Physical and Health Disabilities

Physical Disabilities General Information Review of definitions Associated medical conditions Medical and therapeutic interventions Onset of disability Congenital Acquired Nature of disability Acute Chronic Impact and strategies

Neuromotor Impairments Originate in the CNS Affect nerves and muscles Types CP Seizure disorders Neural Tube defects TBI

Neural Tube Defects (NTD’s) Malformations of the brain, spinal cord, and/or vertebrae Commonly referred to collectively as spina bifida Failure of spinal column to close properly Contributing factors Nutrition Medication Temperature Folic acid supplements Genetic links - ethnic prevalence Gender ratio

Types of NTD’s Malformation of skull and portion of brain pushes out - encephalocele Absence of brain development beyond the brain stem - anencephaly Most common - spina bifida Few vertebrae are bifid and no protrusion - spina bifida occulta Covering or meninges protrude through open defect in spine - meningocele Protrusion of spinal cord and meninges through vertebral defect - myelomeningocele

Associate Medical Conditions with Myelomengingocele Location of vertebral defect is directly associated with the level of paralysis and loss of sensation Lower level may impact only spinal nerves and higher level may impact spinal cord Loss of sensation Loss of bowel or bladder control Lack of urge may lead to overfilling or reflux Infections and overstretched bladder results

Associate Medical Conditions with Myelomengingocele Blocked cerebral spinal fluid (CSF) drainage - hydrocephalus Head enlargement Brain abnormalities Seizures Joint deformities and spinal curvature Spinal cord “caught” on vertebrae or restricted by scar tissue - tethered cord Cord is stretched Causes spinal curvature or nerve damage

Interventions Surgical interventions Closure shortly after birth to prevent infection and protect nerves from injury Placement of shunt to allow CNF drainage and prevent brain damage Release of tethered cord Orthopedic treatment Prevention of deformities of spine, hip, and legs through supported standing and prone Surgery, braces, and splints Impact on ambulation Therapeutic interventions Physical therapy Occupational therapy Clean intermittent catheterization (CIC) and program for regular bowel movements

Developmental Impact Early intervention School age programs Sensory-motor skills Social development School age programs Motor development Functional skills self-care mobility

Developmental Impact Physical and cognitive development Motor impairment Increased dependency Limited manipulation of materials and play Contraindicated activities due to shunt Cognitive impairment Restricted opportunities Damage to brain tissues Psychosocial development Motivation and frustration level Lack of mastery of skills Stigmatization due to odor associated with incontinence Self-esteem and body image issues

Educational Impact Unique needs Academic challenges Language issues Frequent absences Self-care training needs Therapy activities Academic challenges Learning disabilities Emotional disorders Motor planning issues Language issues  “cocktail party language” False impression of ability may lead to unrealistic expectations

Educational Impact Personal autonomy Career and adult outcomes Signs of shunt malfunction (see Fig. 2-2, p. 36) Headache, lethargy, nausea or vomiting Subtle changes in performance, handwriting, or social behavior Management and strategies for care of personal needs Skin Fractures Bladder and bowel Independence Career and adult outcomes

Traumatic Brain Injury (TBI) Head injury No fracture - closed Penetration of skull - open Brain injury Traumatic or non-traumatic events Acquired condition Concussion - mild TBI There may be no apparent damage Second impact syndrome (swelling and bleeding) may result if not resolved Contusion Sudden movement of brain towards inside of skull - coup/contracoup

Associated Medical Conditions with TBI Cognitive impairment Memory and attention Organization and perception Problem-solving and reasoning Seizure activity Sensation loss Damage to eyes Cortical visual impairment (CVI) and nystagmus or diplopia Damage to ears Motor impairment Spasticity Ataxia Tremors Other impairments Feeding Communication Behavior

Interventions Medical response Neurological assessment Support vital functions - ABC (Airway, breathing, circulation) Appropriate head and neck positioning Medication management Reduction of environmental stimulation Neurological assessment Neurosurgery may be indicated Reduce intracranial pressure Remove foreign objects

Therapeutic Interventions Acute care Coma stimulation Stabilization Passive mobility Rehabilitation Compensatory skills Prevention of complications Promote residual skills

Coma Recovery Definition Measurement Loss of consciousness Unresponsiveness Measurement Glascow Coma Scale (GCS) (table 2-1, p. 40) Baseline of responsiveness 3 measures - Eye movement, motor response, and verbal response Emerging from coma - “lightening” Rancho Los Amigos Cognitive Scales (table 2-2, p. 41) Initial stages of recovery Reference for rate of recovery and functional ability

Developmental Impact Physical and cognitive development Factors Injury-related Treatment-related Patient-related Physical changes Sensory problems Balance issues Seizure activity Cognitive changes Attention Perception Memory and learning

Strategies for Physical and Cognitive Problems Attending and limited response rate is not deliberate Stimulation needs to be controlled Reduce complexity Modify instruction Repetition Localized versus diffuse damage

Developmental Impact Psychosocial development Behavioral changes Emotional lability Response to specific “antecedents” may be predictable Poor self-esteem or image Depression

Educational Impact School reentry (Fig. 2-3, p. 47) Transition needs Gradual introduction to academics Gradual introduction to teachers and peers Career and adult outcomes

Degenerative Diseases Features Progressive loss of motor movement Increasingly restricted physical ability Psychosocial factors - control, fatigue, discomfort, and mortality Muscular Dystrophy is one of the many types of degenerative diseases Progressive weakness and death of muscle fibers Most common is Duchenne Muscular Dystrophy (DMD) - absence or alteration of protein called dystrophin

Duchenne Muscular Dystrophy Symptoms observed between 2-6 years Weakness usually begins in lower legs and pelvic girdle muscles Muscle tissue replaced with fat and fibrous tissue Uses arms to support posture Sway back leads to scoliosis Gradual loss of mobility leads ultimately to respiratory dysfunction Death at young adulthood usually due to respiratory or heart failure

Associate Medical Conditions with DMD Loss of respiratory function secondary to abdominal and thoracic muscle weakness Difficulty coughing up secretions may lead to pneumonia Cardiac muscle weakness Deterioration of ambulatory skills Development of contractures

Interventions Goal is to maintain function and slow progression of symptoms Surgery may be indicated Release contractures to prolong ambulation Stabilize vertebrae to improve respiratory function and aid sitting Orthopedic treatment Mobility equipment Handling issues Powered mobility Therapy needs Mobility Self-care

Developmental Impact Physical development Initially normal development Slow, progressive loss of function Implications for physical changes Understanding of mobility and progression Periodic monitoring of skills Match status with appropriate level of assistance Allow maximal level of independence while monitoring endurance Monitor weight and dietary changes

Developmental Impact Cognitive development Psychosocial development May impact verbal performance Low performance expectations Frequent absences Psychosocial development Implications of terminal illness Increasing dependency Social isolation Changing body image Depression

Educational Impact Maintain level of activity and educational rigor Use adaptation strategies Low-tech High-tech Personal autonomy Maintain level of participation Introduce adaptations carefully Maintain expectations Career and adult outcomes

Orthopedic and Musculoskeletal Conditions Any condition related to muscular or skeletal system Limb deficiency is one disorder in this category Absence or partial loss of a limb Congenital or acquired Terminal or intercalary

Associate Medical Conditions with Musculoskeletal Conditions May be related to a condition which is characterized by multiple anomalies Thalidomide treatment in the 50’s and 60’s is now available for cancer and AIDS related nausea

Interventions Surgery Orthopedic treatment Therapy Surgical amputations Corrective procedures to improve function Preparing limb for prosthetic device Orthopedic treatment Prosthetics Extend length, reach, and motion of limb Therapy Prosthetic training Adjusting to loss limb Monitor health and fit of prosthesis’

Developmental Impact Not related to cognitive development, unless associated with syndrome or injury Early development stages may be limited due to limited mobility and exploration Adaptations may be necessary to promote access to materials Temperature awareness due to difficulty regulating body temperature

Developmental Impact Psychosocial development Age is important factor Family attitudes and expectations Loss of ability versus development of compensatory skills Dealing with reactions of others

Educational Impact Adaptations Compensatory skills Personal autonomy Allow different ways of completing tasks Care for own prosthesis Allow student to struggle to achieve independence Career and adult outcomes