CNS: Cerebral palsy

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

Classification System for TBI

• Mild, Moderate, and Severe classifications exist

Glasgow Coma Scale (GCS)

• Used to objectively describe the extent of impaired consciousness in all types of traumatic brain injuries
• A score of 13-15 indicates a mild TBI
• A score of 9-12 indicates a moderate head injury
• A score of 3-8 indicates a coma and severe brain injury; immediate emergency care is required
• The lower the score, the worse the injury.

Duration of Unconsciousness

• Less than 30 minutes is associated with a GCS of 13-15 and post-traumatic amnesia lasting less than 24 hours.
• 30 minutes to 24 hours is associated with a GCS of 9-12 and post-traumatic amnesia lasting 1-7 days.
• More than 24 hours is associated with a GCS of 3-8 and post traumatic amnesia lasting greater than 7 days

Concussion (mTBI)

• It is a traumatic brain injury caused by a direct blow to the head, neck, or body resulting in an impulsive force being transmitted to the brain.
• Symptoms and signs may present immediately or evolve over minutes or hours.
• Commonly resolves within days, but may be prolonged.
• Rotational force is the most likely to lead to loss of consciousness and is the most likely to lead to persistent post-concussion symptoms.
• Concussion and whiplash often occur together

Post-Concussion Syndrome

• PPCS symptoms develop in 20-30% of concussed patients
• It occurs after the concussion has occurred
• The neurometabolic cascade following concussion should normally resolve within 4-6 weeks (30 days)
• If symptoms persist beyond that time (and cannot be explained by other means), the person is said to be experiencing persistent post-concussion syndrome

Common signs and symptoms of Post-Concussion Syndrome

• Autonomic dysfunction
• Headaches
• Dizziness
• Loss of concentration and memory
• Ringing of the ears
• Emotional and psychological changes
• Sleep changes
• Vision changes

Coup-Contrecoup

• A coup injury occurs under the site of impact with an object
• A contrecoup injury occurs on the side opposite the area that was hit.

Concussion Treatment

• Rest, sleep at night and naps throughout the day if needed, avoiding vigorous activity, NSAIDs to control headaches, avoid bright lights and electronics, and limit activities that require heavy concentration or intense focus
• Severe cases require physical therapy, speech therapy, recreation therapy, and occupational therapy

Concussion and PPCS Massage Considerations

• Remove noxious stimuli, position and pillow for comfort, avoid rocking/shaking, promote relaxation, and encourage and support light aerobic exercise.

Seizure Disorder - Epilepsy

• Involves explosive episodes of uncontrolled and excessive electrical activity in the brain, leading to sudden changes in behavior or level of consciousness
• Antiseizure medication and cannabinoids are used to reduce the frequency of seizures

Two Main Types of Seizures

• Focal (Partial) Seizure and Generalized Seizure
• A seizure is limited to a single area of the brain in 60% of cases

Focal Seizure

• 2 categories:
  • Without loss of consciousness
  • With impaired awareness
• May experience changes in the way things look, feel, smell, taste or sound, and result in involuntary movements or abnormal sensations like dizziness
• With impaired awareness, a person may appear to have a blank stare or have repetitive movements like hand rubbing or smacking, or start walking in circles

Generalized Seizures

• Involves more of a diffuse area and is approximately 30% of cases

Absence - Petit Mal

• Brief loss of awareness and often facial movements lasting up to 10 seconds and have no memory of what happens during the seizure

Tonic-clonic - Grand Mal

• Intermittent contract-relax pattern in muscles and are associated with loss of consciousness
• Can last for several minutes
• If lasts longer than 5 minutes, call 911

Seizures-Massage Considerations

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

Special tests for TBI

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

General Treatment for TBI’s

• Warm bath for 10-15 minutes for sleep
• Aerobic exercise, ADLs change (avoid triggers), stretching neck muscles, and journal for symptoms

Cerebral Palsy

Etiology

• Hypoxia, ischemia and trauma
• Is a group of non-progressive, irreversible motor disorders caused by brain damage to an immature brain
• The brain damage may occur 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 in utero or postpartum hypoxia or ischemia
• Trauma to, or rupture of cerebral blood vessels
• Postpartum head injury from an accident or abu

Common causes of Hypoxia & Ischemia - In utero

• Kink in the umbilical cord or the cord wrapping around the fetus's neck
• Maldevelopment of the placenta
• Shock in the mother from an accident

Common causes of Postpartum hypoxia or ischemia

• Suppression of the respiratory centres b/c of overmedication of the mother; or pneumonia, a collapsed lung or drowning of the infant

Common causes of Trauma to, or rupture of cerebral blood vessels

• Separation of the placenta
• Difficult of prolonged delivery
• Postpartum head injury from an accident or abuse

Four Main Types of Cerebral Palsy

• Spastic, Athetoid, Ataxic, and Mixed.
• Increased tone; accounts for 75% of all cases - most common.
• Uncontrolled movement, slow & writhing (dyskinesia); increase with intention & stops with sleep; has trouble holding themselves upright.
• Poor coordination, least common and it is due to damage to cerebellum.

What Spastic CP mostly affects

• Proprioception

Sub types of Spastic CP

• Monoplegia - 1 arm or leg involved
• Diplegic - usually both legs, m/c of spastic form, fully ambulatory, scissor gait
• Hemiplegic - 1 side of body, usually most ambulatory
• Quadriplegic - all 4 limbs involved

Mixed CP is usually:

• Spastic & athetoid

Classic Gait Pattern for CP

• Not noticeable in early infancy - become more obvious as nervous system matures.
• Early signs are delayed milestones, persistence of primitive reflexes, in toddlers not walking or forming sentences

Common Signs and Symptoms of CP

• Spasticity
• 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-scoliosis (can lead to respiratory difficulties), hyperlordosis, hyperkyphosis
• Contracture formation-equinus deformity (short achilles); internal rotation of hip, hip flexion
• Permanent skeletal changes and arthritis
• Stenosis of C-spine
• Osteoporosis-because they arn't weight bearing
• Peripheral nerve compression- due to postural imbalances
• Variety of sensory losses; decreased proprioception
• Speech - dysarthria; can be difficulty swallowing and inability to control saliva
• Hearing impairment
• Bowel and bladder function compromised
• Intellect may or may not be affected

CP is linked to

• Epilepsy, mental development delay and emotional disturbances
• Compromised tissue health, vision can be normal or limited, frustration and anger, disuse atrophy > 60 yrs; edema ---> decubitus ulcers

Scissors Gait

• A result of spastic paralysis of the hip adductor muscles, which causes the knees to be drawn together so that the legs can be swung forward only with great effort
• This is typically seen in spastic paraplegics and may be referred to as neurogenic or spastic gait

Treatment for Cerebral Palsy

• There is no cure, however treatments such as physical and occupational therapy, speech therapy, drugs to control seizures, relax muscle spasms and alleviate pain can assist with this
• Surgery to rect anatomical abnormalities or release tight muscles
• Utilized Brace other orthotic devices, Wheelchairs and rolling walkers and Communication aids
• Communication is important because Some people w/ CP are non-verbal or non-communicative

Massage Considerations for Cerebral Palsy

• Pillowing and positioning (often in a wheelchair) for support and comfort; may need to accommodate high amounts of salivary secretions therefore make sure you let them know that this massage may fatigue yo
• NO PRONE-FOR CEREBRAL PALSY, CONCUSSION, SEIZURES
• Systemic Outcomes Help w/ inhalation and rib function; help w/ gastrointestinal motility; and promote relaxation and comfort
• Musculoskeletal Outcomes: Decrease mm tightness; increase ROM; decrease contracture formation; decrease pain and promote joint health

Massage History Questions for CP Patients

• Check for decubitus ulcers, improve proprioceptions -PNF strengthening, core PNF, What are your challenges? What are secondary conditions? Who are you working with? Any assistance What it assessed? Check in at the 24 hour mark to see if there are any changes How often are people looking at bony prominences? Prev massage history? Drooling and sleeping position and any issues w/ swallowing?

Assessments for CP

• Peripheral nerve compression tests, walking gait assessment, functional assessment, and a breathing assessment
• NO PRONE-FOR CEREBRAL PALSY, CONCUSSION, SEIZURES