliva or vomit are inhaled into the lungs. Frequent aspiration can lead to respiratory problems, like aspiration pneumonia, and may be life-threatening.

Those with impaired fine motor skills may also have trouble using their hands to transport food or drink to their mouth. These children may have to rely on a caretaker or assistive equipment to feed them. Feeding and swallowing problems can lead to poor nutrition, dehydration and low weight.

It’s estimated that 85 to 90 percent of children with cerebral palsy experience feeding and swallowing difficulties, especially those with moderate to severe cases of CP.

Oral motor impairment also causes drooling in about 30 percent of cerebral palsy patients. Problems with feeding and swallowing, as well as drooling, can be improved through speech and occupational therapy.

Speech Impairment

Many children with cerebral palsy have dysarthria, a motor speech disorder. People with dysarthria have difficulty controlling the muscles used for speech, such as the:

Apraxia of speech is another common motor speech disorder that affects children with cerebral palsy. Childhood apraxia of speech, as it’s referred to in children, is when a child has difficulty saying words, sounds and syllables. The child knows what they want to say, but their brain is unable to plan and coordinate the muscle movements needed to do so.

Children with cerebral palsy may also struggle with speech sound disorders. These include problems with articulation and phonological processes, or speech patterns used by children to simplify adult speech.

It’s estimated that more than half of children with cerebral palsy have some sort of speech impairment. Speech disorders can usually be improved through speech therapy.

 

Sensory Problems

A child’s ability to process information received from the senses may also be affected depending on the severity and extent of their brain injury. This is called sensory processing disorder. Children with sensory processing disorder can experience increased or decreased sensory reactions, which can lead to problems with development and behavior.

For example, a child who has an increased sensitivity to touch (known as hypersensitivity) may not like the feeling of certain textiles and will act out or scream if they come in contact with one. On the other hand, a child with a decreased sensitivity to touch (known as hyposensitivity) may play aggressively or bump into things without showing pain.

Sensory problems are common among children with other neuro-developmental disorders, like autism.

 

2.2 Assessment, Curriculum and teaching techniques- positioning, lifting and carrying, balance voluntary control, communication

Assessments are used to understand the types and severity of cerebral palsy (diagnosis), to help make predictions about the future (prognosis), to assist with planning interventions and to measure the outcomes or effectiveness of interventions and therapies (outcome measures). Assessments are also used in research.

The assessments and outcome measures which we include on this site have either been developed specifically to be used with people with cerebral palsy or are widely understood to be appropriate to use with people with cerebral palsy. We have focused on including assessments and outcomes measures which are typically used in clinical practice, rather than in research.

There is no single test to diagnose cerebral palsy. But since cerebral palsy is the result of multiple different causes, the tests performed are used to identify specific causes when possible. Other tests will be performed to assess the condition of the child (nutritional status for example) or to assess other concomitant conditions that the child might have.

Evaluation of an ambulant child with CP requires a unified Multi-Disciplinary Team (MDT) often comprising of a medical doctor or paediatrician, rehabilitation consultant, neurologist, orthopaedic consultant, physiotherapist, occupational therapist, clinical scientist and orthotist.  The MDT needs to have a close working relationship with the parents or caregivers to ensure consent is provided for assessment or for any proposed interventions and to ensure the treatment is incorporated into everyday family life.  

Recommended activities at home and school

Stretching: Stretching of muscles is done by moving the arms or legs in a way that produces a slow, steady pull on the muscles to keep them loose. Children with cerebral palsy have increased tone and tend to get very tight muscles. Therefore, it is extremely important to perform daily stretches to keep arms and legs limber so the child can continue to move and function. 

Strengthening: Strengthening exercises work specific muscle groups to enable them to support the body better and increase function. 

Positioning: The body is placed in a specific position to attain long stretches. Some positions help to minimize unwanted tone. Positioning can be done in a variety of ways, including: bracing, abduction pillows, knee immobilizers, wheelchair inserts, sitting recommendations, and handling techniques.

Positioning the child in class

The head should be straight, the body symmetric, the arms straight, both hands in use and weight bearing should be equally distributed.

·        Functional position should be comfortable

·        Seating adaptations for children (to meet specific needs) like special cushions, corner seats, wheelchairs cut out tables, and walkers should be provided.

·        Teachers should see that the aids do not restrict a child’s movement.

·        Educational goals for individuals students must be developed on the basis of evaluation data.

·        Consider the present physical and communication capabilities of the child.

Use of walkers

There are several types of walkers.  The infant walker is designed for children from 1 ˝ to 4 years of age.  The child walker is for children from 2 to 8 years who are not expected to be ambulatory in future.  

Instructional activities

·        Place a rattle or a toy of the child’s  choice on a chair in the corner of a room.  Tell/gesture  the child who is using an infant walker to move across the room and retrieve the toy.  Then ask him to bring it to you.

·        Tell/gesture the child in an upright walker to follow a group of cardboard arrows that have been placed on the floor.

·        Play a “retrieval” game.  Tell the child to move forward in the walker to retrieve a toy or object from a chair.

Use of crutches

Crutches are used to increase balance and stability as well as to reduce or eliminate stress on weight bearing joints.  Basically they compensate for  loss of muscle control. However any assistive device should be used only after the appropriate medical consultations. 

Instructional activities

·        Show the child the four-point gait.  This gait offers maximum support because there are always three points of contact with the ground.  The cycle for the child to follow is (1) right crutch forward (2) left foot forward (3) left crutch forward and (4) right foot forward.  Assist the child in practicising this gait pattern.

·        When appropriate, tell the child to practise going from one end of the room to the other using two-point gait.  This requires the child to be able to balance on one leg and involves a significant amount of skill.

·        At home, take the child to a community event such as holi celebrations or Diwali Mela.  Assist him when necessary.  Wait until he is ready and moves independently with crutches inside the house before you take him out. 

Use of canes

Canes provide less support than crutches.  Some canes are weighted with lead to provide added stability but most are not.  Canes are of various types e.g. wood, aluminum, Tripod cane and so on.

Instructional activities

·        Indicate to the child that he should walk towards you using his cane.  Indicate that he should bring the cane and affected leg forward simultaneously and then bring the unaffected limb forward.  Practice with the child and correct him when this sequence is not followed.

·        Place empty paper cups next to the `x’ marks on the floor.  Plan a game in which the children walk to each  `x’ and pick up the empty cup.  The child with the maximum cups at the end of a time limit wins the game and should be rewarded.

·        In the community, take the child to a street where there is a high curb.  Tell him to step up on the curb the same way he climbed stairs.

Use of wheelchair

When wheelchair is prescribed by the doctor, it should be judged for its durability, strength, size and weight.  It should fold easily and have replaceable parts and accessories.  
Instructional activities

·        First practise by yourself how to unfold and fold a wheelchair.  Show the child how to unfold a folded wheelchair.

·        Show the child to close the wheelchair.  First check to see if the arms are locked.  Fold up the footrests.  Make a fold in the seat from above or below.  If above, pull up, closing the chair.  Assist the child in carrying out each of the steps.

·        Show the child how to use his wheelchair seat belt.

·        Ask the child in a wheelchair to wheel the chair a very short distance.  Show the child how to lock and unlock the brakes of an empty chair.

·        Stand behind the child and call  him to come to you in a backward movement.  Show the child how to make turns in his wheelchair.  Also show how if the child is in bed, can be transferred to wheelchair.  Supervise all the actions till the child is independent.  Use various prompts suitably and fade support gradually.

2.3 Sensory impairments –curriculum and teaching techniques – ADL, orientation and mobility, communication, safety and security

Recommended Teaching Methods for Students with CP

When deciding that a student with CP would have their interests best served in a mainstream classroom environment, teachers, parents, and therapists should develop an Individualized Educational Plan (IEP). The IEP should detail information on the child's diagnosis and the degree to which the child is affected by the condition. This includes listing the child's present level of performance in the various subject areas. These performance levels should describe in detail what the child is able to accomplish and what their current skill levels are. In any of the areas in which the child is functioning below age level, goals and objectives should be written to address the areas of weakness.

The IEP should also include a list of services and accommodations that the school district will provide. Teaching children with cerebral palsy is often an unfamiliar circumstance for a regular education instructor, but with assistance from therapeutic programs and access to modifications in the classroom, students with CP can thrive in a general setting alongside their non-disabled peers.

It is important for children with CP to have an educational program that is conducive for learning. When setting up a learning program, teachers should consider the child’s capabilities as well as limitations, and keep in mind that unrealistic expectations can be frustrating for the child as well as the parents. Patience is a key factor when working with children with CP, as studies have shown that these students take longer to respond than their neurotypical peers.

It is important for students with CP to assume a variety of positions throughout the school day in order to prevent tightening of muscles. Equipment needs are extremely important, as proper positioning can facilitate eye-hand coordination and improved motor control. Most importantly, teachers should maintain open communication with the child’s family in order to encourage carry-over regarding home programs and recommendations.

Teaching strategies

·         Break tasks and assignments into short, easy-to-manage steps. Provide each step separately and give feedback along the way.

·         Provide copies of notes or use student writers if handwriting is difficult.

·         Provide clear expectations, consistency, structure and routine for the entire class. Rules should be specific, direct, written down and applied consistently.

·         Give clear, brief directions. Give written or visual directions as well as oral ones. Allow extra time for oral responses.

·         Teach strategies for what to do while waiting for help (e.g. underline, highlight or rephrase directions; jot down key words or questions on sticky notes).

·         If the student uses an alternative form of communication, like a communication book or device, make sure it is available to him or her at recess and lunchtime. Teach peers how interact with the student using the communication device or book.

·         Use low-key cues, such as touching the student's desk to signal the student to think about what he or she is doing without drawing the attention of classmates.

·         Use instructional strategies that include memory prompts. Teach strategies for self-monitoring, such as making daily lists and personal checklists for areas of difficulty.

Assistive technology for limited mobility

There are numerous mobility aids, also called assistive technologies or assistive devices, to help with mobility limitations associated with cerebral palsy. Most assistive devices can be adjusted to fit a child’s height or can be specially made to fit their individual needs. Assistive devices greatly improve a child’s quality of life, as well as increase their independence.

Orthotic Devices

Orthotic devices are braces worn externally that improve and strengthen mobility. There are two types of orthotic devices: accommodative orthotics and functional orthotics.

Accommodative orthotics are “over the counter” devices, which means they do not require a prescription or the approval of a doctor to be purchased. They are made in various sizes to fit anyone and can be bought in most pharmacies or sporting goods stores.Functional orthotics are specifically made for the individual.

Functional orthotics are commonly used by those with cerebral palsy because they can be customized to fit the individual’s needs.

Orthotic devices come in hard, semi-soft or soft forms. There are many types of orthotic braces, including:

Walkers

Walkers can assist children with cerebral palsy with their mobility issues, including problems with balance and posture. They also allow the child to bear weight on their legs, which increases bone strength and reduces the risk of fractures and osteoporosis.

There are several kinds of walkers available to help those with cerebral palsy, such as:

Walking Sticks and Canes

Walking sticks and canes are a cost effective option that provide extra balance and stability for those with milder forms of cerebral palsy. They are most helpful in patients with hemiplegia or monoplegia.

Canes and walking sticks can be adjusted to fit the child’s height. There are several types of canes, including:

Crutches

Crutches are often used by those with cerebral palsy who have the ability to ambulate, or walk, but need extra help with balance and stability. There are two types or crutches: underarm crutches and forearm, or elbow, crutches.

Underarm crutches are mostly used for short term disability, like a broken leg. Forearm crutches are used for long term or lifelong disabilities and more commonly used by cerebral palsy patients. These crutches attach to the forearms and help with balance, but are not meant to take on the user’s full weight.

Standers

Standers are devices that allow those with cerebral palsy to stand for short or extended periods of time. They help to support a person’s weight and provide stability while in the upright position.

There are many benefits of using a stander. Standers:

The following types of standers may be helpful to those with cerebral palsy:

Lifts

There are a number of lift options to help those who have difficulty transferring positions and supporting their body weight. Some lifts that are helpful with cerebral palsy include:

Wheelchairs

Wheelchairs are common mobility aids for non-ambulatory cerebral palsy patients. There are numerous design options and features to choose from, but there are two basic types: manual wheelchairs and power, or electric, wheelchairs.

Manual wheelchairs must be propelled by the user or pushed by another person, while power wheelchairs are motorized.

Manual wheelchairs are a more cost effective option, but they do require upper body strength to move them. There are several types of manual wheelchairs, including:

Power wheelchairs are more expensive, but are more convenient for those who do not have the ability to propel a manual wheelchair. They’re also well suited for those who maintain an active lifestyle. These chairs come with many different features and options. They’re also very customizable to an individual’s needs. Electric wheelchairs come in rear wheel, front wheel or mid wheel drive and have a variety of different battery options.

It’s important to consider the following when buying a wheelchair:

Power Scooters

Power scooters are an alternative to wheelchairs and are often cheaper than power wheelchairs. They’re great for use outdoors and for those who do not have the upper body strength to operate a manual wheelchair.

While power scooters are more compact than power wheelchairs, they’re more difficult to maneuver because of their longer design. They’re also not as customizable for day-to-day activities and can be difficult to transport because of their heavy weight.

Communication Devices

Children with various types of cerebral palsy often struggle with the essential ability to communicate. This is due to symptoms of CP such as muscle spasms in the throat, mouth and tongue. These physical limitations make it difficult to form words or sentences, which can make daily life a challenge for children and parents alike.

Assistive communication devices empower a child with CP to meaningfully contribute to conversations and form friendships and relationships. With the help of these devices, children with CP are able to ask questions, express emotions and actively engage in the world around them.

Electronic Communication Boards

An electronic communication board is a tool that allows children to choose letters, words and phrases on a screen to verbally express their thoughts and emotions. These boards are similar to electronic tablets and contain letters, images, photos and symbols that a child can point to with their finger or a pointer tool. Then, the selected words or symbols are generated into sentences that are read out loud for others.

Images and phrases are organized into categories such as food, people, sports and objects so that children can easily search and select the words or phrases they want. Generally, communication boards can produce 8-12 words per minute.

The level of training needed to operate a communication board depends on the child’s existing level of literacy, as they may need to be taught the meaning of symbols and images before using the device. This can be done in speech therapy where a Speech Language Pathologist (SLP) will teach the child how to use the assistive device to communicate.

Communication boards come in two basic types:

Eye-Tracking Devices

Oftentimes, individuals with cerebral palsy have difficulty moving their arms, wrists, hands or fingers. This can make selecting images or symbols on a communication board difficult. Fortunately, there is eye-tracking technology available that eliminates the need to actually push a button or use a pointer.

Many high-tech communication boards feature eye-tracking technology that functions like a mouse on a computer, allowing users to make eye contact with a symbol or letter for a short period of time to make a selection. Once a symbol has been “selected,” it is received by the device in the same way it would have been with a physical point or click.

Eye-tracking devices are incredibly helpful for children with a more severe level of CP that limits their upper mobility. This type of technology is often utilized during speech therapy and treatment to improve the ability to express thoughts and ideas. Parents of children who have limited movement in their arms, hands or fingers should seek out communication devices that operate using eye-tracking technology. This will assure that a child’s development or communication isn’t being restricted by physical capabilities.

Adaptive Writing and Typing Aids

Children with CP often have reduced hand or finger movement, as well as decreased grasping power and strength. This can affect their ability to write or type, as they may have difficulty using a traditional writing utensil or keyboard.

Adaptive tools that help children with disabilities gain control over their movements and perform tasks such as writing and typing are instrumental to ensuring that they stay on track with their educational program.

Writing Aids

There are various aids that can help individuals with CP learn the valuable skill of writing without having to worry about being in pain or straining different parts of the body.

Writing aids come in the form of:

Typing Aids

For children with limited mobility in their hands and arms, a typing aid can be extremely beneficial to provide the additional support needed to press small buttons or keys on devices such as communication boards.

Typing aids are fastened around the hand with a Velcro or elastic brace and come with a metal or steel “pointer” that extends out of the brace. Individuals can use the “pointer” of the typing aid to press down on the keys on a keyboard or to steadily push smaller buttons, such as on a telephone or calculator. This can allow children to use technology that was previously difficult for them, as it is transferrable to any device.

Specialized technology devices provide individuals with cerebral palsy the opportunity to enjoy life independently. Devices are available in various shapes and sizes to ensure that every child with CP is able to receive the assistance they need as they transition into adulthood.

Benefits to using assistive devices include:

Similar to mobility aids, the overall advantage to using assistive devices is that they allow for an improved quality of life for a child with cerebral palsy. With the help of these tools and devices, children with CP are given the opportunity to be self-sufficient and participate in everyday life with confidence.

 

2.4 Sensory motor stimulation

The senses play a big role in how people perceive the world. The sights, smells and tactile experiences inform a child’s impressions early on, and often. They inform the body of so many things people find appealing in life, such as the fragrance of a rose, the vibrant colors of a beautiful painting, or the softness of a blanket.

When a child has a brain injury, sometimes these perceptions are off kilter with a decreased or increased ability to process. Sensory integration helps build the mental and physical framework within an individual’s nervous system to properly perceive sensory input, regulate his or her responses, and understand the significance behind a particular, texture, movement, or sound. The benefits of sensory integration therapy are often physical, but also psychological.

Sensory integration

Individuals with Cerebral Palsy or children born prematurely can display symptoms of sensory integrative dysfunction, an abnormal degree of sensory processing, whether decreased or increased. Sensory integrative dysfunction can make a child appear clumsy when he or she walks, or create difficulty with fine motor skills such as pencil control, which, in turn, can lead to delay in writing ability.

Sensory dysfunction can also cause over-sensitivities or under-sensitivities that lead to mental and physical distraction or fatigue. Problems with sight, hearing and balance can be addressed through sensory integration therapy.

What is sensory integration therapy?

Developed in the 1960s by occupational therapist and researcher Jean Ayers, Ph.D., sensory integration therapy is a process by which children build and strengthen the connections within the brain that most young people develop through childhood experiences. Therapy is designed to help children interpret sensory input, understand its relevance, and respond – especially to external stimuli that are often beyond their control.

For example, a child may be asked therapy to pick up an object such as a ball. Though the child sees the ball, and understand what it’s used for, he or she may not be able to recognize or describe the ball because of visual miscues. The child may also inaccurately perceive the weight or texture of the ball due to over-sensitivity, or lack of sensitivity, to touch.

The senses that sometimes are disordered in children with Cerebral Palsy are:

·         Auditory – hearing

·         Olfactory – smell

·         Oral – taste

·         Prioprioception processing – unconscious information obtained by the muscles and joints regarding your position in space, the weight of objects, the pressures felt, the stretch, body movement, and position changes.

·         Tactile or somosensory – Touch

·         Vestibular processing – unconscious information obtained through the inner ear for equilibrium, position in space and gravity.

·         Vision

A child’s sensory processing is problematic if they are:

·         Over-responsive – avoidance, caution and fearful

·         Sensory seeking – impulsive and takes risks

·         Under-responsive – withdrawn, passive or difficult to engage

The goals of sensory integration therapy are:

·         Assist children with perception issues in sorting out mixed messages

·         Create a physical environment that fosters participation in activities that depend on the senses

·         Determine how a child’s specific sensory perceptions affect their overall physical, social and human development

·         Encourage activities that allow children to explore their environment, learn and develop their senses

·         Identify and eliminate barriers caused by disordered perception

·         Implement new sensory processing approaches that organize multiple sensations, filter out background stimuli, and compensate for deficits in perception

·         Restore a child’s sense of body position and function (also known as vestibular and proprioception)

·         Restore motor planning (praxis) capabilities, so a child can focus on his or her senses to plan movement, respond to other’s movements, and understand the body’s relationship to space

The physical benefits of therapy include:

·         Balance responsivity – over responsivity and under responsivity

·         Gravitational security

·         Hand-eye coordination

·         Improved motor-planning

·         Improved sleep cycles

·         Language development

·         Posture

The psychological benefits of therapy include improvements in:

·         Attention

·         Confidence

·         Emotional outbursts and frustration

·         Moodiness

·         Procrastination

·         Restlessness

·         Socialization

 

2.5 Adaptive and Assistive devices.

Assistive technology is a broad term that includes any device or piece of equipment that can be used to help a person perform some type of activity or improve their ability to function. An adaptive device is any tool or other device that has been altered in a specific way that makes it easier for a person with a disability to use.

Assistive technology inspires:

Alternative and augmentative communication (AAC) technology has direct benefits for children with CP, helping them overcome challenges and successfully interact in diverse social settings.

Assistive Devices Help With Routine Tasks

Cerebral palsy patients face challenges completing everyday tasks.  From dressing and eating to personal care, daily activities can pose difficulties.  Various adaptive devices make routine tasks easier, empowering CP patients to enjoy independent lives. Assistive devices and equipment contribute in diverse settings:

Bath –

Kitchen –

Bedroom –

Classroom –

It’s important to remember that technology needs may change as a person grows and develops. Technology should match the developmental needs of children and be reevaluated regularly. Similarly, adults with cerebral palsy have unique and changing needs, requiring technology to be adjusted over time.