Brain Injury & Cerebral Palsy

• Traumatic Brain Injury (TBI) includes concussion, contusions, and seizures.

Conditions

• Concussion is also known as mild TBI (mTBI).
• Seizure disorder is also known as epilepsy.

Classification System for TBI

• Mild TBI is classified as a score of 13-15 on the Glasgow Coma Scale (GCS), with less than 30 minutes of unconsciousness and less than 24 hours of post-traumatic amnesia.
• Moderate TBI is classified as a score of 9-12 on the GCS, between 30 minutes and 24 hours of unconsciousness, and 1-7 days of post-traumatic amnesia.
• Severe TBI is classified as a score of 3-8 on the GCS, more than 24 hours of unconsciousness, and more than 7 days of post-traumatic amnesia.
• The Glasgow Coma Scale is used to objectively describe impaired consciousness in traumatic brain injuries; a lower score indicates a worse injury.
• A GCS score of 15 indicates the patient is fully awake, responsive, and has no issues with thinking ability or memory.
• A GCS score of 13-14 indicates a mild head injury.
• A GCS score of 9-12 indicates a moderate head injury.
• A GCS score of 3-8 indicates a coma and severe brain injury.

Concussion - mTBI

• It is a traumatic brain injury caused by a direct blow to the head, neck, or body, which transmits an impulsive force to the brain.
• This initiates a neurotransmitter and metabolic cascade, causing possible axonal injury, blood flow changes, and inflammation in the brain.
• Symptoms can appear immediately or evolve over minutes or hours.
• Symptoms commonly resolve within days, but can be prolonged.
• The neurometabolic cascade following a concussion typically resolves within 4-6 weeks.
• Persistent post-concussion syndrome (PPCS) is diagnosed when symptoms persist beyond 4-6 weeks and cannot be explained by other means.
• PPCS symptoms develop in 20-30% of concussed patients.
• Creatine, at a dose of 5mg, is recommended for people who have suffered concussions.
• Coup-contrecoup injuries are common, where a coup injury occurs at the site of impact, and a contrecoup injury occurs on the opposite side.
• Loss of consciousness isn't a requirement for a concussion diagnosis.
• Rotational force is the most likely cause of loss of consciousness and persistent post-concussion symptoms.
• Concussion and whiplash often occur together.
• Because concussion and whiplash often occur together, some researchers recommend guidelines for care should be combined.
• Imaging can be done (MRI and CT scans) to rule out structural damage, which would appear as a dark spot.

Concussion Treatment

• Treatment consists of rest, including sleep at night and naps during the day as needed.
• Vigorous activity should be avoided.
• NSAIDs can be used to control headaches.
• Bright lights and electronics should be avoided.
• Heavy concentration or intense focus activities should be limited.
• Severe cases may require physical therapy, speech therapy, recreation therapy, and occupational therapy.

Post-Concussion Syndrome

• Post-Concussion Syndrome occurs after a concussion.
• Signs and symptoms include autonomic dysfunction, headaches, dizziness, loss of concentration and memory, ringing of the ears, emotional and psychological changes, and sleep changes.

Concussion and PPCS - Massage Considerations

• Remove noxious stimuli like bright lights and noise.
• Position and pillow for client's comfort.
• Be aware of dizziness and/or onset of symptoms with neck movement (cervicogenic dizziness).
• Avoid rocking/shaking movements.
• Promote relaxation.
• Encourage and support light aerobic exercise.
• Refer to a chiropractor/physiotherapist/MD that are well trained in concussion assessment and treatment (BTT, VOM).

Seizure Disorder - Epilepsy

• Seizures are explosive episodes of uncontrolled and excessive electrical activity in the brain.
• This leads to a sudden change of behavior or level of consciousness.

Two Main Types of Seizures

• Focal (Partial) Seizure- accounts for 60% of epilepsy cases and is limited to a single area of the brain.
• Generalized Seizure - involves more of a diffuse area and accounts for approximately 30% of cases.

Focal Seizures

• It is a type of seizure that is limited to a single area of the brain, accounting for approximately 60% of epilepsy cases.
• There are 2 categories: without loss of consciousness and with impaired awareness.
  • Without Loss of Consciousness:
    • May cause changes in how things look, feel, smell, taste, or sound.
    • May result in involuntary movements or abnormal sensations, such as dizziness.
  • With Impaired Awareness:
    • Change or loss of consciousness.
    • Appear to have a blank stare or have repetitive movements like hand rubbing, smacking, or walking in circles.

Generalized Seizures

• It is a type of seizure that involves a more diffuse area of the brain, accounting for approximately 30% of epilepsy cases.
• Two types of generalized seizures: absence (petit mal) and tonic-clonic (grand mal).
  • Absence (Petit Mal):
    • Involves a brief loss of awareness and often facial movements which lasts up to 10 seconds.
    • Often patients have no memory of what happens during the seizure.
  • Tonic-Clonic (Grand Mal):
    • Involves intermittent contract-relax patterns in muscles and are associated with loss of consciousness.
    • Can last for several minutes.
    • If it lasts longer than 5 minutes, call 911.
• Antiseizure medication and cannabinoids are used to reduce the frequency of seizures.
• Mild sedatives may be used to treat seizures.
• Understanding triggers if there are any, such as flashing lights or smells/odors, is important.

Seizures - Massage Considerations

• Understand and remove triggers.
• Follow first aid procedures if a seizure occurs.
• A template of gentle, relaxing massage techniques should be used.
• Adjust the face rest to ensure comfort.
• Limit position changes if a client is experiencing dizziness.
• If a client has difficulty communicating, establish a form of communication.
• Avoid techniques that cause the client to rock or shake.

Special Tests for TBI

• Spurlings or decompression test
• Neck ROM assessment
• Cognitive ability assessment
• TrP referral
• VAT test
• BP assessment
• Postural assessment

Treatment

• Warm bath for 10-15 minutes for sleep
• Aerobic exercise
• Adjustment of Activities of Daily Living (ADLs) to avoid triggers
• Stretching neck muscles
• Journaling symptoms

Cerebral Palsy

• CP is a group of non-progressive, irreversible motor disorders caused by brain damage to an immature brain.
• Brain damage may occur: from the second half of pregnancy onwards (in utero), during the birth process, or in early childhood (usually the first 3 years of life).
• Cerebral Palsy is usually due to hypoxia, which may occur via: A very premature birth or Intrauterine virus (TORCH) or other infection/toxicity or source of damage.
• Ischemic insults can also cause Cerebral Palsy.
• In utero or postpartum hypoxia or ischemia.
• OR postpartum trauma.

Hypoxia & Ischemia - In Utero

• Hypoxia & Ischemia in utero may be caused by a kink in the umbilical cord or the wrapping of the cord around the fetus's neck, maldevelopment of the placenta, or shock in the mother from an accident.
• Postpartum hypoxia or ischemia may be caused by suppression of the respiratory centers due to overmedication of the mother, pneumonia, a collapsed lung, or drowning of the infant.
• Trauma to or rupture of cerebral blood vessels.

Strokes

• Separation of the placenta, difficult or prolonged delivery, postpartum head injury from an accident or abuse.
• The brain of a premature baby is particularly susceptible to hemorrhage
• Strokes can be a result of dehydration.

4 Main Types of Cerebral Palsy

• Spastic
• Athetoid
• Ataxic
• Mixed

Spastic CP

• Increased muscle tone; accounts for 75% of all cases - most common. a. Monoplegia - 1 arm or leg b. Diplegic-usually both legs, m/c of spastic form, fully ambulatory scissor gait c. Hemiplegic - 1 side of body, usually most ambulatory d. Quadriplegic- all 4 limbs

Athetoid CP

• Uncontrolled movement, slow & writhing (dyskinesia).
• Increase with intention & stops with sleep.
• Has trouble holding themselves upright

Ataxic CP

• Poor coordination- least common.
• Due to damage to cerebellum.

Mixed CP

• Usually spastic & athetoid.

Symptoms

• Presentation varies widely in cerebral palsy, from mild to profound disability.
• Not noticeable in early infancy - become more obvious as nervous system matures.
• Early signs: delayed milestones, persistence of primitive reflexes, in toddlers not walking or forming sentences.
• Spasticity is the most common symptom.
• Athetoid movements = slow and writhing.
• Choreiform movements = quick, uncontrolled, and without purpose; do not stop with sleep.
• Ataxia-lack of coordination and clumsiness of movements - ataxia in the face causes grimacing.
• Reflex movements-development reflexes not integrated.
• Flaccidity may be present in the 1st year or two then change to spasticity or athetoid movement.
• Pain - resulting from muscular, neurological, and bony changes; can be acute or chronic.
• Postural dysfunctions can cause scoliosis which lead to respiratory difficulties, hyperlordosis, and hyperkyphosis.
• Contracture formation causes equinus deformity (short achilles) and internal rotation of the hip, hip flexion and Toe walkers.
• Permanent skeletal changes and arthritis.

Cerebral Palsy Treatment - Systemic Outcomes

• Treatments include physical and occupational therapy, speech therapy, drugs to control seizures, relax muscle spasms, and alleviate pain. Surgery to correct anatomical abnormalities or release tight muscles.
• Use of braces and other orthotic devices.
• Use of Wheelchairs and rolling walkers.
• Use of Communication aids.
• Treatment does not result in a cure.
• Massage helps with inhalation and rib function.
• Massage helps with gastrointestinal motility.
• Massage promotes relaxation and comfort.

Systemic Outcomes

• Establishing a method of communication via a carer is most important for people with CP who are non-verbal or non-communicative.
• Yes/no/stop signals. Comfort with pillowing and positioning (often in a wheelchair) for support and comfort.
• Accommodate high amounts of salivary secretions.
• Clients should let know that the massage may fatigue them.
• NO PRONE position is used for cerebral palsy, concussion, and seizures.

Musculoskeletal Outcomes

• Decrease muscle tightness
• Increase ROM
• Check for decubitus ulcers
• Improve proprioceptions with PNF strengthening, core PNF.
• Decrease contracture formation
• Decrease pain
• Promote joint health

Cerebral Palsy Treatment- Patient History

• What are the patient's challenges?
• Secondary conditions
• Therapy team
• Assistance required?
• Assessment of bony prominences Previous massage history
• Drooling (modify positioning)
• Issues w/ swallowing
• Sleeping position-whats comfortable

Cerebral Palsy Treatment- Assessments

• Breathing assessment
• Peripheral nerve compression tests
• Walking gait assessment
• Functional assessment
• NO PRONE position is used for cerebral palsy, concussion, and seizures.

Test your knowledge of concussion and head injury assessment. Questions cover Glasgow Coma Scale scores for head injuries, the impact of rotational forces in concussions and post-concussion symptoms. Also, explores the role of imaging in acute management and appropriate interventions following traumatic brain injury.