2. Introduction  Cerebral Palsy (CP), Traumatic Brain Injury (TBI) and Stroke are conditions that result in damage the brain.  They might exhibit common motor, cognitive and behavioral characteristics.

3. Cerebral Palsy (CP)  Cerebral: Brain  Palsy: disordered movement or posture.  Definition: Group of permanent disabling symptoms as a result of damage to the control areas of the brain. Non-progressive condition originated before, during or shortly after birth.

4. CP: Characteristics  Loss or impairment of control over voluntary musculature.  Symptoms vary widely: Total inability to control bodily movements (severe cases) to mild conditions such as a speech impairment.  Abnormal reflex development.  Difficult to coordinate and integrate basic movements patterns.

5.  CP is commonly associated with other impairments such as: Seizures Speech and language disorders Sensory impairments Abnormal sensation and perception Intellectual disability

6. CP: Causes  Rubella  Rh incompatibility  Prematurity  Birth Trauma  Anoxia  Meningitis  Poisoning  Brain hemorrhages or tumors  Other brain injuries caused by accident or abuse.

7. CP: Incidence  In 2010, 800,000 people were estimated as having CP.  10% of the cases are acquired in the 2 first years of life.

8. CP: Classifications  There are three different criteria to classify the particular type of CP: 1. Topographical – in accordance with the anatomical site ○ Monoplegia ○ Diplegia ○ Hemiplegia ○ Paraplegia ○ Triplegia ○ Quadriplegia

9. http://physicaltherapydatabase.blogspot.com/2011/04/cerebral-palsy-part-ii.html

10. 2. Neuromotor – From the American Academy for Cerebral Palsy 2.1 Spasticity: Results from damage to motor areas of the cerebrum, characterized by: - Hypertonicity, - Problems with balance and locomotion. - More commonly associated with other disorders.

11.  2.2 Athetosis  - Damage to the basal ganglia resulting in a overflow of motor impulses to the muscles. http://www.alinenewton.com/neuroscience.htm

12.  Caused by blood incompatibilities during birth.  Slow and writhing movements uncoordinated and involuntary.  Abnormalities in muscle tones. http://medical-dictionary.thefreedictionary.com/athetosis

13.  Facial grimacing;  Protruding tongue;  Lack of head control;  Difficulty in eating, drinking, and speaking;  Lordotic stand is common  Aphasia: impairment or loss of language.

14.  2.3 Ataxia Damage to the cerebellum resulting in balance and muscle coordination problems. http://www.dana.org/news/brainhealth/detail.aspx?id=9774

15.  Its usually diagnosed when the child tries to walk. – Wide-based gait.  Nystagmus: involuntary movement of the eyeball.  Difficult with basic motor skills.

16.  3. Functional Classification Based on the abilities possessed by the individual. Which varies with the severity of the disability. Used by the National Disability Sports Allience (NDSA) and the Cerebral Palsy-International Sport and Recreation Association to equalize competition.

17.  The classification has 8 classes: Severe spasticity or athetosis with severe locomotion and object control restrictions (Class I) to Minimal coordination problems (Class VIII)

18. General Education Considerations  Condition to be managed not treated.  Alleviating symptoms and promoting maximum potential in growth and development.

19. Strategies to alleviate symptoms  Practice activities to train voluntary muscle control and muscle relaxation.  Promote the development of functional motor skills.  To avoid permanent contractures: braces and orthotic devices.

20.  Surgery on the tendons, muscles or the brain might be performed in severe cases.  Physical therapy  Social and psychological attention.  Keep in mind: primary concern is the total person.

21. Traumatic Brain Injury (TBI) Definition: Injury to the brain that might produce a diminished or altered state of consciousness.  Possible impairments of physical, cognitive, social, behavioral and emotional functioning.

22. Causes  Accidental traumas;  Lack of oxygen (anoxia);  Cardiac arrest;  Child abuse;  Near drowning  Motor vehicle accidents, violence and falls are the leading causes.

23. Characteristics  Physical impairments might require the use of crutches or wheelchairs.  Might involves: lack of coordination, spasticity, headaches, speech disorders, paralysis, seizures.  Disorders of motor planning - Apraxia: loss of the ability to execute or carry out learned purposeful movements.

24.  Cognitive impairments might involve: Memory deficits, poor attention and concentration, poor judgment, etc.  Social, emotional and behavioral impairments: Mood swings, difficulty in controlling impulses, in relating with others; depression, etc.

25. Incidence  TBI is the leading killer and cause of disability d young adults (under 45).  Affects more the 1.7 million persons on the US each year (Thompson et al, 2012).  Young males are in more risk to sustain a TBI.

26. Classification  Open Head Injury: Usually comes from accident, gunshot, or blow to the head – visible injury.  Closed Head Injury: Caused by severe shaking, anoxia or cranial hemorrhages – diffuse brain damage.

27. LEVELS OF SEVERITY  Accordingly with “The Ranchos Los Amigos Hospital Scale”:  - 8 levels of cognitive functioning varying from very severe to very mild condition: - Level 1 – No response, coma. - Level 5 – Confused and inappropriate response. Responds well to simple commands, highly distractible, in need of frequent redirection. - Level 8 – Purposeful and appropriate behavior, doesn’t require supervision.

28. General Educational Considerations  First of all: Individualized rehabilitative program with a interdisciplinary team. - Usually on the hospital facilities.  Long term rehabilitation program. The individualized educational program normally goes to the rehabilitation center. - Lasts from 6 to 12 months, focus on cognitive skills, speech therapy, readaptation to daily live activities.

29. Basic Principles for Educators  Provide each student with unique cognitive, behavioral and psychosocial challenges.  Assessments need to be functional and contextualized.  Systematically reduce in support offered as appropriate.  Collaborative decision making.

30.  Develop additional instructions strategies: e.g.: cooperative learning activities, additional time to reviews. Simplify information and directions.  Development and implementation of transitional plans for high school-age students.  Focus on a functional transitional approach to establish links with community and postschool.

31. Stroke  Also referred to as cerebrovascular accident (CVA)  Definition: Damage to the brain tissue resulting from faulty blood circulation Can result in serious damage to areas of the brain that control vital functions ○ Examples: Motor ability and control, sensation and perceptions, communication, emotions, and consciousness Can result in death http://www.sciencedaily.com/releases/2009/03/09 0312114803.htm

32. CVA: Characteristics  People who survive CVA have varying degrees of disability  Depending on the location of damage, symptoms are similar to CP and TBI  Common Characteristics: Partial or total paralysis on either the left or right side of the body ○ One limb (monoplegia) or body segment ○ One entire side (hemiplegia)

33. CVA: Characteristics cont. Right-sided hemiplegia ○ Problems with speech and language ○ Slow and cautious, and disorganized with approaching new or unfamiliar problems Left-sided hemiplegia ○ Problems with spatial-perceptual tasks ○ Overestimate their abilities

34. CVA: Adult versus child characteristics  Typically children experience the same effects as adults do  Research shows that children show more improvement following brain trauma (TBI and CVA) than adults do

35. CVA: Classifications  Two categories: 1. Hemorrhagic ○ Hemorrhage within the brain as a result of an artery that loses elasticity and ruptures 2. Ischemic (Majority) ○ Lack of blood results from a blocked artery Blockage caused by progressively narrowing artery or embolism (blood clot r piece of plaque that lodges in small artery)

36. CVA: Causes  Several factors contribute to CVA occurring Uncontrolled hypertension Smoking Diabetes mellitus Diet Drug abuse Obesity Alcohol abuse  Most can be controlled through lifestyle change Moderate and high levels of physical activity are associated with a reduced risk of CVA (Blair, 2003)

37. CVA: Incidence  Primarily viewed as occurring in elderly, but it also strikes infants, children and young adults  Risk is greatest in the first year of life Peaks during the perinatal period  Occurs in about one of every 4,000 live births  Risk from from birth through age 18 is nearly 11 per 100,000 children per year  50 to 80 percent of surviving children will have permanent neurological effects  One of top 10 causes of death for children  CVA is a leading cause of long-term disability in the United States

38. CVA: Considerations  Teachers and coaches should be aware of common warning signs Sudden weakness or numbness of face Sudden weakness or numbness of arm and leg or entire side of body Sudden dimness or loss of vision in only one eye Sudden loss of speech or trouble understanding speech Sudden severe headache with no apparent cause Unexplained dizziness, unsteadiness, or sudden falls  Seek medical attention immediately  Survivors immediately placed on a planned, systematic and individualized rehabilitation program

39. CP, TBI and CVA Characteristics: Physical  Reduced muscular strength, flexibility, and cardiorespiratory endurance Inability to maintain balance or independently transfer weight or moves one’s body

40. CP, TBI and CVA Characteristics: Motor  Restricted from experiencing normal functional movement patterns Delays in motor control and development  People with CP: Few opportunities to move + Lack movement ability + Difficulty control movements  People with CVA: Difficulty planning and performing movements because of damage to the cerebrum  People with TBI and CVA: Unable to execute fundamental motor skills in an appropriate manner

41. CP, TBI and CVA Characteristics: Behavioral  Lack self-confidence  Have low motivational levels  Exhibit problems with body image

42. General Program Implications: Safety Cont.  Students with severe impairments need special equipment Support upper body while in the prone position (crutches, bolsters, etc.) Assist in maintaining a standing posture (standing platform) Aid in in performance of certain motor tasks (orthotic devices, seating systems, etc.)

43. Implications to PE program: Recommended teaching strategies  Safe, secure environment to explore capabilities of own body and interact with surroundings  Closely monitor games and activities  Assist by: Getting a student into and out of activity positions, physically supporting her during activity, or helping her perform a skill or exercise Apply pressure with hands on key points of body  Gradually reduce the amount of support to key points of body over time  Personalized approach to enhancing health-related fitness Develop strength and flexibility Develop adequate level of aerobic activity

44. Implications to PE program: Recommended teaching strategies cont.  Brockport Physical Fitness Test (BPFT): Provides test items, modifications for disabilities, and criterion-referenced standards for achieving fitness Components of aerobic functioning, body composition, and musculoskeletal functioning Various test items can be selected within components ○ Selection based on functional classification http:/www.sciencedirect. com/science/article/pii/S1 05827460800476X http://www.todayfitness.net/o nlinetrainer/TFOT- skinfoldsites.htm

45. Implications to PE program: Recommended teaching strategies cont.  Be sensitive to frequency, intensity, duration, and mode of exercises and activities Rest breaks and player substitutions  Choose activities students find enjoyable

46. Implications to PE program: Recommended teaching strategies cont.  Encourage the sequential development of fundamental motor skills Authentic assessment  Be concerned primarily with the manner in which a movement is performed Ecological Task Analysis (ETA)  Encourage students to achieve maximum motor control and development related to functional activities Standardized motor development tests

47. Implications to PE program: Recommended teaching strategies cont.  Provide successful movement experiences that motivate students and help them to gain self-confidence  Promote that failing is a natural part of the learning process

48. Implications to PE program: Recommended activities/exercises  The club throw http://www.youtube.com/watch? v=5b_JZIrbN1E http://www.youtube.com/watch? v=5b_JZIrbN1E  Bowling  Cycling  Archery  Boccia http://www.youtube.com/watch?v=CA lQzcqw0Zw&feature=relmfu http://www.youtube.com/watch?v=CA lQzcqw0Zw&feature=relmfu  Tennis  Table Tennis  Riflery  Archery  Badminton  Horseback riding  Billards  Track and field http://www.blazesports.org/sports/archery/ http://www.blazesports.org/?cat=2 7 http://www.blazesports.org/?cat= 26

49. Adapted Sports  The National Disability Sports Alliance (NDSA) administrates the participation of athletes with CP, TBI and CVA  Participation occurs on the basis of their functional ability levels as displayed on the eight-level classification system.

50. Placement  Two testing procedures to determine placement: 1. Observation and questioning 2. Measurement of speed, accuracy of movement and rang of motion for upper extremity and torso function.  For ambulant athletes: assessment of lower extremity function and stability.

51. References 1. Thompson, et al. Utilization and Costs of Health Care after Geriatric Traumatic Brain Injury. Journal of Neurotrauma, n.29, pag. 1864-1871. July, 2012. 2. Knowing No Bounds: Stroke in Infants, Children, and Youth. Retrieved from: http://www.strokeassociation.org/idc/groups/ stroke- public/@wcm/@hcm/@sta/documents/downloadable/ ucm_311389.pdf 3. Winnick, Joseph P. (Ed.) (2011). Adapted Physical Education and Sport (5 th ed.). Champaign, IL: Human Kinetics.