Cerebral Palsy PDF

CEREBRAL PALSY Chronic disability of central nervous system origin characterised by aberrant control of movement of posture, appearing early in life and not the result of progressive neurological disease. Is defined as a : 1) Persistent but not unchanging 2) Disorder of movement, tone and postur...

CEREBRAL PALSY Chronic disability of central nervous system origin characterised by aberrant control of movement of posture, appearing early in life and not the result of progressive neurological disease. Is defined as a : 1) Persistent but not unchanging 2) Disorder of movement, tone and posture 3) Due to non-progressive defect/lesion 4) Of immature brain ( fetal life, infancy, childhood) 5) Commonly associated with a spectrum of developmental disabilities such as: – Mental retardation (60%) – Epilepsy (33%) – Visual , hearing (deafness-10%) and speech defects – Strabismus: abnormal alignment of the eyes (50%) – Cognitive dysfunction – Sensory problems – Emotional and behavioral problems.  EXCLUDING progressive pathology and lesion of the spinal cord. INCLUDING non-progressive genetic or Congenital malformation. Classifications Monoplegia: One Limb (most often an arm, but it can also affect one of your legs). Hemiplegia: UMNL (Upper motor neuron lesion) of one side of body. Double Hemiplegia: Bilateral UMNL. – Arms and legs. (but one side of the body is more affected than the other). Diplegia: UMNL - of all four limbs(legs or arms) but legs more than arms. Quadriplegia: Equal involvement of arms and legs. Paraplegia: Legs involved only. – Lower parts of the body. The areas of impaired mobility usually include the toes, feet, legs, and may or may not include the abdomen. Functional CLASS 1 – NO limitation of activity CLASS 2 – Slight limitation CLASS 3 – Moderate limitation CLASS 4 – No useful physical activity Gross Motor Function Classification System for Assessing Severity of CP 142 Early Signs of Cerebral Palsy 1. Birth History a) Prematurity. b) Seizures. c) Intracranial haemorrhage ( bleeding within the skull). d) Periventricular leukomalacia (white-matter brain injury). 2. Delayed Milestones 3. Abnormal Motor Performance a) Handedness. b) Abnormal crawling (Reptilian crawl). c) Toe walking (spastic diplegia). Early Signs of Cerebral Palsy 4. Altered Tone. 5. Persistence of primitive reflexes. (Asymmetrical tonic reflex ) 6. Abnormal posturing. Early markers of CP Cortical thumb beyond 8 weeks Slow head growth. Handedness Poor head control. lack of limb movements Scissoring of lower limbs Eye – roving eyes, poor hand regard, persistent squint. Ear – lack of auditory response Irritability, seizures, poor suck, poor quality of sleep. Extreme sensitivity to light. Toe walking Abnormal tone Stereotypic abnormal movements Lack of alertness Cerebral Palsy 1. Typically incidence of Cerebral Palsy in low-birth-weight babies. 2. ⇧ in incidence in babies 2.5-4kg (2/3 of cases). 3. Excess boys (58%). 4. ⇧ in lowest socio-economic groups. 5. Maternal age. TYPES OF CP Terms Commonly Used to Describe Involuntary Movements Athetosis – slow, writhing movements, particularly in the hands and face. Ataxia – unsteady walking and balance problems. – Ataxia results from damage to the cerebellum, the brain’s major center for balance. Chorea – jerky movements of the head, arms or legs. Dystonia – twisting movements and postures of the trunk or limbs. Assessment of Cognition and Behavior Mental retardation was found to be the commonest associated problem in children with CP. Conventional tests of intelligence may prove erroneous in children with CP because of motor and communication deficits. Age-appropriate non-verbal intelligence tests have to be administered for this purpose. Assessment of Vision and Hearing In children with hearing impairment with associated microcephaly and congenital heart disease. Sensorineural hearing loss is a prominent feature of CP due to Iodine deficiency in endemic areas. Assessment of Speech and Language These may be due to hearing impairment, cognitive deficits, or oromotor dysfunction. Difficulty in communication by language or gestures further compound behavior problems. Comprehensive assessment A multidisciplinary team comprising a neuro-developmental pediatrician as the team-leader Physiotherapist Otorhinolaryngologist (ENT) Occupational therapist Ophthalmologist Clinical psychologist teacher Speech pathologist Play therapist Orthopedic surgeon Social worker is required Preferably under one roof.  Treatment of CP Cerebral palsy can’t be cured, but intervention will often improve a child's capabilities and quality of life. Many children go on to enjoy near-normal adult lives if their disabilities are properly managed. In general, the earlier treatment begins, the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them.  Treatment of CP CP usually affects several areas of functioning, as a result, several disciplines are involved in its management. The activities of the disciplines must be coordinated in order to yield effective treatment outcome. The disciplines usually involved in CP management include:  Pediatricians – they take care of development, care and diseases of children and are in the position to coordinate the management of CP. Surgeons – they carryout surgeries to correct anatomical abnormalities or release tight muscles. Occupational therapists- they take care of fine motor activities. They are usually better trained to advise on activities of daily living like feeding, bathing, dressing, toilet training etc, and the equipment needed to facilitate these.  Physiotherapists- they take care of gross motor activities. Speech therapists -they apply remedies, treatment, and counselling for the improvement of speech functions. Clinical Psychologists- they provide emotional wellbeing as well as cognitive evaluation for school placement. Special need educators – the provide the kind of education CP children with cognitive impairment could benefit from. Parent Counselling This is one of the most important aspects because parents are pivotal in the management of their child. It is an ongoing process, as the parents need to be counseled periodically at various stages of their child's development.  Prognosis Cerebral palsy doesn’t always cause profound disabilities. While one child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, another with mild cerebral palsy might be only slightly awkward and require no special assistance. Supportive treatments, medications, and surgery can help many individuals improve their motor skills and ability to communicate with the world.  Conclusion It is important to remember that limbs affected by CP are not paralyzed and can feel pain, heat, cold and pressure. It is also important to remember that, just because someone with CP may not be able to speak, it does not mean she or he has nothing to say.  QUESTION Does Cerebral Palsy Get Worse Over Time?  ANSWER No. Cerebral palsy is not considered a progressive disorder which means that it will not continue to get worse over time. Cerebral palsy is the result of damage to the brain of a baby during pregnancy or childbirth. Once the brain damage occurs it does not spread or otherwise worsen. In fact, with effective therapy and treatment, the symptoms of cerebral palsy can be often be reduced over time.  QUESTION Does CP affect everyone the same way?  ANSWER No. CP affects everyone differently. With so many different causes of CP, it is no surprise that it takes many forms. Every person with CP is a unique individual, but is likely to be classified as having a particular type of CP. Classification can be according to the type of movement disorder and/or by the number of limbs affected. MSD TREATMENT 167 How are MSD Treated? Treatment focuses on (re)-learning motor aspects of speech production, which requires acquisition, retention, and generalization. – Acquisition: temporary improvements during treatment. – Retention: lasting performance enhancements. – Generalization: improvements in either related but untrained behaviors (response) or in targeted behaviors in different contexts, tasks, or settings (stimulus). Treatment Targets The use of nonspeech tasks (e.g., pursing the lips, smiling, moving the tongue) in assessment does not mean that nonspeech tasks should be used in treatment. Few research supports “oral motor activities” to strengthen the articulators or improve their movements. Focusing on more complex targets results in greater learning than focusing on simpler targets. Treatment Strategies Two Approaches Primary Strategies: – Improve impaired subsystem – focus on specific functions in relevant speech tasks e.g., improve respiratory support for speech Compensatory strategies … For the affected individual … for the environment … for the communication partners Treatment Contexts An important indicator of treatment effectiveness is generalization. Speech production in other tasks and with different conversational partners should be included the routine assessment process. The Treatment Plan Pre-practice considerations – several conditions should be considered and discussed prior to treatment: – Memory – Attention – Motivation – Goal setting Establishing a reference of correctness. Treatment of Respiratory System Establishing respiratory support (e.g., making postural adjustments). Modifying inhalation (e.g., increasing duration of air intake). Modifying exhalation (e.g., vowel prolongation). Improving inhalation/exhalation relationship. Increasing respiratory flexibility (e.g., producing words with a variety of stress patterns). Treatment of Phonatory System Improving voice quality (e.g., postural adjustments, relaxation therapy). Controlling vocal folds to enhance the naturalness of speech. Improvement of strength and control of velopharyngeal port (e.g., practicing nasal vs. oral airflow patterns). It might be necessary to use a palatal lift – a device that helps raise the velum – depending on severity of subsystem impairment. 175  Treatment of Articulatory System Focus the patient’s attention to the accuracy, range, and direction of movement during speech. Feedback from the clinician can include articulatory placement cues (e.g., modeling speech production). Treatment of Prosody and Rate Control Prosody involves manipulation of three factors: loudness, pitch, and duration. Each of these factors should be focused on during treatment. Approaches to reducing the rate of speech: – Rigid control techniques – Non-rigid control techniques  Rate and rhythm control approaches (also called prosodic facilitation approaches) use intonation patterns (melody, rhythm, and stress) to improve speech production. Although these approaches are aimed at improving prosody, they may also result in improved articulation for individuals with AOS. Using these patterns, the clinician guides the individual through a gradual progression of steps that increase the length of utterances, decrease dependence on the clinician, and decrease reliance on intonation. APRAXIA TREATMENT 179  How Is Apraxia of Speech Diagnosed? In formal testing for both acquired and childhood AOS, a speech-language pathologist may ask the patient to perform speech tasks such as repeating a particular word several times or repeating a list of words of increasing length (for example, love, loving, lovingly). Treatment Asking for the same word or phrase to be repeated multiple times. Practicing saying specific syllables or words to help you learn to move from one sound to another. Having you carefully observe how the therapist’s mouth moves when they say words or phrases. Using visual cues, such as practicing speech in front of a mirror, to remind yourself how to move your mouth to say specific words or phrases  Apraxia: Speech Characteristics Articulation errors. Longer sequences of sounds cause more Inconsistent errors. articulation errors. Substitution errors of placement Voluntary speech more affected than automatic. most common. Prosody errors. Anticipatory errors. Slow rate. Perseverative errors. Equal stress. Metathetic (transposition) errors. Mono pitch. How is apraxia of speech treated? Spontaneous recovery: In some cases, people with acquired AOS recover some or all of their speech abilities on their own. Speech-language pathologists use different approaches to treat AOS, and no single approach has been proven to be the most effective.  Frequent, intensive, one-on-one speech-language therapy sessions are needed for both children and adults with AOS. – The repetitive exercises and personal attention needed to improve AOS are difficult to deliver in group therapy. – Children with severe AOS may need intensive speech-language therapy for years, in parallel with normal schooling, to obtain adequate speech abilities. 184  In severe cases, adults and children with AOS may need to find other ways to express themselves. These might include: – Formal or informal sign language – A notebook with pictures or written words that can be pointed to and shown to other people. – An electronic communication device—such as a smartphone, tablet, or laptop computer— that can be used to write or produce speech. 186 187  Such assistive communication methods can also help children with AOS learn to read and better understand spoken language by stimulating areas of the brain involved in language and literacy. 188 Treatment (General Procedures) Progress is slow. Intensive, repetitive drill. Controlled sequencing of phonemes. Functional speech is the goal. Specific programs Restructuring Oral Muscular Phonetic Targets (PROMPT) and Melodic Intonation Therapy (MIT) for more severe cases. Rosenbek Hierarchy of Apraxia Drills 8-step continuum for more mild cases.  In general, therapy tends to follow a sequential organization, progressing from simple to complex speech tasks. We can progress from CV or VC combinations, CVC, CCVC, syllable shapes, words, phrases, sentences, conversational speech. II. GENERAL PRINCIPLES OF TREATMENT A child with CAS may have experienced failure. Make sure there is initial success in tx. Treatment may start with vowel errors if these are dominant. Auditory discrimination is not important. Initial treatment targets may include sounds that are stimulable, early-developing, and visible. Sounds should be treated in order of increasing phonetic difficulty (e.g., begin with vowels, end with affricates). Start with voiceless sounds, then progress to voiced sounds.  Train sounds first in word-initial position. Have short breaks these kids get tired! Do repeated trials of the same movement (program muscle memory). Practice each target word or phrase several times before moving on. Select a core vocabulary of meaningful words for initial treatment. Specific Treatment Approaches Always remember to use a multimodality approach! For children with severe CAS, sign language or augmentative communication may be necessary. 1. Phonetic Placement Techniques to Elicit Sound Production We can give detailed descriptions of how to produce sounds using diagrams and pictures Get in there and get physical! Use tongue depressors, cotton swabs, mirrors 2. Shaping/Progressive Assimilation To get a child to produce a sound, use non-speech gestures or sounds that are not affected. For example, if a child cannot produce /v/, she may be asked to bite her lower lip, turn on her voice, and breathe out. 3. Contrastive Stress Drills Work especially well to teach stress and rhythm of spoken language as well as promote better articulation Example for /k/ SLP Is your name Ben? Child No, my name is Ken. SLP Is his name Ken? Child No, my name is Ken. Remember CAS therapy takes years. Children quickly lose the gains they have made if these gains are not constantly reinforced!  Rosenbecks 8 step continuum 1. Clinician presents verbal stimulation (watch me listen to me). Clinician/client produce target utterance in unison. 2. Clinician presents stimulation with visual cue only (e.g. mouths utterance without sound) while client produces the target aloud. 3. Clinician presents stimuli. 4. Repeat step 3, but requires target to be produced several times in a row without additional model. 5. Clinician presents written stimuli, which client reads aloud. 6. Clinician presents written stimuli, removes the stimulus, client produces target. 7. Clinician presents a question designed to elicit target utterance and client responds. 8. Clinician engages in role-play situations to elicit target utterance. 200 201 202 203 AOS Treatment Strength or ROM is not the problem Speech difficulties may increase with increased effort Facilitate increasing automaticity of speech Approaches: – Progressive complexity automatic oral/nasal, voicing, manner, place bilabial->alveolar-> velar singletons->clusters high frequency -> low frequency short -> long length of utterance  AOS Treatment Approaches: – Many repetitions – Visual cues – Tactile cues – Decreasing rate MAY help 10/20/2024 205 Treatment for Dysarthria Signs of Dysarthria Have "slurred" or "mumbled" speech that can be hard to understand. Speak slowly. Talk too fast. Speak softly. Not be able to move tongue, lips, and jaw very well. Sound robotic or choppy. Have changes in their voice. – It may sound hoarse or breathy. – Or it may sound like they are talking out of their nose. Treatment for Dysarthria Depending on the type of dysarthria, you may work on: Slowing down the speech. Using more breath to speak louder. Making mouth muscles stronger. Moving lips and tongue more. Saying sounds clearly in words and sentences. Using other ways to communicate, like gestures, writing, or using computers. This is augmentative and alternative communication, (AAC)  Important Issue The SLP must work with the family and friends to help them learn ways to talk with and understand pt. Treatment of Dysarthria Focus of therapy is dictated by: 1. Affected subsystems. 2. Type of dysarthria (type of neurologic damage). Some thoughts about goals: Flaccid: Increase tone & strength. Spastic: Decrease tone, increasing ROM. Hypokinetic: increase ROM and strength. Hyperkinetic: increase control. Ataxic: increase control. General Goals: Increase speech accuracy and communication efficacy. Improve level of independent communication. Respiration – Goals: To establish correct breathing pattern. To increase vital capacity. To facilitate control of inhalation and exhalation. To improve strength and coordination of respiratory muscles. – WHY: To establish breath support for speech production. 212 Respiration – Strategies: Modify posture: – For most, sitting upright is best. – For some overweight patients, standing or lying flat may work better. Establish diaphragmatic breathing: – Use hands on diaphragm to feel downward and outward movement – Model on yourself – May have to put hands on shoulders to get pt to attend to clavicular breathing Practice slow, deep breathing Sustained phonation – maintain intensity – increase intensity – decrease intensity – increase then decrease intensity Monitoring breaths during connected speech Phonation Goals: – To establish good coordination of respiration and phonation. – To achieve an appropriate vocal onset. – To control loudness. – To achieve comfortable pitch. – To facilitate variation of pitch and inflection. – To achieve appropriate resonance. Lee Silverman Voice Therapy (LSVT) LSVT Began as a treatment program for Parkinson disease, and now includes other neurological disorders. Intensive, behavioral treatment (at least 3-4 times/week). Actual techniques are common voice treatment approaches. Goals: to increase intelligibility and loudness. LSVT Concept 1: Increase/improve vocal fold adduction 1. Maximum impact on intelligibility 2. Immediate reinforcement 3. Simple: "THINK LOUD/THINK SHOUT" LSVT Concept 2: focus on HIGH EFFORT 1. Deal with rigidity and hypokinesia by pushing patients to new effort levels. 2. Trains new target by putting the "load on the larynx. 3. Dealing with a progressive neurological disease. 4. Clinician effort equals patient effort (scaling). LSVT Concept 3: Focus on INTENSIVE Daily opportunity to practice increases likelihood of "building daily increments of vocal effort." Maintain motivation. Maximize habituation and carry over. Provides an opportunity for the clinician to see the patient's daily changeability. - TREATMENT (16 sessions of individual treatment in one month) LSVT Concept 4: Calibration – Establish right amount of effort/result. – Patient needs lots of feedback and knowledge of results in functional situations. – Convince patient that “loud” voice is normal sounding – it won’t feel normal to patient. – Habituation and carry over. Resonance Goals: – Improve velopharyngeal closure. – Improve oral flow. Strategies: – Intra-oral pressure (blow cheeks up with air – then SPEAK). – Blowing (straws, Kleenex, balloon) – then SPEAK. – Oral vowels. – Pressure consonants. – Alternate oral and nasal consonants. Other: – Pros-theses (left or lift). – Surgical management. – Improve speech and swallowing. Resonance Feel, Hear, See Connect plastic nasal olive to one of the patient’s nostrils-tape it in place. Ask patient to prolong a vowel /a/ as long and steadily as possible. Using a tongue depressor, simulate the effect of a palatal-lift. Note changes in resonance. Perceptual judgment. Positive results are generally evident within 4 or 5 sessions.  Approximately 80% of all patients with PD exhibit reduced loudness, unclear speech, monotone, vocal tremor, hoarseness, and rapid rate of speech. The assumption behind this approach to the behavioral treatment of neurological disorders is that modification or compensation for underlying laryngeal dysfunction includes problems with VFs adduction and the generation of a stable voice. Articulation Goals: Increase power (force + speed). Increase/decrease tone. Increase ROM. Improve coordination during speech tasks. Improve single phoneme accuracy. Increase co-articulatory coordination. Articulation Therapy Approaches: Strengthening – Tongue – Maximum contractions » lateral, superior, inferior » anterior, midportion, and posterior tongue – Lips & Face – Maximum contractions » retraction, protrusion, closure – Resistance movements » neuromuscular facilitation Articulation Therapy Approaches: ROM/Reduce tone Tongue, lips, face. Massage, stretching. Articulatory precision Reduce rate. Over articulate. Articulation drill. Modify articulation difficulty. Intelligibility & Comprehensibility Goals: – Intelligibility within specific contexts Clinic With spouse With strangers In noise On the phone – Self-monitoring – Clarification strategies Intelligibility & Comprehensibility Approaches: Pacing board. Over articulate. Increase effort. Modify environment – background noise – lighting – contextual cues Train listeners. Teach nonverbal communication strategies. Augmentative devices.  Pacing board for speech. – It is designed to help individuals with dysarthria / unclear or slurred articulation and a fast-speaking rate to pace their speech and improve their intelligibility in conversation. Disorders that a pacing board could be used for include: Verbal apraxia Motor planning Dysarthria Cluttering/Fluency Language disorders Autism Articulation/Phonological Processing 229 The treatment goals are endless, here are a few of the big ones I use a pacing board for: Breaking up syllables. Slowing a sentence utterance down (especially for those superfast talkers). Inclusion of medial or final consonants as a sentence strip. Expanding mean length utterance. 230 Intelligibility & Comprehensibility Alphabet boards (AAC)– Pt points to the first letter of every word spoken Decreases rate Gives listener a visual cue Delayed auditory feedback Prosody Goals: – To improve emotive stress. – To improve linguistic stress. – To produce natural speech melody. Approaches: – Pitch control. – Loudness control. – Imitation of stress patterns. – Production of specified stress patterns. – Terminal declination. – Question inflection. – Intra-word stress that changes meaning. ADDress -- addRESS Tips for Patients Say one word or phrase before starting to talk in sentences. This will tell the listener what the topic is and help them understand what you say. – For example, you can say "dinner" before starting to talk about what you want to eat. Check with listeners to make sure that they understand you.  Speak slowly and loudly. Pause to let the other person think about what you have said. Try not to talk a lot when you are tired. Your speech may be harder to understand. Try pointing, drawing, or writing when you have trouble talking. Children may need help remembering to use these tips. 234