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Cerebral Palsy
- 2. Cerebral Palsy - Heterogenous group of motor function disorders - Non-curable - Life-long condition - Non-progressive - May be congenital or acquired
- 3. Prevalence - 1 in 500 babies or 0.2% - Occurs equally among males and females
- 4. Causation - Insult / Injury to the brain - In single or multiple areas of motor centers - E.g. Meningitis, bleeding in the brain - Development malformations, failures - Cerebral dysgenesis - Neurological damage - Illness - Lack of oxygen - Trauma to the head during labour and delivery - Infections - Rubella, cytomegalovirus
- 6. Assessment Practices Physical evaluation Assessment tools Neuroimaging Interview Laboratory Tests
- 7. *Types CP According to - Neurologic deficits - Extent of damage - Area of brain damage - Type of movement disorder (and location of brain injury) - Spastic (80%) -- Upper motor neuron - Ataxic (5-10%) -- Cerebellar - Dyskinetic (5-10%) -- Basal Ganglion - Mixed (10%) -- Spastic & Athethoid
- 8. *Types CP
- 10. * Classification by Motor Function
- 11. *Degree of Severity Mild - Can live independently, move without assistance; his or her daily activities are not limited. - 20% Moderate - Require self help for assisting their impaired ambulation capacity - need braces, medications, and adaptive technology to accomplish daily activities. - 50% Severe - Totally incapacitated and bedridden, significant challenges in accomplishing daily activities. No CP - Signs of CP, but impairment acquired after completion of brain development - Incident that caused the cerebral palsy Eg. Traumatic brain injury or encephalopathy
- 12. *Symptoms Early Signs Baby Below 6 Months - Head lags when picked up - Stiff and/ or floppy Baby Older than 6 Months - Does not roll over - Cannot bring hands together - Difficulty bringing hands to mouth General Symptoms - Posture / balance problem - Loss of control or coordination - Abnormal tone - Abnormal strength - Abnormal reflexes - Persistent motor delay - Cognitive deficit - Associated handicaps
- 14. *Associated Problems *Pain - Contractures, Abnormal postures, Skin breakdown
- 15. Hands-On Activity (5-7min) Goal: To experience what it is like to have cerebral palsy or a caregiver Client’s goal: To put on and button a shirt Caregiver’s goal: To encourage independent function
- 16. Hands-On Activity (5-7min) Instructions 1.Get into pairs 2.Choose A & B 3.Be given your scenario 4.Prepare for the scenario 5.Begin
- 17. Hands On Activity (5-7mins) Fine Motor Impairment + Associated Problems Scenarios: - Blind - Deaf - Speech Impairment - Arm spasticity - Scissor Leg Gait
- 18. Hands-On Activity: Sharing What’s your experience?
- 19. *Impact of Disability: Intelligence & Perception Intelligence - Mental retardation - Learning difficulties - Working Memory - Numeracy - Literacy Perception - CNS damage - Sensory integration dysfunction - Difficulty processing sensory cues - Difficulty judging distances
- 20. *Impact of Disability: Language - Information input - Auditory information processing - Muscular control - Over muscles of the mouth, tongue, throat - Respiratory coordination - Communication output - Disjointed speech - Slurred speech - Cued speech / Sign language - 1 in 4 cannot talk
- 21. *Impact of Disability: Language - Augmentative & Alternative Communication - Any device, system or method that improves the ability of a person with a communication impairment to communicate effective - Types - Aided communication: low-tech, high-tech - Unaided communication: facial expression, gestures
- 22. *Impact of Disability: Social - Self Adolescence - Research found lower self concept in females → physical appearance, social acceptance Adults - Less participation in social interactions, employment, marriage and independent living compared to adults without CP
- 23. *Impact of Disability: Social
- 24. *Impact on the Family - Adequate knowledge helps family to cope better - Frustration - Financial costs - Need for behaviour management - Financial costs - Social Stigma
- 25. *Impact of Disability: Personality Development Challenging behaviours
- 27. Cerebral Palsy Alliance Singapore - Established in 1957 - Formerly Spastic Children’s Association of Singapore - Vision: Empowering all persons with CP to realise their full potential and lead fulfilled, dignified lives.
- 29. Educational Pathways Early Intervention Programme for Infants and Children (EIPIC) - Students: 6 months - 6 years - Provide early intervention - Prepare them for admission into Special Ed or mainstream school - Provide holistics and individual development programmes - Interdisciplinary team: interventionist, physiotherapist, occupational therapist, speech and language pathologist, social worker, psychologist - Curriculum domains: cognitive, adaptive, social, fine motor, gross motor, social-communication
- 30. Educational Pathways Cerebral Palsy Alliance Singapore School - Students - Junior levels (7-12 years) - Senior levels (13-18 years) - Curriculum - SPED - Learning outcomes: living, learning, working - Domains: social-emotional, academic (literacy, numeracy, science), daily living, vocational, physical education and sports, the arts - Programmes - Academic: OWL - Functional: EAGLE - High Support: DOVE - Community Integration Activities - Total Defence Day, Racial Harmony Day, National Day - Co-curricular Activities - E.g. boccia, music and dance, scouts, special arts, swimming, deskbells and percussion
- 31. Educational Pathways - Sensory impairment - PSLE - Mainstream education - Intellectual disability - Vocational education programme - Delta Senior School or Metta School - National vocational certification - ITE Skills Certificate - WDA Workforce Skills Qualifications - Others - Training centres / workshops - Volunteer Welfare Organisations - Open employment or - Sheltered workshops / Work activity centres
- 32. Educational Implications (1) Collaboration - Necessary to ensure successful experiences and support teachers to solve learning and behaviour problems - Specialist support - Physical therapist, occupational therapist, educational psychologist, speech language pathologist, orthotist, counsellors, social workers
- 33. Educational Implications (2) Environmental Modifications - Accessibility and mobility within school - Transportation and mobility between home and school - Toileting needs - Seating arrangements, desks, worktops
- 34. Educational Implications (3) Teaching Modifications - Special allowances for academic requirements - Reduced workload - Extra time for completing assignments, examinations
- 35. Educational Implications (4) Assistive Technology - Any systematic device or method for accomplishing a practical task - Mobility devices - Communication devices - Writing implements
- 36. Assessments Assessments - Intelligence Tests - Vineland - WISC - Waschler - Academic performance - Capacity to learn - Others - Adaptive delay or impairment - Communication level - Emotional status - Health - Motor abilities - Social ability - Vision and Hearing
- 37. Realised Potential, Fulfilled Lives
- 38. THANK YOU
- 39. Suggested Videos Singapore case study of CP: https://www.youtube.com/watch?v=PyxJmHi6atk Singapore Unsung Heroes: https://www.youtube.com/watch?v=-OIvZTOI3Gw Singapore National Cerebral Palsy Football Team: https://www.youtube.com/watch?v=kg07tCb8ddk Maysoon Zayid on TED: https://www.youtube.com/watch?v=buRLc2eWGPQ
- 40. Further Sources - http://www.cpas.org.sg/ - https://www.cerebralpalsy.org.au - http://www.originsofcerebralpalsy.com/ - http://www.cdc.gov/ncbddd/cp/data.html - http://cerebralpalsy.org/about-cerebral- palsy/types-and-forms/ - http://www.cdc.gov/ncbddd/cp/facts.html
- 41. References Challenging Behaviour and Cerebral Palsy, Capability Scotland, http://www.capability- scotland.org.uk/media/57694/challenging_behaviour_and_cerebral_palsy_12.pdf Emerson, E., Cummings, R., Barrett, S., Hughes, H, McCool, C. & Toogood, A. (1988). Challenging behaviour and community services: 2. Who are the people who challenge services? Mental Handicap, 16, 16-19. Olawale, O. A., Deih, A. N., & Yaadar, R. K. (2013). Psychological impact of cerebral palsy on families: The African Perspective. Journal of Neurosciences in Rural Practice, 4(2), 159-163. Penner, M., Xie, W. Y., Binepal, N., Switzer, L., & Fehlings, D. (2013). Characteristics of pain in children and youth with cerebral palsy. Pubmed. doi: 10.1542/peds.2013-0224. Shapiro, B. (2008). Health and well being of adults with cerebral palsy. Current Opinion in Neurology, 21(2), 136-142. doi: 10.1097/WCO.0b013e3282f6a499. Shields, N., Murdoch, A.,Loy, Y., Dodd, K. J., & Taylor, N. F. (2006). A systematic review of the self-concept of children with cerebral palsy compared with children without disability. Developmental Medicine & Child Neurology, 48(2), 151- 157. doi: http://dy.doi.org/10.1017/S001262206000326. Nomanbhoy D.M., & Nonis K.P. (2004).Learners with Physical Disabilities. In Levan Lim & Marilyn Mayling Quah (Eds.) Educating Learners with Diverse Abilities. Singapore: McGraw-Hill Education Reddihough, D. S., & Collins, K. J. (2003). The epidemiology and causes of cerebral palsy. Australian Journal of physiotherapy, 49(1), 7-12.
Notas del editor
- Presenters Goals: Complexity of CP in the disability and treatment Giving people a good overview of what CP is and is like Focus on educational pathways, interventions and strategies
- Cerebral (Latin: Cerebrum) Affect part of brain Palsy (Para: beyond; lysis: loosening) Lack of muscle control A heterogenous group of movement disorders an umbrella term not a single diagnosis
- Can be congenital (before, during birth) or acquired (28 days after birth) Insult / Injury to the brain Fixed, static lesions In single or multiple areas of the motor centers of the brain Early in central nervous system development Development malformations Brain fails to develop correctly Neurological damage Can occur before, during or after delivery → Causal Pathway Illness, severe lack of oxygen or blood flow to the brain, stroke Infection Placenta or blood of mother
- Every CP person is unique. CP persons might need help in one or more areas such as cognitive, functionality, mobility, fitness, emotional, psychological, speech, social, sensory and independence.
- Interview History taking May include all that may predispose an infant to brain damage or CP Risk factors Psychosocial factors Family adaptation Child’s health history Often admitted to hospitals for corrective surgeries and other complications Respiratory status Motor function Presence of fever Feeding and weight loss Any changes in physical state Medical regimen No treatment to cure cerebral palsy Brain damage cannot be corrected Crucial that there is: Early identification Multidisciplinary care Support General management Proper nutrition and personal care Pharmacologic Botox, Intrathecal, Baclofen Control muscle spasms and seizures Glycopyrrolate Control drooling Pamidronate May help with osteoporosis Surgery Loosen joints Relieve muscle tightness Straightening of different twists or unusual curvatures of leg muscles Improve the ability to sit, stand and walk Physical adis Orthosis, braces, splints Positioning devices Walkers, special scooters, wheelchairs Special education Rehabilitative services Speech and occupational therapies Family services Professional support Neuroimaging: Magnetic Resonance Imaging Computer Tomography Scan EEG Laboratory Tests Blood tests, urine tests Assessment tools Peabody Development Motor SKills Denver Developmental ScreenTest II
- Spastic CP: Tight or stiff muscles Dyskinetic CP: Difficulty controlling and coordinating muscles Twisting and repetitive movements Chorea: Dance-like Irregular movements Athetosis: Slow and involuntary movements → present as rest and in attempts to move Ataxic: Depth perception and balance affected Intention tremor occurs when reaching for an object, and worsens as they go nearer to the object
- Quadriplegia (4) Both arms and limbs are affected (so are mouth, face and trunk) Triplegia (3) Three limbs are involved, usually affecting both arms and one leg Hemiplegia (2) One side of the body affects. The arm is usually more affected than the leg Monoplegia (1) Only one limb is involved, usually affecting an arm
- The children with cerebral palsy gained bladder and bowel control at older age in comparison with their siblings and healthy children. They also had more frequent enuresis and urinary infections.
- Hearing Visual Refractive errors Most prevalent visual impairments: Hyperopia (farsightedness) Myopia (nearsightedness) Astigmatism Strabismus Crossed eyes Amblyopia Lazy eye Brain purposely suppresses the weaker eye preventing the child from having blurred or double vision Cataracts Clouding of the lenses Cortical blindness Brain cannot interpret and process information correctly Intellectual & Functional Problems Eating, Sleeping Communication Digestive, Bladder and Bowel movement Pain → Contractures, Abnormal postures, Skin breakdown Seizures, Epilepsy → Partial seizures, Generalized seizures Intellectual impairment, Mental Retardation, Learning Disabilities Psychological/ Behavioural Emotionally unstable/ Problems Behavioural/ Conduct Problem Others Dental Problems Sensory Integratory Problems Pain: http://www.ncbi.nlm.nih.gov/pubmed/23858420
- Mental retardation Brain functioning 35% will have normal intelligence Includes above average intelligence Learning difficulties Short attention span Motor planning difficulties Perceptual difficulties Language difficulties Literacy When it comes to literacy, children with cognitive impairments may not read like other children, but it doesn’t mean they are incapable of understanding what words mean. Different methods of learning eg. visual cues, technology and demonstration to aid learning
- Cerebral palsy often affects the language centers of the brain that control speech. In mild cases of cerebral palsy, a child may have difficulty using the correct words, but in more severe cases, a child’s ability to verbally express himself or herself might be seriously impeded. Under these circumstances, the speech and language pathologist will assist in finding ways in which the child can begin to communicate through ques (winking or lifting a finger), sign language, or with the assistance of augmentative communication devices (DynaVox or computers).
- Articulation Moderate to profound vocal communication disorders (70-80%). The muscles that control speech are often affected. Poor speech can complicate cognitive assessment. Dysarthrias Most common Difficulty controlling muscles to coordinate speech movement Hypernasal Hyponasla Speech may sound slow and slurred Voice Problems Spastic Palsy Harsh vocal quality, increased intensity, high pitch Athetoid Palsy Hoarse vocal quality, fluctuating intensity, variable pitch Ataxic Palsy Hoarse vocal quality, fluctuating intensity, and variable pitch Dysphagia Related to muscular speech mechanisms Due to muscles beginning spastic, athetosis, ataxic or flaccid People with cerebral palsy may cough, gag, or choke when eating.
- Challenging behaviour “behaviour of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to and use of ordinary community famiclities (Emerson et al 1988) Reasons: Biological causes, genetically linked, levels of arousal Learned May be a means of communication Sign of distress, anger, frustration, discomfort, pain May be response to environment: over/ under stimulation
- Asian Women’s Welfare Association School Spastic Children’s Association School now known as Cerebral Palsy Alliance of Singapore School of which we take an indepth look CPAS Early Intervention [Preschool: 0-6 years] Special Education → SPED [7-18 years] MOE Access to mainstream schools Approved Training Centres / Organisations Vocational training
- Teacher to student ratio: 1:6
- Delta Senior School / Association for Persons with Special Needs Metta Welfare Association CPAS: Goodwill, Rehabilitation and Occupational Workshop (GROW) Sheltered workshop Vocational training Assembly work Social enterprise initiatives Orange Garden Cafe Art and Craft Workshop Pushcarts We are still in the planning phase to help our clients with job placements. Our GROW workshop is our best example. Trainees get allowances and are sheltered and trained for projects such as Pilot Pen Project, Direct Funeral, Panasonic (Refrigerator & Aircon)
- Multiple assessments conducted by psychologists Placement is ultimately based on the student’s needs that can best be met. Regularly reassessing appropriateness of placement is necessary Decision will require a collaborative appraoch involving student, transdisciplinary team and the parents
- Beautiful artwork Maysoon Zayid - actress, comedienne, activist Jack Caroll -- Winner of US’s got Talent 2013 Laurentia Tan -- Silver & Bronze medalist at 2012 Summer Paralympics, London Singapore CP Football team