CHAPTER
14
Cerebral Palsy,
Traumatic Brain Injury,
and Stroke
David L. Porretta
Chapter 14 Cerebral Palsy, Traumatic Brain Injury, and Stroke
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
Three Classification Schemes
of Cerebral Palsy
• Topographical (anatomical)
• Neuromotor (medical)
• Functional (movement related)
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)
Neuromotor Classification
of Cerebral Palsy
• Spasticity—increased muscle tone
• Athetosis—low uncoordinated movements,
involuntary movements
• Ataxia—abnormal hyptonicity, balance
problems, clumsiness, awkwardness
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.
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.
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)
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)
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.
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.
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.
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)
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
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.
Selected Instructional Strategies
for Teachers of Students With TBI
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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.
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
Selected Risk Factors
Associated With Stroke
• Hypertension
• Smoking
• Diabetes mellitus
• Drug abuse
• Obesity
• Alcohol abuse
• Diet
Stroke Symptoms
• Cognitive or perceptual deficits
• Motor deficits
• Seizure disorders
• Communication problems
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
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.
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
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)
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
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)
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.
BNDSA Events
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Archery
Boccia
Bowling
Cross country
Cycling (bicycle and tricycle)
Equestrian
Powerlifting (bench press)
Slalom
Soccer (seven a side; indoor wheelchair)
(continued)
BNDSA Events (continued)
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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)