Chapter 18- Children with Orthopedic and Neurological ...



Chapter 18- Children with Orthopedic and Neurological Impairments

Definition of Orthopedic and Neurological Impairments

• Children with orthopedic impairments may be limited to walking, crawling, or scooting

• Disabilities included under orthopedic and neurological impairments are those in which nerves, muscles, and bones don’t respond in a coordinated way

• These include: movement disorders such as developmental coordination disorder and correctable orthopedic impairments

• Neurological Impairments: cerebral palsy, neural tube defects, spinal cord injuries, and traumatic brain injury; and musculoskeletal conditions including absent limbs and muscular dystrophy

• According to the Individuals with Disabilities Education Act, “Orthopedic impairment means a severe orthopedic impairment that adversely affects a child’s educational performance caused by congenital anomaly, impairments caused by disease (poliomyelitis, bone tuberculosis), and impairments from other causes (cerebral palsy, amputations, and fractures or burns that cause contractures).”

Cause of Orthopedic Impairments

• lack of oxygen in the child’s brain either while the mother is pregnant or during birth can cause physical impairments; diseases that affect the brain, such as meningitis and encephalitis, and prolonged high fevers can also cause permanent brain damage; poisoning and other conditions that lead to lack of oxygen in the brain, as well as head, neck, and back injuries, sometimes causes paralysis or abnormal movement patterns

• Neurological impairments: those that affect the nervous system, the brain, and the spinal cord.

0 to 3 years

• Missed motor milestones is one of the markers we use to identify children with orthopedic impairments.

• Delays in things like: rolling over, sitting up straight, standing, walking, self-feeding, dressing, using the pincer grasp, toilet training,

• Severely involved children may have delays in language and problem solving abilities

3 to 6 years

• difficult time keeping up with their peers; most gross and fine motor skills are set, so the aim to intervention is to capitalize on what the child can do; it is clear to children by this age that they are different from other children

6 to 9 years

• more fine motor skills; assistive technology can be beneficial for many children; learning disabilities come into play

Muscle Tone

• Children with low muscle tone, or hypotonic, may have problems picking up a cup. Grasping very small objects is difficult

• Example of hypertonic muscle tone: lie with your back on the floor, tense all of your muscles (make fists, squinch up your face, tense your legs, trunk, and back), and try to sit up. You will probably find that it does not work.

• Example of hypotonic muscle tone: relax, let your arms become floppy as you pretend to be a rag doll, try to sit up without tensing any of your muscles, this probably doesn’t work either

• The biggest issue with young children is establishing trunk stability; much of the focus in early therapy is in stabilizing the large muscles

• Muscle tone also affects small muscles of the mouth and face, which means you might have a hard time understanding children’s speech

Classifications of Orthopedic and Neurological Impairments

• Impairments are classified by severity, type, and the parts of the body that are involved

• Children with mild impairments: can walk (with or without help from crutches, walker, or other devices), use their arms, and communicate well enough to make their wants and needs known. Take more time to do things, but can do what most other children can; problems are mostly fine motor skills

• Children with moderate impairments: require some special help with locomotion and need more assistance than their peers with self-help and communication skills

• Children with severe impairments: usually not able to move from one place to another without a wheelchair; self-help and communication skills are usually challenging

Developmental Coordination Disorder

• The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) added the category of Motor Skills Disorder, specifically, Developmental Coordination Disorder (DCD), also referred to as clumsy child syndrome and developmental dyspraxia.

• 6 percent of children between 5 and 11 years have some degree of Developmental Coordination Disorder

• Affects more boys then girls

• It is a chronic condition that continues into adolescence and adulthood

• The DSM-IV-TR has four characteristics that must be present for a diagnosis of DCD: 1. motor coordination that is substantially below expected motor milestones or clumsiness in the performance of motor tasks; 2. the level of performance must be great enough that it interferes with either academic achievement or the performance of task of daily life; 3. the disturbance is not due to a medical condition such as cerebral palsy; 4. if the child has mental retardation, the motor problems are in excess of those expected because of the mental retardation

• There is no cause of the developmental dyspraxia; it is a hidden disability- the child looks like other children, but finds it more difficult to accomplish the same tasks that other achieve with little effort

• Some clumsy children are diagnosed with Developmental Coordination Disorder

• Children who have dyspraxia have trouble with learned, voluntary, skilled movements such as buttoning buttons, handwriting, using a fork, and speaking clearly.

• Children with dyspraxia have a disruption in their motor planning abilities at one or more of the following levels: 1. perceiving a demonstrated movement accurately or understanding verbal direction to move in a specific way; 2. integrating the information and developing a motor plan; 3. motorically carrying out the plan in the correct sequence

• The cause of dyspraxia is the physical inability of the brain’s neurons to effectively communicate movement instructions to the body’s muscles; it can affect specific areas like large motor skills or areas of fine motor skills

• Activities that are enjoyable to many, can be frustrating with people who have dyspraxia; the develop and understand at the age-appropriate rate

• A child will not grow out of it; it is a lifelong tribulation that may require therapy

• A teacher may need to scaffold certain areas for children because they may need more time and more practice developing skills

Correctable Orthopedic Impairments

• if not treated, these problems can result in some degree of orthopedic impairment

• Examples are: bowlegs and inwardly rotated feet- cured through natural growth, sometimes having to use braces, casts, or surgery; clubfeet-treated with casts, splints, and physical therapy or surgery; congenital hip problems- treated by a webbed brace, traction, cast, or surgery

Neurological Impairments

Cerebral Palsy

• used to refer to a group of neurologically related motor disorders that come in many varieties and severities. “Cerebral palsy is a disorder of movement and posture that is caused by a nonprogressive abnormality of the immature brain.”

• Posture, balance, and movement are disorganized

Causes

• premature births and problems during pregnancy account for the majority of cases

• 1.4 to 2.5 children per 1,000 have CP

• Low birth weight babies are the most typical

• Diplegia: whole body is involved; legs more then the arms; some head control and moderate to slight paralysis of the upper limbs

• Hemiplegia: involvement of the upper and lower extremities on the same side of the body; spastic type

• Monoplegia: involves one arm

• Paraplegia: lower extremities are involved; found among spinal injuries and spina bifida and rarely found in CP

• Quadriplegia: involves all four limbs; head control is poor; impairment of speech and eye coordination

• Triplegia: three extremities, both lower extremities and one arm

Types of Cerebral Palsy

• classified by the extremities involved, the type of brain damage, and the motor disability

• Spastic Cerebral Palsy: the abnormalities in the brain pathways originate in the gray matter of the brain; the motor cortex of the brain is damaged; this results in limb muscles that are very tight and are difficult to move; voluntary movements are jerky and inaccurate

• Most common type

• This type of cerebral palsy is associated with prematurity

• Children with spastic quadriplegia: not just the four limbs are involved, but the mouth and tongue may be affected and there may be other damage to the brain the causes mental retardation, seizures, medical complications, and sensory impairments

• Dyskinetic Cerebral Palsy: damage outside the pyramidal tracts

• Different implications: the most common type is called choreoathetoid cerebral palsy:

• Rapid, random, jerky movements- chorea part; combined with slow, writhing movements- the athetoid part

• In athetoid cerebral palsy only the later characteristics occur

• The variable muscle tone makes it difficult to develop the stability needed for sitting and walking

• 10 percent of children with cerebral palsy fall into this category

• Ataxic Cerebral Palsy: abnormalities in voluntary movement; children who walk use a wide base and have an unsteady gait; problems controlling their hands and arms; problems with timing of their motor movements; children can have increased or decreased muscle tone

• Mixed Cerebral Palsy: damage to both the pyramidal and extrapyramidal areas of the brain (rigidity in the arms and spasticity in the legs).

• Account for 10 percent

• Cognitive delays and other development delays

Early Diagnosis and Treatment

• The absence of primitive reflexes, abnormal muscle tone, and resting positions give clues to the possibility of cerebral palsy

• Some children with cerebral palsy also have sensory impairments, speech disorders, and delayed cognitive development

• Usefulness of medication for children with cerebral palsy has not been answered definitively

• Surgery is sometimes part of the treatment process

• Goal to intervention: maximize the children’s functioning and minimize disability-related problems

• Orthotic devices, braces and splints, are used to prevent contractures of specific joints- help provide stability and control involuntary motion

• Contractures: irreversible shortening of muscle fibers, which causes decreased muscle joint mobility

• Neurodevelopmental therapy is the most commonly used form of physical and occupational therapy for children with cerebral palsy

Neural Tube Defects

• a group of congenital malformations of the vertebrae, spinal cord, and brain

• Three major neural tube defects: spina bifida, encephalocele, and anencephaly

• Most common: spina bifida: a split in the vertebral arches

• Individuals with spina bifida occulta have no symptoms and many not even know they have a split

• 10 percent of the general population his this hidden separation

• Occult spinal dysraphism: the child has a visible abnormality on the lower back- a birthmark, a small opening in the skin, a small lump, or a dimple

• The form of spina bifida that we typically think of is meningomyelocele where the spinal cord is malformed and the children show an array of symptoms; the fluid-filled sac protrudes through the spine of the newborn above the defect in the vertebral column; it looks like a flat bubble on the infant’s back and contains the malformed spinal cord; the nerves below the protrusion do not develop properly, leading to loss of sensation and paralysis below the site- surgery is performed on this

• Encephalocele- neural tube defect; involves a malformation of the skull that allows a portion of the brain to protrude; it can be at the back or front of the brain

• At the back: children usually have mental retardation and hydrocephalus (excessive fluid in the brain cavities), spastic diplegia, and/or seizures

• Front of the head: the impact is more variable and potentially associated with better outcomes for the child

• Anencephaly- more severe malformation of the skull and brain and no neural development occurs above the brainstem

• Worldwide prevalence is falling- based on better overall nutrition and particularly the use of folic acid supplements during pregnancy

Cause of Neural Tube Defects

• Neural tube defects occur in 1 in 10,000 births in the U.S.

• Problem occurs 26 days after conception, when the neural tube has folded over itself to become the spinal cord and vertebral arches

• If the neural tube does not close completely and the spinal cord is malformed, neural tube defects result

• Hydrocephalus: a related problem that occurs for children where the meningomyelocele is in the lumbar of thoracic region; excess fluid in the brain

• it is diagnosed through ultrasonography in infancy and an MRI in older children

• treated surgically with a shunt

• Children with myelomeningocele can not usually tell when they are wet

• Parents and surgeons have to make a decision about what to be done about this problem- frequently- a clean intermittent bladder catheterization (CIC) is used

• Children with neural tube defects have decreased strength and sensations- special care must be taken to protect their lower limbs

• Bones not as strong as they should be and are prone to fractures

• Many children with spina bifida are allergic to latex- can be life-threatening

• Intervention begins in infancy

• Children with meingomyelocele have IQ scores in the low average range- eventually will be labeled as having a learning disability

• Impairments in: perceptual skills, organization, attention span, memory, speed of motor responses, and hand function

• As children grow- concerns relate to bowel and bladder control and social problems

Spinal Cord injuries

• uncommon in young children

• Spinal cord- sends motor and sensory messages from the brain to toher parts of the body

• Spinal cord is divided into 4 major regions and has about 30 different segments or sections

• If the spinal cord is damaged, messages do not reach beyond the impaired area and hence are not delivered or received

• Some infants are born with malformed spinal cords or conditions where the spinal cord deteriorates

• Anyone who has a spinal cord injury is permanently paralyzed and unable to feel pressure or pain below the lesion

• Spinal atrophy- progressive degeneration of the motor-nerve cells, resulting in slow weakening of the body’s muscle strength

• effects include: skill decrease, fatigue, and decreased coordination

• congenital atrophy- progressives rapidly, resulting in an early death

• acquired atrophy- develops much more slowly, first affecting the legs and then progressing to the upper extremities

Traumatic Brain Injuries

• Increasingly frequent cause of orthopedic impairment is head injury- automobile accidents, falls off a bicycle, gunshot wounds, or from other accidental causes

• Can include: sensory, motor, emotional, and cognitive impairments

• Each year, 1 child in 25 receives medical attention because of a head injury

• Traumatic brain injury (TBI): defined as trauma sufficient to change a level of consciouness or having an anatomical abnormality of the brain

• Occurs in every 1 to 500 children

• Boys are more likely to sustain head in juries then girls

• Occur in the spring and summer, on weekends, and in the afternoon

• Traumatic brain injury was acknowledged as a separate category of disability under IDEA in the 1990 reauthorization

• Causes of brain injury vary with age

• Children under four- half of brain injuries are caused by falls (55%), followed by motor vehicle accidents (19%), sports and recreation (13%), assault (7%), and all other causes (6%).

• Children 5 to 9- sports and recreation (32%), falls (31%), and motor vehicle accidents (31%), assault (1%), and all other causes (5%).

• Scalp injuries bleed a lot, but they do not injure the brain.

• A linear fracture of the skull also has little impact, but a depressed fracture, when part of the skull is broken and presses into the underlying brain tissue, may cause a weakness or disability

• Brain contusions, usually the result of direct impact, such as a baseball striking the head, bruises the brain. This can be minor or may require surgical removal.

• Epidural hematomas are the most lethal, but also the most treatable. A hematoma is a blood clot, in this case between the skull and the outer covering of the brain. Typically, the child falls or is injured and appears fine, then symptoms begin to develop as the hematoma grows. These lead to headaches, confusion, vomiting, and perhaps even lethargy and coma. If this is treated quickly, children usually recover completely, it treatment is delayed, there may be physical and cognitive delays and even death.

• Acute subdural hematomas: blood clots that form beneath the dura or the brain covering; result from sheering forces applied to the veins that actually displace the brain from the dura to rupture the membranes. This could cause brain swelling and stroke. A large area of the brain is affected, surgery is done, but the prognosis is not positive.

• Diffuse axonal injury: the nerve fibers throughout the brain have been damaged, usually by violent motion. The child usually becomes unconscious and stays that way for at least six hours. Recovery may take weeks to years depending on the amount of damage done.

• Sometimes the brain injuries are inflicted rather than accidental. Inflicted injuries are more common with children younger than age three and are leading causes of traumatic death in infancy. Confirmed abuse accounted for 33 percent of hospital admissions for head injuries for children under three, and 19 percent of those under six and a half years.

• Shaken baby syndrome is certainly one of the factors taken into account in these figures, it also appears that when the baby is shaken the head also comes in contact with a surface such as a bed, wall, or floor.

• If the loss of consciousness is more than momentary, a skull X-ray or CT scan should be done.

• X-ray shows the bones of the skull, and the CT scan the soft tissues of the brain itself.

• If a child is unconscious for more than a few minutes, call the paramedics.

• The seriousness of a brain injury when the child is in a coma is usually rated on the Glasgow Coma Scale, used within the first six hours. This rating looks at the eye-opening, motor, and verbal responses. A child with a score of 3 has no eye-opening, no movement, no verbal response, and is in a deep coma. A score of 15, the highest score, reflects the ability to spontaneously look around, move limbs on request, and make relevant verbal responses.

• Almost 95% of children admitted to a hospital for a TBI survive.

• Brain injury appears to impair new learning more than the retention of old learning

• Most recovery takes place in the first six months after the injury and will take place at a slower rate after that.

• These are all very stressful for the child and their family. Psychological stress, whether the child will live or die, the financial consequences of paying for the child’s treatment

• Most childhood trauma is preventable by teaching children good safety habits such as using helmets while riding bicycles, supervise playgrounds, and ensure that equipment and surface areas are at safe and appropriate heights.

Musculoskeletal Conditions

Absent Limbs

• Some children are born with deformed or absent limbs.

• These disorders can be the result of genetic or chromosomal causes or environmental influences such as drugs or chemicals.

• Muscular Dystophies is an umbrella term for a group of chronic, progressive disorders that affect the voluntary muscles. It is an inherited sex-linked disorder, in which the child has a decreased or absent production of the protein dystophin, which stabilizes the muscle membrane during contraction.

• Most common type: Duchenne muscular dystrophy: detected when a child is between two and five and begins to fall down frequently due to muscle weakness. Affects 1 in 3,000 males. The process, which can occur quickly or slowly, leads to increased disability and death (young adulthood).

• It is important that teachers know the purpose for all equipment. Also, the teacher must communicate well with the parents and the physical therapist.

• The purpose of bracing and splinting is to improve motor function.

• Walkers, scooters, crutches, and canes are the most common mobility aids for short distances.

• Strollers and wheelchairs constitute the most common long-distance mobility aids.

• Transferring: the term used when you move children from one piece of equipment to another.

• requires two people

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