PAPER B 9

INTRODUCTION TO LOCOMOTOR AND MULTIPLE

DISABILITIES

Unit 1: Cerebral Palsy (CP)

Authors
Mrs DeepshikhaMathur
Dr ShabnamRangwala
 Unit 1

1.1 CP: Nature, Types and Its Associated Conditions

Objectives:

After going through this chapter you will be able to know and understand:

 The nature and characteristics of CP

 Types of CP, the characteristics of each type and the associated conditions

Content:

As early as the mid 1800’s an English surgeon named William Little wrote the first medical
descriptions and the first documentation and information on cerebral palsy. Little wrote of a
puzzling disorder that affected children in the first years of life, causing stiff, spastic muscles in
their legs and to a lesser degree, their arms. These children had difficulty grabbing objects and
learning to crawl and walk. Their conditions did not improve as they grew up nor did it become
worse. Their condition, which was called Little's disease for many years, is now known as
spastic diplegia. It is one of several disorders that affect control of movement due to
developmental brain injury. These conditions are grouped together under the term cerebral
palsy.

What is Cerebral Palsy?

The term Cerebral Palsy represents a group of heterogeneous conditions, neurological as well as
psychological and educational.Cerebral Palsy is usually defined as a non-progressive, permanent
impairment of movement, posture and coordination resulting from defect, lesionor injury in the
brain. This may occur due to events during pregnancy, delivery, the neonatal period or the first
years of life, or hereditary factors. There is no cure but with early diagnosis and suitable
intervention, there is scope for improvement regardless of the severity of the condition.

Cerebral palsy is a very diverse and complex condition with varying degrees, from mild to
severe. This means that each specific case of cerebral palsy is very individual. ‘Cerebral’ means
that the cause of difficulties lay in the brain, not the muscles as originally thought. ‘Palsy’ means
having problems with movement and posture, or motor control impairment.So, cerebral palsy is
characterized by an inability to fully control motor function, particularly muscle control and
coordination.
Depending on which areas of the brain have been damaged, one or more of the following may
occur:
 muscle tightness or spasticity;
 involuntary movement;
 disturbance in gait (walk) or mobility,
 difficulty in swallowing
 problems with speech. Source: http://www.newindianexpress.com

In addition, the following symptoms are sometimes

associated with cerebral palsy: abnormal sensation and
perception; impairment of sight, hearing or speech,
language and communication. Other problems that may

Source: http://www.photos.merinews.com
arise are difficulties in feeding, bladder and bowel
control, problems with breathing because of postural
difficulties, skin disorders because of pressure sores, and learning disabilities.

Associated conditions that may coexist with Cerebral palsy are intellectual disabilities, autism
and specific learning disabilities such as dyslexia.Some children with cerebral palsy also suffer
from epilepsy.

Incidence of cerebral palsy

Estimates of the incidence of cerebral palsy have varied considerably, mainly due todiffering
techniques of case finding, differing definitions of cerebral palsy andchanging demographic
trends and social conditions. The incidence of cerebral palsy is about 2 per 1000 live births
orslightly lower in the world.
Of the 2.21%, (26 million persons) of the differently abled population (as per census 2011), 20.3
% (over 5.4 million) have movement disability. Also there are 7.9% (over 2.1 million) with
multiple disabilities. Cerebral Palsy is again not a different category and the numbers of people
are divided in the multiple, movement and ‘any other’ category. In 2001 census, 2.1% of
disabled persons were present of which 27% are having difficulty in movement.
Causes of cerebral palsy
Cerebral palsy that affect children may have their origins in the
 prenatalperiod commonly defined as the time up to the 27th week of thegestation period.
 Perinatal period from the 27th week of gestation through the first week after birth
 postnatal period or thefirst years of life
A number of aetiological factors originating pre, peri or post natally are associatedwith increased
risk for cerebral palsy.
Prenatal risk factors such as congenitalmalformations, lack of oxygen (asphyxia) and infectionor
illness to mother during pregnancy are associated with cerebral palsy.
Premature births, prolonged labour, breech presentation and lack ofoxygen may represent
increased risk at the perinatal stage.
During the postnatalperiod infections such as meningitis and encephalitis, excessive jaundice,
rubella,andheadtraumacanincreasethe riskfor cerebral palsy.
Maternal characteristics such as adolescent pregnancy, low socio-economic status and poor
health are associatedwith increased risk of cerebral palsy in children.

Types of Cerebral Palsy

Cerebral Palsy can be divided in four types classified on the basis of the muscle tone:

 Spastic(due to the lesion in the motor area

in cerebral cortex)
 Athetosis(due to the lesion in the basal
ganglia in midbrain).
 Ataxia (due to the lesion in the
cerebellum)
 Mixed, a combination of any of these.

There are three types of cerebral palsy classified on the basis of extremities affected:

 Quadriplegia
 Diplegia
 Hemiplegia
 1. Spastic Cerebral Palsy

A type of cerebral palsy, called spastic cerebral palsy, occurs when the brain damage occurs in
the cerebral cortex, the outer layer of the brain. Spastic cerebral palsy is the most common form
of cerebral palsy, affecting 70 to 80 percent of students. Spastic cerebral palsy has varying forms
depending on the areas of the body it affects, whether its one side of the body or just the legs.

Spastic cerebral palsy refers to the increased tone, or tension, in a muscle. Normal muscles work
in pairs. When one group contracts the other group relaxes, allowing free movement in the
desired direction. Due to complications in brain-to-nerve-to-muscle communication, the normal
ebb and flow of muscle tension is disrupted. Muscles affected by spastic cerebral palsy become
active together and block effective movement. This causes the muscles in spastic cerebral palsy
patients to be constantly tense, or spastic. Spastic cerebral palsy may be mild that affect only a
few movements, or severe that can affect the whole body.

Although spastic cerebral palsy is not thought to be a progressive disorder, as brain damage does
not get worse over time, spasticity in muscles can increase over time. This increased muscle tone
and stiffness in spastic cerebral palsy can limit the range of movement in the joints. The effects
of spastic cerebral palsy may increase with anxiety or exerted effort, leading to excessive fatigue.

Spastic cerebral palsy also limits stretching of muscles in daily activities and causes the
development of muscle and joint deformities. Children born with spastic cerebral palsy do not
have deformities of the extremities at birth but develop them over time due to joint contractures.
Oral medications have been tried but the general consensus is that they do not reduce spasticity.
Orthopaedic operations are also used for the treatment of spastic cerebral palsy.

2. Ataxia

Ataxic cerebral palsy is caused by damage to the cerebellum, which is in the base of the brain.
The cerebellum is the control centerfor balance and coordination. Ataxic cerebral palsy therefore
affects coordination of movement. Ataxic cerebral palsy usually affects all four limbs and the
trunk. In addition, ataxic cerebral palsy is characterized by poor or low muscle tone, also known
as hypotonic.

Ataxic cerebral palsy can affect an individual in several ways. A person with ataxic cerebral
palsy will usually have a wide-based gait, or walk. Because of their poor sense of balance they
tend to walk with their feet unusually far apart. In appearance, a person with ataxic cerebral palsy
will look very unsteady and shaky. This is due to low muscle tone where the body is constantly
trying to counter-balance itself.

The most significant characteristic of ataxic cerebral palsy is tremor, especially when attempting
quick or precise movements, such as writing or buttoning a shirt. Also known as intention
tremor, this symptom of ataxic cerebral palsy worsens when attempting a voluntary movement.
For example, when reaching for an object, such as a book, the hand and arm will begin to shake.
As the hand gets closer to the object the trembling gets more severe, increasing the completion
time necessary for the task.

Although there is no cure for intention tremor in ataxic cerebral palsy, several treatments for
cerebral palsy can help in reducing its effects. Although not suggested for long term use in ataxic
cerebral palsy, drugs such as primidone and benzodiazepine can be effective in alleviating ataxic
cerebral palsy symptoms. Botulinum toxin A, commonly referred to as botox, has also been
found effective in treating head, hand, and voice tremors by relaxing tightened muscles.

3. Athetosis

Athetoid cerebral palsy is marked by slow, writhing involuntary muscle movement. A mixed
muscle tone where some are too high and others too low also characterize Athetosis. Damage to
the basal ganglia, located in the midbrain, is the cause of athetoid cerebral palsy. Approximately
25 percent of cerebral palsy patients are affected by it and is also be referred to as dyskinetic
cerebral palsy.

The slow, writhing movements associated with athetoid cerebral palsy usually affect the hands,
feet, arms, or legs. In some cases, athetoid cerebral palsy can affect the muscles of the face and
tongue, causing grimacing and drooling. The involuntary and uncontrollable muscle tone
fluctuations sometimes affect the whole body. The movement caused by athetoid cerebral palsy
often increases during times of heightened emotional stress. Symptoms usually tend to disappear
completely during sleep.

The main cause for these problems is the muscles alternating between floppy and tense.
Unwanted movements may be small or big, rapid, irregularly repetitive, random, or jerky.
Athetoid cerebral palsy can also cause a person to appear restless and constantly moving, only
being still when fully relaxed and sometimes only when asleep.

One difficulty caused by this fluctuation is the inability to hold posture. Children often have
trouble holding their body in a steady, upright position for sitting or walking. This can delay, and
even prevent the child from having any control over his or her mobility.

Athetoid cerebral palsy can also affect speech and the condition is known as dysarthia. In
dysarthia, speech is affected to a degree in every case because of difficulty in controlling the
tongue, breathing and vocal chords. Similarly, the person may experience difficulties with eating
and drooling.

A person with athetoid cerebral palsy can also have difficulty holding onto an object, like a
pencil or eating utensil, because of the mixed tone of muscles. He has to work and concentrate
harder than usual to get their hand to a certain spot, like scratching their nose. This is also
concurrent with big, involuntary movements and is found through the entire body rather than
being restricted to a certain area.

The treatment of athetoid cerebral palsy varies on the concentration of symptoms. It is important
for physical therapy to begin soon after diagnosis is made. Daily range of motion exercises will
help prevent muscles from growing weak and atrophied or rigidly fixed from contracture. For
those suffering from dysarthia, speech therapy can help improve swallowing and
communication. A speech therapist also can work with the child to learn to use special
communication devices like computers with voice synthesizers.

Other problems associated with CP

Speech and eating: If the muscle control of the tongue , lips and throat is poor, the child will
have difficulty in learning to chew and swallow. This difficulty can be looked into with the help
of positioning of the child and and the type of food he takes. Learning to speak would be also
delayed. If there is no speech, other forms of communication can be tried like communication
boards.

Learning difficulties: About half of the children with CP have learning difficulty. This means
that they have difficulty in learning academic concepts and are very slow in learning basic daily
living activities and self care. Since many children have difficulty in communicating and
expressing, it is often assumed that they have not understood which may not be the case. Some
children have perceptual difficulties that have to be remediated as it interferes with reading,
writing and number work.

Behaviour problems: Since children with CP have difficulty in movement, they may not be able
to participate fully in activities or express themselves effectively. This could result in feelings of
frustration, anger, anxiety, and insecurity. The child may display behaviour such as food
throwing, constant crying, screaming, throwing things or he may become unusually quiet.

Epileptic episodes: Epilepsy is seen in many children with CP. Uncontrolled fits can further
damage the brain and therefore further impairment and disability. Care needs to be taken to give
the medications on time, have the contact number of the doctor and family ready and the teacher
must know what to do when the child has a fit.

Delay in developmental milestones: Because of all the difficulties related to CP, the child will
CP will not achieve developmental milestones or reach it late.

Inappropriate reflexes: After birth, children show signs of primitive reflexes like startle reaction
that disappears totally as the child grows. These reflexes persist in children with CP and are
evoked automatically like grasp reflex whenever anything touches the hand.
To bring positive change in the condition of children who have cerebral palsy, they would have
to undergo several therapies and also would have to be given special attention in schools.
Teachers at special schools are trained to teach children with disabilities. Teachers of special
children are expected to show great patience with such children. In special schools, every child is
given individual attention and the curriculum is also planned so as to cater to their individual
needs. All this helps to develop the child's abilities with a view to foster his independent / near
independent functioning at a later stage.
Facts

 A person having cerebral palsy and Locomotor disability is not mad. Many people with
cerebral palsy have normal intelligence.

 Cerebral palsy is not hereditary.

 Cerebral palsy and Locomotor disability is not a curse. It can affect the rich and poor,
irrespective of caste or creed.

 Cerebral palsy and Locomotor disabilities are not the fault of either parent.
All children with cerebral palsy have physical disability but the degree of disability differs from
person to person. Some may be able to move and walk independently while others may be
dependent on others even for basic activities of daily living and need the help of mobility aids
such as a wheelchair or crutches. Some may be able to do tasks that require fine motor
coordination such as buttoning and handwriting, others may not be able to use their hands for
any functional activities.

Many have average or above average intelligence and given the necessary supports, their
academic performance could be like any other student in the class. Others may have learning
difficulties in varying degrees.

Many persons with CP have speech difficulties; for some this may result in slurred and indistinct
speech while others may not be able to use speech for communication and will need an
augmented and alternative mode of communication.

Thus CP is only an ‘umbrella’ term as there is no ‘typical’ case of the CP - individuals with CP
differ greatly from one another. The heterogeneity of the population becomes a challenge for
teachers and other service providers.
Summary

Cerebral Palsy is a condition characterized by paralysis, weakness, incoordination , and/ or other

motor dysfunctions. It affects body movement, muscle control, coordination, muscle tone, reflex,
posture and balance. It can also impact fine motor skills, gross motor skills and oral motor
functioning. The type of movement dysfunction, the location and number of limbs involved, as
well as the extent of impairment, will vary from one individual to another. It can affect arms,
legs, and even the face; it can affect one limb, several, or all. Other complications, such as
intellectual impairment, seizures, and vision or hearing impairment also commonly accompany
cerebral palsy.

Cerebral palsy is the result of a brain injury. While most individuals are born with cerebral palsy,
some acquire it later also. Current research suggests the majority of cerebral palsy cases result
from abnormal brain development or brain injury prior to birth or during labor and delivery.
Accidents, abuse, medical malpractice, negligence, infections, and injury are some known risk
factors that may lead to cerebral palsy.

In Spastic Cerebral palsy muscles can contract too much, too little, or all at the same time. Limbs
can be stiff and forced into painful, awkward positions. In Athetoid CP, fluctuating muscle
contractions can make limbs tremble, shake, or writhe.In CP Ataxia, balance, posture, and
coordination can also be affected by cerebral palsy. Tasks such as walking, sitting, or tying shoes
may be difficult for some, while others might have difficulty grasping objects.

The symptoms of CP differ in type and severity from one person to the next, and may even
change in an individual over time.

Cerebral palsy related to genetic abnormalities cannot be prevented, but a few of the risk factors
for congenital cerebral palsy can be managed or avoided. For example, rubella, or German
measles, is preventable if women are vaccinated against the disease before becoming
pregnant. Rh incompatibilities can also be managed early in pregnancy. Acquired cerebral palsy,
often due to head injury, is often preventable using common safety measures.
Cerebral palsy can’t be cured, but treatment will often improve a child's capabilities. 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.

There is no standard therapy that works for every individual with cerebral palsy. Once the
diagnosis is made, and the type of CP is determined, a team of professionals work with a child
and his or her parents to identify specific impairments and needs, and then develop an
appropriate plan to tackle the core disabilities that affect the child’s quality of life. Physical
therapy, speech therapy, occupational therapy and special education works in tandem to provide
the best intervention plan for the child.

Questions

1. What is cerebral Palsy?

2. Name types of cerebral palsy and describe two features of each.
3. What are the additional difficulties that are faced by a child with cerebral palsy?

Fill in the blanks:

1. Prenatal risk factors for CP are ___________________________________________

2. Postnatalrisk factorsfor CP are __________________________________________
3. Spasticity is due to the lesion in the _______________ area in ______________ of the
brain
4. Athetosisdue to the lesion in the _______________________________________
5. Ataxia is due to the lesion in the _________________________________________
6. In children with CP, dysarthia affects the _________.
7. If there is no speech, other forms of communication can be tried like _____________.

References:

 http://cerebralpalsy.org/about-cerebral-palsy/definition/
 http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.Htm
 SarvaShikshaAbhiyan; Training Module onTraining of Resource Teachers under SSAin
Cerebral Palsy and Locomotor Impairments in www.ssa.nic.in/
 www.cp-pack.eu / Knowledge about CP
 1.2. Assessment of Functional Difficulties of CP including Abnormalities of Joints and
Movements (Gaits)

Objectives:
After going through this chapter you will be able to know and understand:

 What is gait and what constitutes normal gait patterns

 The different type of gait patterns of CP and associate the gait with the joint and muscle
abnormalities

 Assessment of functional difficulties of children with CP

Content:

What is normal Gait?

The process of walking or locomotion which consists of using the lower limbs to propel oneself
forward is called gait. It basically consists of use of the lower limbs but needs the trunk and
upper limbs to provide the required stability.

Gait consists of two phases namely

 Stance phase – This phase is when there is no movement of the body in space ONLY the legs
and the whole body is just preparing to take the step forward. It consists of the following sub
parts: Heel Strike, Foot Flat, Mid-Stance and Heel-Off
 Swing phase - This is the phase in which the body moves forward and consists of two sub
parts namely Toe-Off and Mid-Swing
Some anatomical considerations for gait include
 The gait cycle involves movement in each part of the entire body and a disorder in any
segment of the body can have consequences on the individual's gait pattern.
 Stability in stance is important to have a stable base of support to be able to move
forward.
 Clearance in swing or able to clear your leg from the ground to move forward requires
good muscle strength in the hip and ankle muscles.
 The ankle complex which is made up of 10 bones is crucial to normal gait. Any
deviations in ankle movement will lead to deviations in the knee and hip also.
  To work efficiently a good step length (the distance between the two legs when we walk)
is essential. If you have shorter or greater step length your energy expenditure will be
higher.
 Energy expenditure: If deviations in any of the above, the energy spent on walking will
be much greater and lead to a person getting tired more easily. Energy expenditure is also
directly related to body weight.

Figure 1: Normal Gait cycle

Gait deficits in children with cerebral palsy

Gait deficits in children with

cerebral plasy

Primary deficits
Secondary deficits Tertairy deficits
Balance
Muscle contracture Inability to participate in
Spasticity
Bony deformities functional activities
Poor muscle strength
Primary deficits

The neurological damage to the brain causes some muscles to have increased tone or to have
spasticity. The firing of these muscles is more and causes them to become stiff. This stiffness
will in turn lead to poor balance and also lead to the muscles not developing adequate strength to
move. Therefore we can say that the neurological damage to the immature brain that has led to
the child having CP leads to primary deficits of increased tone leading to poor muscle strength
and poor balance. Poor strength and poor balance result in gait deficits or abnormal walking
patterns.

Secondary deficits
Due to the above mentioned spastic muscles and poor muscle strength the child/person with
cerebral palsy is not able to move his/her body parts freely. Due to the inability to move the body
part through its full range of motion the body part remains in a particular position. This leads to
that body part being developed into contractures or inability to be moved through its full range.
Contractures of long standing develop into bony deformities.

Tertiary deficits
Dues to the contractures or deformities the person with cerebral palsy becomes limited in their
functioning and that may limit their participation in activities of daily life.

Abnormalities of gait in CP
Gaits abnormalities arise as a result of the primary and secondary deficits as mentioned above.
The common gait deviations in cerebral palsy are

Scissoring gait in diplegia Crouch gait in diplegia

 Ataxic gait

Hemiplegic gait

Functional assessment of children with cerebral palsy

There are various tools or assessment scales that can be used to assess the functional abilities of
children/persons with CP. In most instances functional assessment scales are used that include an
observational assessment called functional assessments. They are so called as they assess the
abilities of the children rather than their inabilities.
1. Observational scales: The therapist will observe the abilities of the child with CP in
different positions like supine (lying on back), prone lying (lying on stomach), sitting,
crawling and standing.Based on the observations the therapist will do the program
planning using a functional frame of reference.
2. In addition to observation of abilities the functional assessment also includes some
clinical assessments such as assessment of tone, assessment of range of motion/ROM and
assessment of muscle power/ MP. These assessments gain importance ONLY when there
is a need to undergo a medical intervention like surgery or medicines to reduce tone are
being given.
a. Assessment of tone
Various rating scales used to assess tone are
 Modified Ashworth Scale
o Grade 0 – no increase in muscle tone
o Grade 1 - Slight increase in tone, evident as catch followed by minimal resistance
throughout the remainder (less than half) ROM
o Grade 2 – More marked increased in muscle tone thru most of the ROM, but joint
is easily moved
o Grade 3 - Considerable increase in muscle tone, passive movement is difficult
o Grade 4 – Joint is rigid in flexion and extension
 Modified Tardieu Scale
o R1= dynamic tone/catch

o R2=contracture

o R1-R2= Dynamic tone abnormality that can be corrected

Tardieu for knee

Tardieu for ankle

b. Assessment of Joint Range of motion

 Joint Range of motion is assessed using a goniometer
 For example using a goniometer the range at the ankle is measured as shown in figure 2
below
 The common muscles that have restricted ranges in cerebral palsy that impact gait
include; hip flexors, hip adductors, hamstrings, gastronemius, tendoachilles. The
tightness can vary from mild to moderate to severe.
Knee range using goniometer
Ankle range using goniometer

c. Assessment of muscle strength

 Muscle strength is assessed using manual muscle testing
 For cerebral palsy it is difficult to assess true muscle power as there is no isolation of
movement muscles act together as a unit and therefore for cerebral palsy one assesses
selective motor control at each joint.
3. Assessment of activities of daily living (ADL)
This is usually done by a questionnaire to the care giver. There are also available
standardized scales to assess ADL skills such as the Functional independence measure
(FIM) and Barthel’s index. The WEE FIM scale is used especially for children with CP.
Assessment of ADL skills is done across the domains of
1. Self care
 Eating/drinking
 Dressing/ undressing
 Personal hygiene/ bathing
2. Toileting
3. Mobility
Grades for the above range from 1 – 5 which includes completely independent, needing
25% support, needing 50% support, needing 75% support to fully dependent or needing
100% support. Details and description is taken about each activity via the parent to
enable the therapist to work towards greater independence using task analysis (breaking
the activity into smaller parts and practicing the smaller parts rather than the whole task)
As a teacher the areas of ADL that are important to you are: feeding/drinking, toileting
and mobility. Understanding the child’s support needs in these areas is of critical
importance to the teacher to help carry over of therapy learning into real life situation.

4. In addition to the above mentioned functional assessments there is a standardized

assessments developed by CAN Child Canada, that is used to assess children with
cerebral palsy. The measure is called the Gross Motor Function Measure or the
GMFM. This had been developed for purposes of research and track the progress
after intervention for children with CP. In addition there is the Pediatric Evaluation of
Disability Inventory (PEDI) which may be used for assessing the functional skills of
all children with disabilities.
 GMFM: The Gross Motor Function Measure (GMFM) is a clinical tool
designed to evaluate change in gross motor function in children with cerebral
palsy. GMFM measure has been designed and validated for children with
cerebral palsy but can also be used for children with Down Syndrome or other
 motor delays. Items on the GMFM-88 span the spectrum from activities in
lying and rolling up to walking, running and jumping skills. There is a 4-point
scoring system for each item on the GMFM. Scores can be summed to
calculate raw and percent scores for each of the five GMFM dimensions.
 PEDI: The PEDI is used to assess and evaluate functional status in children
aged 6months to 7½ years. It can be used by PT’s, OT’s and other health
careprofessionals. It helps in identifying delay or deficit and can also be used
for evaluating or monitoring change over time. It takes 45-60 min for
administration and consists of a structured interview, anobservation by the
therapist and a questionnaire to the care giver. It covers three domains namely
self-care, mobility and social function. It is based on the ICF (mostly activity
and participation) and focuses on the capabilities and performance of the
child. It is a family centered tool and supports a family-centered practice.Its
disadvantage is that it is time consuming and covers only children in the age
group of 6mo-7½ years.

Educational functional assessment

For CP students, it is important to conduct a functional skills assessment. A functional skills
assessment targets the skills needed in a given environment and activity, and includes measures
of social and adaptive functioning with a focus on basic life skills. It focuses on practical
independent living skills. It also considers students’ functioning in their environments, and
examines the process of learning and performance. Based on the results of the assessment,
intervention techniques are implemented and evaluated on a regular basis. Body positioning is of
specific relevance to students with CP. Students should be positioned in a way that facilitates the
support of the trunk and independent use of the arms and hands. Appropriate positioning can
permit better fine motor function, facilitate attention, reduce fatigue, and promote improved
social interaction, thereby optimising performance. Students should be assisted to make
responses (e.g., stabilising their hands) or use assistive devices (e.g., via the use of a pointer
attached to their headgear). Family/caregiver involvement may be crucial during the assessment
of students with CP. The various areas of Functional Assessment are: Gross Motor, Fine
motor,Self help skills – Toileting, brushing, bathing, drinking, eating and grooming,
Communication – expressive and receptive, Socialisation – at home and community, Cognitive –
matching, identification, functional literacy, Orientation and mobility – indoor and outdoor ,
Sensory – vision, hearing, touch, taste, smell and Pre-vocational / vocational.

A sample of basic assessment areas of functional ability is given below (Reference:SSA training
module on Cerebral Palsy and Locomotor Disabilities for training Resource teachers and IICP,
Kolkatta Booklets)

Need Based Assessment and Recommendations (Please tick wherever applicable)

Name Sex Age Diagnosis

Address Parents Main care giver/s Educational background

occupation at home
Priority needs Present abilities Need areas Recommendations/comments
areas (tick wherever (tick wherever (tick wherever applicable)
applicable) applicable)
Physical - Can sit without Special chair & Already using
Sitting support Tray
Using it but need modification
– need professional advice

Can sit with Wheelchair with Needs professional advice

support Tray
Standing Can stand without With supervision Need to provide furniture
support or wall or a bar to hold on
Can stand with Needs physical Needs professional advice
support Assistance
Mobility & Can walk Need supervision Need supervision during
Access independently during play
climbing up staircase and
getting down

Can walk with Walker Already using it

mobility Aids
Wheelchair Needs professional advice
Name Sex Age Diagnosis

Crutches

Any other
Priority needs Present abilities Needs Recommendations /
areas (tick wherever (tick wherever comments
applicable) applicable) (tick wherever applicable)

Eating & Can eat & drink Special chair with Already using - if it needs
Drinking Independent when Tray modification see section on
seated special furniture
Can eat and drink Tray to be fitted on See specifications given in
with physical help Wheelchair section on special furniture

Need to be fed Needs caregiver Orientation to peer group/

to feed under care givers;
Guidance
Toileting Can go to toilet Needs supervision Orientation to peer group/
independently care givers; accessible toilet
without mobility aid

Can go Needs help in the Orientation to peer group/

independently toilet for taking off care givers; accessible toilet
using aid & putting on the
clothes

Need to take on Needs help for Orientation to peer group/

wheelchair sitting, washing care givers; accessible toilet
and putting on and
off clothes.

Language and Can speak clearly Need orientation Orientation to other students
Communication in sentences to listen carefully and teachers

Can speak but Needs to be Needs professional guidance

speech is not clear Assessed
and takes long
time
Name Sex Age Diagnosis

Communicate with
signs and gesture

Uses
communication
board
Writing Can write with an
Can use ordinary
ordinary pen/ chair and table
pencil

Can write but Needs table and Needs professional guidance

slowly chair or special
chair with tray

Wheel chair
with tray
Cannot write Orientation for teachers
Needs a writer,
extra time,
examination
concessions,
objective type
questions

Vision Appears to be No problem in

normal Class

Can see with Needs eye check Needs professional guidance

difficulty Up
Uses glasses

Hearing Appears to be No problem in the

normal Class

Difficulty in Needs hearing Needs professional guidance

hearing assessment &
orientation in care
Uses hearing aids
and maintenance
of hearing aids
Name Sex Age Diagnosis

Language and Can speak clearly Need orientation Orientation to other students
communication in sentences] to listen carefully and teachers

Can speak but Need help to Need help from expert.

speech is not clear Communicate
and takes long understand by
time Others

Communicate with Need help to use

signs and gesture Communication
board.
Uses
communication
board.
Summary

Functional assessment of children with CP requires a full assessment of the abilities of what a
child can do. This can be used for therapy and educational interventions. Assessments can be
done through observations, clinical assessments and using standardized scales. The areas
assessed for functional skills by therapists are muscle tone, muscle strength, range of motion
and activities of daily living.

Functional assessment for education id done by setting up an environment and engage the
child in activities that allow to test specific skills. The various areas of Functional
Assessment are: Gross Motor, Fine motor,Self help skills – Toileting, brushing, bathing,
drinking, eating and grooming, Communication – expressive and receptive, Socialisation – at
home and community, Cognitive – matching, identification, functional literacy, Orientation
and mobility – indoor and outdoor , Sensory – vision, hearing, touch, taste, smell and Pre-
vocational / vocational.

Questions

1. What are the primary and secondary deficits found in gait for children with
cerebral palsy?
2. List the various areas of functional assessment for educational purposes.
3. Which two standardized tests are used to assess children with cerebral
palsy? Describe them in brief.

Reference:

1. www.moe.gov.sg/

2. SarvaShikshaAbhiyan; Training Module onTraining of Resource Teachers under

SSAin Cerebral Palsy and Locomotor Impairments in www.ssa.nic.in/
 1.3. Provision of Therapeutic Intervention and Referral of Children with
CP
Objectives:
After going through this chapter you will be able to know and understand:

 The various treatment methods that therapist vis occupational therapist and physio
therapist use to treat children with CP.
 The need for holistic interventions will be explained through case studies
 The need to network and liaise with specialists will be understood

Content

This section has been divided into two parts

Part 1: Provision of Therapeutic Intervention for child with CP

A therapist provides therapeutic intervention for children with CP either on a one on one
basis when it is called individual intervention or in a group situation when it is called group
interventions.

Individual interventions: There are different frames of references that the therapists use when
treating children with CP. Here you will be explained in brief about them.

The common treatment techniques used to provide individual interventions are

 Bobath/Neuro developmental therapy ( NDT)

 Vojta therapy
 Sensory Integration

Here we will discuss Bobath/ NDT therapy which is the most widely used treatment
technique by therapist all over the world.

Bobath/NDT

Neurodevelopment Treatment is used for individuals who have Central Nervous System
(CNS) dysfunction. It is derived from the words 'neuro' for brain & nerve plus ‘development’
for growth and maturation. Its origin began under the name of Bobath therapy developed in
England by Mrs. Berta Bobath, Physiotherapist and her husband Dr. KarelBobath,
Physician.The treatment approach continues to evolve and approach varies with the needs of
each individual being treated.The primary modality is the ‘therapist.' They use handling to
help the individual to make modifications in his movement.They often use bolsters, ball, toys
& other equipment as an adjunct to handling. Handling done by the therapist is the key to
good NDT therapy as it is been proven that individuals learn through Sensation. “We do not
learn movement but the SENSATION OF MOVEMENT”.

The principle of NDT is

 Inhibit abnormal movement patterns/postures which arise due to increased tone and
facilitate normal movement patterns using the facilitation of righting and equilibrium
reactions
NDT requires
 Team work
 Participation of family members and the client is considered a key participant
 There must be a carryover in to daily life to achieve optimal function
 Constant ongoing assessment and short and long term goal planning is essential
 Work is focused on quality rather than quantity.
 Treatment is active movements, can be automatic or voluntary but not cognitively
controlled.
 Therapist involvement gradually becomes less.
 It is a living concept and an ongoing change

Case study: Provision of treatment using NDT approach

 A 3 year old girl with spastic diplegia, can walk independently but tends to fall
frequently, range of movements in the legs is full, frequently curls toes, walks with hip
and knee flexion in crouch gait.
 Treatment: she is provided NDT for 30 minutes, three times a week and she is also given
an orthosis/ splint at the ankle and walker to support her in walking.

Treatment Activities:

1. To learn to rise to stand from floor in correct pattern

2. To strengthen hip and knee flexors/ learn to half squat
3. To improve rotations through trunk and develop abdominal
4. To learn to stand erect on one leg a pre - requiste for good walking pattern
Group interventions

The key advantages of group therapy include:

 Group therapy allows people to receive the support and encouragement of the other
members of the group.
 Group members can serve as role models to other members of the group.
 Group therapy offers a safe haven. The setting allows people to practice behaviors and
actions within the safety and security of the group.
 By working in a group, the therapist can see first-hand how each person responds to
other people and behaves in social situations. Using this information, the therapist can
provide valuable feedback to each client.
The common approaches used to provide group interventions include

 Conductive education: This philosophy is based on two main concepts that

isOrthofunctionand dysfunction. Orthofunctionis the inbuilt capacity of the individual that
helps him to satisfy the biological as well as social demands made upon him. Dysfunction
is, therefore, a lack of Orthofunction, an incapacity for satisfying all the demands
generally fulfilled at a given time of life, which is not substantially relieved even by the
use of prosthesis or other appliance. Eg. A functional person is one who though may not
be able to walk can get around the place propelling his own wheelchair. CE used the
following; Physical assistance /guidance for which specific equipment may be used,
verbal guidance is given through rhythmic intentions and repetitions and a daily fixed
schedule is followed.
 Hippo therapy: Hippotherapy is a form of physical, occupational and speech therapy that
uses equine (horse) movement to develop and enhance neurological and physical
functioning by channeling the movement of the horse. Hippotherapy is built on the
concept that the individual’s neuromuscular development is enhanced when their body
makes adjustments to the gait, tempo, rhythm, repetition and cadence of a horse’s
movement.
 Aquatic therapy: This form of therapy is done under the supervision of a trained and
certified professional therapist. Aqua therapy provides deep, intense exercise within a
soothing and comforting environment. This form of therapy promotes physical
functioning with the aid of water’s restorative and detoxifying properties. Water
 buoyancy makes aerobic and anaerobic exercises safe and effective by allowing an
individual to move freely.

Case study: Provision of treatment using group therapy using principles of conductive
education

Five children with spastic diplegia in the age group of 5 to 8 years are given strengthening
exercises in a group to help them develop better walking patterns.

Treatment Activities:

1. Warm up: Cycling in supine or lying on back positi0n. If parents present they can help
doing some stretching
2. All come to quadripod or horse position and do alternate stretches with their arms.
This helps the abdominals.
3. Low stools or chair can be given and all children come to stand and sit
4. Depending on the level of support required children stand with their legs in stride or
as if taking a step and play together
5. Depending on their level of support children do mobility activity using parallel bars/
crutches/walker/independently

Part 2: Referral of children with CP

Children with CP may have associated impairments which you should be aware of as a
teacher so that if required you may network with expert in that area to help your student with
CP in your class better.

Cognitive impairment - About one third of CP population have mild cognitive impairment,
onethird have moderate to severe cognitive impairment and the other onethird have normal
cognition. So it is of utmost importance that you understand your student to be able to help
him/her. You may refer to a psychologist and a special educator who works with children
with special needs.

Learning difficulties–They may have some learning difficulties like visuo perceptual issues
that you may need to be aware of. Details of the same are given in next section. Similar
referral as above.
Seizures – about 30% of all CPs have seizures so you be aware of the medications he/she may
be taking for the same and also be aware of what to do if they have a seizure in class. Usually
children with CP are under the care of a pediatric neurologist for seizure control medicines
and medicines to control their tightness or spasticity.

Eating & drinking–They may have difficulty in chewing/biting and drinking. You may need
to network with an occupational therapists or speech therapist to learn the best method of
feeding the student in your class.It is important to remember that they should never be fed in
a lying position although that may be faster and easier.

Drooling – They may have drooling and open mouth posture due to poor control of muscles
of the mouth. As a teacher you must try and reinforce them to close their mouth through
reminders and positive reinforcements. Never let other students make fun of them. To learn
more about drooling you may need to network with a speech therapist

Visual Impairment – They may have visual issues such as Strabismus or squint, Low Vision,
or visual filed cuts which may lead them not to be able to see the whole picture. Be aware of
this and try and accommodate as per guidelines of a vision therapist or an occupational
therapist.

Delayed language & Hearing impairment – For challenges in this area the services of an
audiologist who will check the hearing and a speech and language therapist who will guide
on how to stimulate language may be needed.

The different professionals who may need to address issues of children with CP
Summary

Therapy for children with CP is one of the most important intervention. They can get
individual therapy or group therapy. Most used therapy for individual treatment is Neuro
developmental therapy. In group therapy many types of therapy are used like conductive
education, hippotherapy and aqua therapy. Children with CP require a multidisciplinary team
for the management of their difficulties. This team consists of doctor, sppech therapist,
special educator, psychologist, occupational and physio therapist.

Questions

1. What are the salient features of Neurodevelopmental therapy?

2. Why is multidisciplinary team essential for treatmet of child with cerebral palsy?
 1.4Implications of Functional Limitations of Children with CP in Education and
Creating Prosthetic Environment in School and Home: Seating Arrangements,
Positioning and Handling Techniques at Home and School

Objective:

After going through this chapter you will be able to know and understand:

 The functional limitations of children with CPthat influence their learning

 Identify educational implication of these limitations and develop strategies to overcome
these limitations to teach effectively
 Seating arrangements in Classroom.
 The importance of using positioning and handling as interventions in school and home

Content:

This section has been divided into three parts

Part 1: Deals with the implications of Functional Limitations of Children with CP

It has been briefly explained in the section above that children with CP may have other
challenge areas that may impact his/her learning. In this section we will discuss this in more
detail. In addition to the challenges listed above vis a vis the classroom situation they may
need help moving around in class or reaching for things, may have uncontrolled movements,
may have difficulty with bladder and bowel control and may need to use a bathroom
frequently, may be wearing braces and using crutches, or a wheelchair to get around.

Besides the above picture, it will always be important to remember that children with
disability are first of all children. They have the same needs as all other children do. They
must, among others, get the opportunity to establish closeness, interaction and
communication with others, to establish self-confidence, and to receive encouragement and
guidance for development and learning.

It is essential for the child’s teacher to possess knowledge about this, in order to adjust his
teaching in the best way possible for the child.Students with CP may need to miss class time
for doctor/therapists visits or to see the school nurse to take medication. Make sure to give
special consideration regarding missed instruction, assignments, and testing. In some cases,
arranging for verbal responses in assignments and testing can be a good way to measure
learning.
Functional Skills or ADL activities are those tasks and activities that most people do, on a
regular basis, as part of their daily living routine. If an individual is unable to do these tasks,
someone will probably have to do them for him or her. A teacher may have to assist children
with CP in their functional skills like helping to get his/her books out of the satchel or bag,
get out of the classroom during breaks and in again afterward, visit the toilet in addition to the
ADLs mentioned in chapters before. In learning environment, he/ she might need a slower
rate of progression than others, special material, extra explanations, etc. Given below are the
details of the functional limitations experienced in various skills in CP.

Problems with motor skills

Children experience difficulties in school due to the problems they have with their motor
skills. Clumsiness, spasms and involuntary movements will affect all functions including
basic functions of communication. This, in itself may reduce the self-esteem and the
emotional and social confidence of these children. Just gripping a pencil or another writing
materialor playing a game can be extremely difficult, and all skills demanding hand
movements will suffer due to clumsiness, spasticity or involuntary movements.

Problems with sensory integration

Many children with CP have difficulties due to insufficient processing of sensory
information. These difficulties can sometimeslead to major limitations in their learning and
mastery of activity in daily life.Children who are hypersensitive (overly sensitive) in the
tactile area, do not like clothes that are tight, have marks or seams. Often they have a few
favorite things that they want to wear all the time like soft shirts. They hate and fear getting
their face washed, getting dirty hands.

You will encounter eating problems that can also be caused by tactile hypersensitivity. Some
children with CP do not like to get food with a certain consistency in the mouth. Tactile
sensitive children often get food stuck in the throat. Problems with sensory processing of the
tactile area can also cause speech problems - the child may have problems shaping the sounds
right because of difficulties interpreting and processing sensory impressions from the mouth
and being able to feel the speech organ positions.
The proprioceptive sense, in children with CP, can be influenced by disturbances in the
sensory process because the child gathers atypical sensory experiences because of motor
disorders. It may be disturbances in the sensory system that leads to reduced sensory
information from muscles and joints. Children with proprioceptive dysfunction spend a lot of
energy to concentrate oneach movement, because although the brain may know what to do,
they can’t figureout how to make their body do it. They are more dependent on vision than
others,knowing how much pressure is needed to complete a task for example hold a cup
ofwater, hold and write with a pencil, turn the page of a book, etc.Children who are unable to
move and use their body effectively like others can, thereby, become frustrated, give up, and
lose self-confidence.

Other sensory dysfunctions

Among cerebral palsied children sensory impairment is more prevalent in children with
hemiplegia. The dysfunctions often reported relate to stereognostic perception (e.g. tactile-
kinesthetic perception of objects), sense of position, sharp-dull discrimination, pain, light
touch and temperature sense. Assessment of the sensory functions mentioned above may
have great implications for educational measures as they are of significant importance for
children’s ability to explore the environment.

Visual dysfunction
The most common visual disturbance associated with cerebral palsy is strabismus or squint
(approximately 50 per cent),nystagmus, visual field cuts, and refractive errors.Children with
cerebral palsy often demonstrate an inability to interpret visual symbols. Visual processing
dysfunctions may be responsible for inability to identify letters, but at other times the
difficulty may be due to cognitive dysfunctions.

Cognitive Difficulties
Due to the physical disability and associated problems, many children with cerebral palsy
have some degree of cognitive difficulties. These learning difficulties may range from severe
intellectual disabilities affecting all areas of the child’s life through to mild or specific
learning difficulties, whose only impact is on the child’s educational progress. Before we
label a child as having an intellectual disability it is important to ascertain whether the
difficulties in academic tasks are due to the disability or the resultant lack of exposure,
accessto education and denial of stimulating and enriching experiences of learning.
The non-specific type of cognitive problems covers fatigue, varied performance level and
slower information processing. Non-specific cognitive problems can be manifested in all
types of activities. Specific cognitive problems cover visuo-perceptual and visuo-constructive
problems, problems with attention, memory and executive problems and communication
problems.Learning problems usually become evident in the pre-school or early school years.
Often they are a result of two other problems common in children with cerebral palsy: visual-
perception disorders or developmental language disorders.

Visual-perceptual and visual-motor dysfunction

Visual perception is the process which ensures that we are able to perceive and interpret
visual impressions. Many children with CP have visual perception difficulties. The child will
be slow or unable to perform tasks, especially when the child is going to use an object or
performing tasks that require cooperation with both hands. It may be difficult to brush one’s
hair while looking in the mirror or put on a hairband , put on a necklace or to take toothpaste
on the toothbrush. Those things can be a big challenge. Clothes and buttons require also good
visual perception. It can be difficult to find your way around in the neighborhood or find
things in a drawer. It can also be a challenge to learn to use computer keyboards. Play and
leisure activities may also be limited by visual perception difficulties.

Many children with cerebral palsy demonstrate problems with matching shapes,
distinguishing shapes that appear similar, seeing a drawing as separate from its surrounding
background and differentiating between varying directions of lines or forms, for example
distinguishing ‘b’ from ‘d’. Other children may have normal perception of forms, but great
difficulties in drawing and writing, completing puzzles and building with blocks, bricks, etc.
These problems are known as visual-motor dysfunctions, and are more often found in
children with spastic than Athetoid cerebral palsy.

Many children with CP are so preoccupied with details that they lose track of the overall
picture. You can observe this phenomenon in many ways; a child may read something and
just remember isolated fragments, completely missing the general meaning of the texts or he
may look at a picture and note that the shadow from the tree resembles a bird, not seeing that
the picture itself is a landscape.
Many children with cerebral palsy frequently develop learning disabilities. A child with a
learning disability has an average or above average level of intelligence, but has difficulty
processing certain types of information. In addition to possibly having a learning disability,
many children with cerebral palsy are limited in their ability to communicate. Because of this,
they are sometimes deemed to have much less intellectual ability than they actually do, as
teachers may not be able to tell whether or not the child understands the lesson if they are
unable to speak.

Auditory dysfunction
Hearing impairment is frequently found in populations with cerebral palsy.Significant
hearing loss may easily be overlooked in children with speech defects and/or cognitive
disability. If educationally significant hearing loss is not diagnosed at an early pre-school age
and proper educational help given, eventually combined with a hearing aid, the language
development may be seriously affected.

Social interaction difficulties

Moreover, children with severe cerebral palsy also show extraordinary difficulties in
establishing reciprocal social relationships of some duration, problems that may be rooted in
comprehensive physical disabilities, communication disorders, mental delays or very limited
experience in social exchange.Brain-damaged children are often more easily distracted than
other children.
Communication
The disability of children prevents them from manipulating the physical world and therefore
they know very little about it. Knowing little about the world will make it difficult for them to
make choices. Knowing little about the world and communicating poorly will deprive these
children of having influence on their situation. Teaching children with cerebral
palsy communication skills is the primary focus ofspeech and language therapy.
Communication skills can mean talking, using sign language, or using a communication aid.
Speech therapists help them build their language skills by learning new words, learning to
speak in sentences, or improving their listening skills. Speech therapists also teach children
how to use a communication aid, which might be a book or poster with pictures that show
things the child might want, or an alphabet board they can use to spell out their message.
With today’s technology there are even computers that actually talk for the person.
It is important for these children, as it is for all children, to use as many senses and body parts
as possible. To achieve this, co-operation with different professionalsespeciallyphysio and
occupational therapists, will provide the best possible foundation for workingwith them.

Physical therapists are effective in teaching children with cerebral palsy to learn better ways
to move and balance. They accomplish this by teaching children with cerebral palsy how to
walk, use their wheelchair, stand by themselves, or go up and down stairs safely. Physical
therapists also work on fun skills like running, kicking, and throwing a ball or even riding a
bike when teaching children with cerebral palsy.

Other people qualified for teaching children with cerebral palsy are occupational therapists.
Occupational therapists usually work by teaching children with cerebral palsy better ways to
use their arms, hands, and upper body. They can also teach children easier ways to write,
draw, cut with scissors, brush their teeth, dress and feed themselves, or control their wheel
chair. They can also help children with cerebral palsy find the right assistive equipment for
cerebral palsy to make some everyday jobs easier.

Working with these specialists can help ease the difficulties of teaching children with
cerebral palsy. The techniques for teaching children with cerebral palsy can be carried over
into the home to expand the child’s learning environment as well. A supportive family
working alongside the child can produce great results.

Part 2: Creating Prosthetic Environment in School and Home: Seating Arrangements

To help children with cerebral palsy overcome or support them in meeting the challenges
mentioned above a teacher needs to have knowledge of available resources or techniques for
the same. A child with cerebral palsy at most times requires special physical changes in the
classroom and home. As a teacher it is important for you to be aware about special furniture
that the child may be using and the purpose and need for the same to help you understand
your pupil better. These can be used at home to facilitate independence. For example, the
tables in the class may be very appropriate for all children except you may find that they are
too low for the arms of the wheelchair to slide under. Hence you may need to raise the height
of the table by placing blocks under the legs to raise it to proper height. While these
modifications and adaptations may take time, they will allow the child to use the classroom
with minimum help.
Children with CP may also have difficultiesin understanding of space which may lead to
academic difficulties i.e. in writing/reading and so they should be given the maximum
opportunity to move around the best of their abilities. Moving directly from one place to
another also teaches children about directions and depths which are precursors for learning
the 3R’s.

Arrangement of class

Keep the room arrangement as simple and uncluttered as possible. For younger children, the
space in which each activity occurs should be clearly marked. You can mark storage areas so
that the child knows their position, knows what is in them and can get them. This would help
a child with visual perceptual difficulties specially.

Make sure that your room is free of obstructions and there is enough space between furniture
spacing or grouping to avoid collisions. There should be enough space for the child on
wheelchair to manoeuvre. A child with crutches or walker can easily be knocked over. A talk
with the class on not pushing could help. Also avoid putting loose mats which might interfere
with crutches or wheelchairs. Floors need to be kept dry to prevent crutches from slipping.
You may need a place near the wall where the child’s aids can be kept during lessons.

The child’s work table may be placed at the outside corner location so that he/ she can
manoeuvre into his place more easily. Some children with cerebral palsy will get startled by
loud or unexpected noise so you should try and seat them away from the windowsand doors.

Since children on wheelchair and crutches are lower in height than the average child, displays
should be at their eyelevel, and equipment should be within their reach and suited to their
size. At home too, all the daily use items and personal belongings can be kept in storage
places that are easily accessible to the child. The sink in the bathroom could be lower as can
be the bed of the child can be at the level of the wheelchair seat so that the transfer is easy.

Special seating

There are many adaptive devices that can help a child with cerebral palsy. The main are the
seating and walking aids.
Special seating is the seats especially designed for an individual child to assist him to sit. It
ensures that the child is sitting as symmetrical as possible to prevent deformities. You should
take care that the pressure areas do not develop. An illustration of adapted seats is given
below.

Each individual will require a different amount of support and type of chair. Some need
smaller chair so that their feet could reach the ground while others may need pelvic straps,
front trays and other supports to maintain their position. Trunk straps should be used
sparingly as they interfere with breathing. Pelvis strap can be used to support the child from
slipping forward. It is important that the accurate measurement of the chair is taken to fit the
child well.
Source: Rehabilitation Therapy Assistant Manual, Mobility India
Appropriate seating should aim to normalise tone, inhibit reflex activity, prevent deformity,
promote optimal function, maintain postural alignment, maintain tissue integrity and
maximise stability. The sitting position influences all the other body movements. If a lot of
strength and energy is spent on just sitting, it is not easy to concentrate on exercises and even
more difficult to use the hands to do things, such as writing.

Abnormal muscle tonus, etc. can make it difficult to bend at thehips, the student may easily
slide forward on the seat. Their legs often cross involuntarily, which makes it even more
difficult to keep the balance. Head and shoulders are pressed backwards and it becomes
difficult to use the hands. The sitting position should be as symmetrical as possible. - Correct
seat depth and height is important. The legs should get good support on the floor or on a foot
rest. Support at the hips and sides are often a valuable help. If a head rest is necessary, it
should not be angled to such an extentthat the head is leaning too far backwards.

Working desk or table

The table is another element which influences the working position. Correct height is very
important: Not too high, causing the shoulders to rise, Not too low, causing the back to bend.
The student must sit comfortably and close to the table to get as much support as possible.
The angle of the table will depend upon the child’s vision. Some children with CP will need
to have toys, books and paper placed in special angles in order to make the utmost of their
vision. An angled table or work top may however often be advantageous. The angle of vision
will be straighter and the pupil needs not bend forward to read. A cut-out semicircle in the
table for the torso allows a secure position, at the same time giving good support for the
forearms when writing.

Attachments

Children with CP often suffer from involuntary movements and may experience problems
because materials, etc. are not lying still. A variety of non-slip supports or pads are available,
made of rubber, foam-rubber, plastic, etc. Other objects may be taped to the tabletop,
clamped down with small clamps, clothes-pegs and clips, or weighted down with sand bags,
weights and stones. An edge around the tabletop may also stop things from sliding off the
table.
Part 3:Creating Prosthetic Environment in School and Home: Positioning and Handling
Techniques at Home and School

Children with cerebral palsy have compromised postural control. Spasticity interferes with
normal functioning of muscles and therefore movement patterns that they control. These
children are at risk for musculoskeletal deformities and contractures and often have or are
prone to develop limitations in performing functional activities. Contractures and other
deformities occur secondary to spasticity or from poor handling and positioning. Functional
limitations in transfers, locomotion, manipulation, and activities of daily living may result
from impairments.

While being handled i.e. being dressed, undressed, picked up, carried, fed etc. the child has to
adjust to being moved. Depending on the degree of the impairment, the child can either
participate or is totally dependent on the carer. In any case the handling will have a direct
influence on tone and movement. Hence, it is crucial that the handling is related to treatment:

a) to facilitate active and normal participation or

b) to inhibit abnormal reactions and responses to being handled

Handling and carrying methods

If the child has low tone, he enjoys fast movements and being bounced around and responds
with some desired increase in tone. Still, you may need to hold and carry him in ways that
support his body and keep joints and muscles in proper alignment. If the child has high tone,
he probably responds best to slow movement and firm touch. Because the child’s tone can
easily increase with excitement and anticipation, it is best to keep interactions low key.

In holding children with low or high tone, how you position the pelvis is of major
importance. Because the position of the pelvis is the key to the rest of your child’s posture. If
you hold your child so that his pelvic area is properly aligned, the rest of his body often
responds positively, and you can hold and support his upper body in a way that is
comfortable for you and your child. Children with high tone often extend and scissor their
legs due to tight adductor muscles in the hips and inner upper thighs. Separating the legs and
flexing the knees can control this. So a good way to carry these children is straddled on your
hip, or for a small baby, in a “football” hold with your arms separating the legs.
Sometimes in addition to problems in the pelvic area, tightness in the shoulders may make it
difficult to hold a child with cerebral palsy. In this case, you may be able to carry the child
more comfortably by bringing his arms up and forward over your shoulder. Sometimes a
child may be tight but with predominance of flexor tone, that is tone that brings the body
forward or into a folded position.

Source: Rehabilitation Therapy Assistant Manual, Mobility India

What was effective one day may not be as effective on another day; this is especially true for
children with fluctuating tone. If one position doesn’t feel right, try another. When you
finally find the right way to hold the child, you will be able to tell by the feedback you
receive from his body. Adaptive chairs, standing frames, wedges and orthotic equipments can
be used for positioning equipments.

Positioning is a word used by therapists to describe the posture or position of the body that
best enables a child to achieve every day activities, such as eating, playing and sleeping. Just
imagine the number of positions and postures you use in your daily life. Imagine if you had to
do everything in your whole day sitting in one position. We all need to change our position
during the day, depending on the activity we are doing, and our comfort. Some children with
a disability may be unable to change their own position and so positioning equipment and
extra help is often needed.

Why is positioning important?

Posture provides a base for movement and function. Impairment of postural control, either in
attaining or in maintaining a posture, can produce functional limitations. If a child is using all
his energy to maintain a position, or is using his hands for support to keep his balance, play
and movement can be hindered. To get some idea of what this is like, imagine trying to learn
to write while lying on your back or swallowing with your head tilted back! Good positioning
can:
 limit fatigue (tiredness) by providing extra support
 provide pressure relief and comfort
 prevent muscles becoming tight over time
 allow children to mix with others and play
 improve concentration and learning
 challenge children to learn new skills
 improve handskills such as handwriting
 improve breathing posture, and improve digestion, eating and drinking
 prevent pain and discomfort.

Types of positioning equipment

There are lots of different types of positioning equipment. Some common ones include:
Standing frames - These can be a good way to get some weight bearing for
healthy bones, while also stretching many leg muscles. Children can use standing
frames for activities when other children are standing, providing them the chance
to be at the same level as their friends.

Corner chairs - These are useful for stretching the muscles behind the
knee (hamstrings). They allow children to be well supported when they
are sitting on the floor.
Floor wedge - Tummy lying (prone) over a
floor wedge is a good way to stretch the
muscles at the front of the groin, (hip flexors) and the
spine. This position works the muscles that help to maintain head and trunk posture.
The parents should specially learn how to move the child, how to carry, position the child for
feeding and how to dress / undress according to the needs of the child, his abilities and
disabilities.

 Positioning while carrying your child

 Carry her in an upright position.
 Bend his hips and knees.
 Helping your child to lie down

• On her stomach: - Place a roll, wedge or cushion under your child.

• On his side: - Keep both arms forward.

- Bend one hip and knee.

 Sitting

- Using a special chair

- Keep your child’s feet flat on the floor.

- Keep the bottom level against the back of the chair

Positioning often involves much trial and error and frequent adjustments.
 Case study
Priti is a three-year-old who has difficulty in maintaining any posture against gravity.
Head control and trunk control are inconsistent. She can bear weight on her arms if they
are placed for her. She can sit on the floor for a short time when she is placed in tailor
sitting. When startled, she throws her arms up in the air (Moro reflex) and falls. She wants
help to get herself dressed and undressed.
Picking up/Carrying: Assist Kelly to move into sitting by using her upper-extremity
weight bearing for stability. PickKelly up in a flexed posture and place her in a corner seat
on casters or in a stroller to transport. Dressing: Position Kelly in ring sitting on the floor,
with the caregiver ring sitting around her for stability. Stabilize one of Kelly’s upper
extremities and guide her free arm to assist with dressing. Another option could include
sitting Kelly on a low dressing bench with her back against the wall and being manually
guided to assist with dressing. Positioning for Functional Activity: Use a corner floor
sitter that would give a maximum base of support. Kelly could sit in a chair with arms, her
feet supported, the table at chest height, and one arm holding on to the edge of the table
while the other arm manipulates toys or objects.

Positioning methods

Prone Position: One of the first positions children use to play in once they have developed
some control is the prone position i. e. lying on the stomach. Depending on your child’s
ability to support his head, you should begin placing your child in this position. If your child
has difficulty maintaining this position, you may want to place a rolled towel under his
shoulder area to keep his arms forward. If hip flexion makes it hard for your child to lie
prone, you can help him with firm downward pressure on the buttocks from your hand. Yet
another way to help children with cerebral palsy achieve a good prone position is to use a
wedge. Wedges can be especially helpful for children who do not have adequate head control.
Supine Position: Supine position is lying on one’s back. Playing while on their backs helps
children to develop lower body control. If the child has mostly high tone, placing a small
pillow or neck roll under his neck can help to reduce muscle tone. Finally for children with
cerebral palsy who are totally extended and need more flexion in their muscles, a hammock is
often helpful in encouraging a good supine position.
 Source: Cerebral Palsy Trainee Bookletfor Parents
AndTeachers, CP- Pack

Side Lying: Besides front and back lying, another good position for many children with
cerebral palsy is side lying. It provides opportunities for developing fine motor skills and eye-
hand coordination. In addition, children who cannot lift their heads to see what is going on
around them while in a prone position have better opportunities to use their vision in a side-
lyingposition.

Sitting: Once the child has some ability to keep his back extended and some head control (or
a seating system that provides that control), you should begin working on sitting. It is from
the seated position that children do most of their early play and exploration of objects, as well
as learn self-help skills such as feeding, dressing, and bathing. Sometimes, you will need to
add rolled towels, foam pieces, to correct your child’s alignment.

Disabled children have a desire to learn and they have the ability to do so; the role as teacher
is not so much to teach as to prepare facilities and encourage the child to learn for himself. It
is important to find the best possible working position for the pupil. Whether the best position
is sitting, lying or standing the child must be comfortable and secure. Stools should
preferably be adjustable. If the child uses a wheelchair it should be of the size of the student
with an adapted table fitted to it same as is applicable when he/she is sitting or standing.

Summary:

In this topic you have read about the functional limitations that a child with cerebral palsy
experiences that place pose difficulties in his education. Motor difficulties limit the child’s
exposure to outside world and affect his cognitive learning. Visuo perceptual, visuo motor
and sensory integration difficulties have direct bearing in his learning to read, write and do
number work. It shows in reversals of letters, and numbers, differentiating between varying
directions of lines or forms, completing puzzle. It can also be a challenge to learn to use
computer keyboards. may read something and just remember isolated fragments, completely
missing the general meaning of the texts. Besides decreased social interactions and
communication difficulties add to learning limitations. Self help skills like grooming,
toileting and eating too are affected due to motor difficulties.

Appropriate postioning, handling and carrying children with CP optimizes the functional
independence. Various methods of positioning facilitate the child to learn. Special seating
attachments and furniture provides extra support, relieves pressure and improves
concentration for learning.

Questions:

Answer in brief:

1. How does difficulty in sensory integration affect the child with cerebral palsy?
2. What are the various methods available to help the child with cerebral palsy who has
difficulty in communication?
3. How can you arrange the classroom for better seating for children on wheelchair or
crutches?
4. What are the attachments used for appropriate seating?
5. What will be the difficulty faced in the classroom if a child has:
o Visuo motor difficulty
o Visual dysfunction
o Visual perceptual difficulty
6. Why is positioning important?

Fill in the blanks:

1. All skills demanding hand movements will suffer due to _____________,

_______________ and ______________.
2. The non-specific type of cognitive problems coversto _____________,
_______________ and ______________.
3. Moving directly from one place to another also teaches children about directions and
depths which are precursors for __________________.
4. _____________ is the seats especially designed for an individual child to assist him to
sit and ensures that the child is sitting as symmetrical as possible to prevent
deformities.
5. If the child has high tone, he probably responds best to ________movement and firm
touch.
6. ____________ is a word used by therapists to describe the posture or position of the
body that best enables a child to achieve every day activities
References

 http://www.cerebralpalsysource.com/Education_and_Patients/teaching_cp/index.html
 http://www.novita.org.au/content.aspx?p=73
 Kieran, Shari Sokes; Connor, Frances; Saaz von Hippel, Caren and Jones, Sherry; 1980;
Mainstreaming Preschoolers: Children with Orthopedic Handicaps; DHHS Publication
No. (OHDS) 80-31114; US Department of Health and Human Services; WashingtonD.C.
 Norris (Mo), Meriel (2001); Rehabilitation Therapy Assistant Manual; Mobility India,
Banglore
 SarvaShikshaAbhiyan; Training Module onTraining of Resource Teachers under SSAin
Cerebral Palsy and Locomotor Impairments in www.ssa.nic.in/
 www.cp-pack.eu / Knowledge about CP
 1.5. Facilitating Teaching-Learning of Children with CP in School, IEP,
Developing TLM; Assistive Technology to Facilitate Learning and
Functional Activities
Objective:

After reading this topic, you will be able to:

 understand the concept and component of IEP
 what equipment to use with different kinds of disability and in what situations;
 gain a general understanding of equipment available in the country for children with
different disabilities;.
 understand when and where to use particular types of equipment;
 know how to make TLM from the locally available material.

Content:

A child with cerebral palsy can face many challenges in school and is likely to need
individualized help as each child is unique. As a result, you require to tailor your child’s
special education program to his or her individual needs. What and how disabled children
should be taught when they enter school, depends at any given moment on the child’s
physical and mental functioning, previous experience and learning capacity.

The IEP can be understood as the blueprint, or plan, for the special education experience of a
child with a disability. Based on the child’s evaluation, a program designed specifically to
address his/ her developmental problems is devised. This is called an individualized
education program, or more commonly and IEP.

Before diving into the specifics of what must be included in an IEP of a child with cerebral
Palsy, it’s important to consider the “Big Picture” of the IEP—its purposes, how it serves as a
blueprint for the child’s special education and the scope of activities and settings it covers.

The IEP has two general purposes: (1) to establish measurable annual goals for the child; and
(2) to state the special education and related services and supplementary aids and services
that the school will provide tothe child. When constructing an appropriate educational
program for a child with a disability, the IEP team broadly considers the child’s involvement
and participation in academic and non-academic areas of school life.
Who Develops the IEP?

The IEP is developed by a multidisciplinary team and the child’s parents. This team meets at
least once a year and more often, if necessary.Team members’ work together to design an
education plan that will address the child’s individual needs. The IEP team then puts its plan
down in writing–resulting in the IEP that will guide the delivery of the child’s special
education and related services. A special educator is an integral part of the team.

Development of IEP:
During the preparation of IEP, the following steps are taken.

IEP

Step 3: Step 4:
Step 2: Determination
Step 1: Development of
Writing of of Start-End
Determination of Long Term Goal dates of the IEP
Performance and the
Student’s needs &
Summaries responsible
Short Term Goal persons

IEPs should be very detailed. Although thinking of specific planning may seem intimidating
at first, a detailed IEP enables you to closely monitor the education the child receives and to
make sure he or she actually receives the services prescribed.

The student’s needs, student performance, Long term goals, Short term goals, start-end dates
and the responsible persons are the essential contents of the IEP. Determination of support
services, materials, environmental arrangements, teaching methods and techniques and IEP
evaluation are the other components of IEP.

Step 1: Determination of a student’s needs

The student with CP is evaluated on his academic, social, communication behaviours and
through the reports his strengths and needs are determined. The things that the student can do
show us the performance of the student, whilethe things that the student cannot do shows us
the needs. E.g. Ali may not be able to do addition operation withoutcarry over in his
academic evaluation. Hence this becomes his need and also the current level of performance
to start the sessions.
In addition to the academic lessons, the needs of the student is determined viacheck lists
prepared in the areas as the self-care and daily life skills of thestudent.In the evaluation
studies related to the self-care skills with Ali, the teacher may find that his need is learning to
wash hands.

Step 2: Describing Performance Summaries

The data obtained as a result of the educational evaluation done withthe student are
documented. The important issue in describing the performancesummaries is to mention the
strong points of the student in every field first and thento write the problematic areas. For
example, Ali diagnosed with CP can sit in the classroom during the teaching period and
canfollow the lesson quietly. However, he can communicate with sentences formed of at
most two words. He needs the repetition of the instructionsgiven to him.

Step 3: Development of Long Term Goal and Short Term Goal

a. Development of Long Term Goal (LTG)
The LTG is developed according to the needs of the student. It shows the successexpected
from the student within one year. However, we must not forget that theachievement of many
goals might take more time than one year. IEP should beconsidered as a plan that aims the
student to gain all the skills within one year.

LTG could be written according to the development areas that the student needs. TheLTG for
the students who are have special needs in the academic field can be in thecognitive
development area. Particularly, the goals developed in the areas of reading,mathematics,
language and comprehension are included in the cognitive field. For example, respects the
rules of the capital letters and punctuation marks in his homework.
LTG for the students having difficulty in adaptive behaviour, social and
emotionaldevelopment can be emotional development field. For example, participates in
group games.
LTG for the students having shortcomings in motor skills as minor, major motorcoordination,
muscles control, reaction time and other physical activities can bepsychomotor field. For
example, eats food independently or participates in physical activities that are done with the
group.

b. Development of Short Term Goal (STG)

STG are the measurable mid steps between the current performance levels of thestudent and
the LTG. STG is formed by dividing logically the main parts of the annualgoals.
LTG is developed for one term, or year while STG shows the daily, weeklyor monthly targets
to reach. In short term goals, the mid steps starting from thecapability level of the student
until the level expected at the end of the year from thestudent are mentioned.STG is prepared
in a certain educational order to achieve the annual goals. Attentionis given to each and every
sub skillsin a logical order and the analysis tobe coherent with the teaching order.
For instance, in mathematics before teaching the addition and subtraction
operations,multiplication cannot be taught. In skill learning, for a student who cannot put
onhis/her shoe, tying shoelace should not be set as a target.

Mathematics Lesson
Long Term Goals Short Term Goals

Adds a 2 digit number 1. Adds one digit number with another one
and another 2 digit number withoutcarry.
digit number with 2. Adds two-digit number with one digit
carry over. number without carry.
3. Adds two-digit number with one digit
number with carry.
4. Adds two-digit number with another two
digit number withoutcarry.
5. Adds two-digit number with another two
digit number withcarry.

Step 4: Determination of start-end dates of the IEP and the responsiblepersons

The development of a realistic timetable in IEP process is important in termsof realization of
the goals in time, planning and review of the services.
Although the class teacher is perceived as the person responsible for the IEP, theremight be
the need for some other responsible persons in the achievement of certain goals. For this
reason, the main responsible persons and the other should beindicated in the student’s IEP.

Determination of Support Services

It should be indicated in IEP whether the child benefits fromservices as support education
room, in-class support, language and speech therapy,physiotherapy, transportation, parental
education and education at home.For Ali the child with CP, he may need the services of
physio therapist, speech therapist and the counselor for various difficulties that impede his
learning.

Determination of Materials
Another issue that should not be neglected during the preparation of IEP is thedetermination
of the materials to be used in the education. e.g, in order to supportthe understanding and
comprehension skill of a child having intellectual disability inaddition to CP, it could be more
effective to use real 3 D material as TLM.

Making Environmental Arrangements

The learning type of each student is different. For instance, when we prepare the IEP with the
information telling us that the children with CP havedifficulty in receiving education in noisy
environments with loud and instant noises,the decision that the education will take place in a
silent environment can be includedin the IEP.

Determination of Suitable Teaching Methods and Techniques

In addition it is also important to determine the teaching methodsand techniques in advance.
In addition to the oral method in order to increase the efficiency of learning, it would be
suitable to use teaching methods as observation, experience, modeling,problem solving,
question-answer, discussion and group work, to use experience, dramatization and
demonstration methods and so on.

Evaluation of IEP
The role of evaluation is significant in the successful implementation of the IEP. Theresults
of the evaluation done will be effective for the preparation and implementationof the new IEP
in the future. In this way, the evaluation gives us information whetherthe gains in IEP are
achieved or not, whether these are suitable for the child, as wellas what the future gains
would be.
The person responsible for the implementation of the student’s IEP is also liablefor
continuously evaluating the success of the student. The individual development reports
showing the individual progressof the student should be prepared at least once a year.
When attaining agoal for IEP, focus needs to be on acquisition, fluency, consistency and
generalization. For instance, thechild learns a concept in the classroom during acquisition
stage, in the fluencystage, student gives correct answers to a question related to that concept
in thefollowing minutes of the lesson, in the stage of consistency although the education is
completed and a certain period of time has passed answers to the question relatedwith this
concept correctly. According to the educational principles, students should be taught through
the teaching route of individualization to socialization, from concrete to abstract, from known
to unknownand from close to far.
The education should be continued in the environments outside the school as it isinside the
school. For this reason, the goals mentioned in the IEP and the activitiescarried out should be
notified to the parents regularly; and homework to support theactivities carried out at home or
in social environments should be given.
IEP for the child with CP needs to include his strength and needs and educational goals in all
areas of cognition, social, emotional, communication and motor and self help.

A sample of part of the IEP for Dan

Developing TLM
Development of teaching learning materials should be so designed that it has a significant
impact on instruction. Materials may use print or electronic format. The teacher’s role is not
diminished rather TLM enhances the ability of the teacher to increase opportunities for
individualization. TLM can make learning much more effective and fun in the classrooms.For
most children particularly those with severe disabilities, considerable amount of equipment
and special TLM are required. Without them no effective teaching will be possible.

Students with cerebral palsy need concrete examples, as they have difficulty in understanding
abstractions. This necessitates materials that can be experienced by the five senses, leading to
understanding and concept formation. In the classroom or outside, use of actual objects along
with verbal explanation is necessary.

 Learning aids
We know studentswith CP need concrete experiences and examples for their learning. For
example, stones, beads, seeds, spoons and such other small objects can be used for
teaching counting. Similarly in reading and writing, initially you may use pictures and
help the child to name them, read and write. Such objects and materials are called learning
aids. They will not be needed by the child for learning purposes once the concept is
understood.

 Consideration and selection/development of TLM

While developing or selecting TLM make sure that the material is

o age appropriate
o affordable
o accessible by school and family and the child
o maintenance is easy
o non breakable/non-toxic
o serves the purpose it is meant for
o minimizes transfer of training (easy to generalize)
o novelty is maintained
o updated
o easily available
o leads the learner towards independent learning
 If well selected, some TLM are used as they are like beads and blocks, garden tools and so
on. Some need modification for use by student with CP –
shirts with Velcro instead of buttons, skirts and pajamas with
elastic instead of tape and a few need to be exclusively
developed – like picture cards, models, name cards, charts, etc.
Examples of functional aids for children with CP include
adapted/simple calculator, digital watch, address card, modified brush/towel to scrub/wipe
difficult to reach areas while bathing, pictorial shopping list (if they cannot read), pictorial
book and so on.

 Other aids to assist in functional limitations of Child with CP

We have to put the child into positions and provide aids and substitutes that will enable the
child to master the tasks presented. If e.g. a child’s hand motor movement is very poor,
alternative use of other parts of the body must be considered: A pointer can be attached to a
helmet, or a mouth stick may be used, if the child’s head control is adequate or good. One or
a few fingers may be used for pointing within a small area, provided the hand is stabilized
with splints or weighted cuffs. Educational material can be reduced in size enabling the child
to reach a larger number of words or pictures without moving the arm. Educational material
can be enlarged, or words and pictures moved further apart to facilitate pointing (should the
child suffer from exaggerated involuntary movements). Boxes with multiple compartments,
in which objects, pictures or words can be placed. Such aids may greatly facilitate pointing at
the correct word. Small, metallic objects (e.g. paper clips) can be fastened to word pictures,
numbers or objects, enabling the pupil to lift them with the aid of a magnet attached to the
hand or other parts of the body. The best possible working posture will greatly enhance the
functions.

For directional problems, a multitude of sensual stimulants

should be employed: - Forming letters/numbers in sand -
Tracing in sand - Writing blindfolded etc.If the child
experiences problems in following a line when reading, the use
of a ruler underneath the line may be the simple solution. It is
also easier for the child to use cards with one task or exercise marked on each, than to cope
with the apparent jumbleof many problems on a page.
Children can be involved in the making of teaching aids and this involvement itself is a
learning experience.Making teaching aids together develops a sharing and caring attitude
amongst the children.
Charts, Flip charts, Boards, Picture cards, scrapbook, Puzzles, counters beads, Lacing boards,
Blocks, Clay, Dough, puppet, paints etc. are the common TLM present in the class.

Assistive Technology to Facilitate Learning and Functional Activities

Assistive Technology (AT) often plays a vital role in the lives of people with disabilities. AT
is any item, piece of equipment, or product that is used to increase, maintain, or improve the
functional capabilities of individuals with disabilities. Three major areas of assistance to
persons with CP are

1. Independent living
2. Alternative and Augmentative Communication (AAC):
3. Information Technology

AT for cerebral palsy can be big product-an automated lift for vanor a small product-a
Velcro-attached grip for a fork or a pen. It can be new-age interactive voice activated
software for speech therapy or a wheelchair. It can be high-tech like a computer screen
operated by eye movement or low-tech like a specially designed door handle for people with
muscle strength or dexterity problems.

Some children may use sign language, some use

picture books and some will use computerized
software programs to communicate and learn. The
computer is probably the most dramatic example of a
communication device that can make a big difference
in the lives of children with cerebral palsy. If a child

has a computer and a voice synthesizer, a child can

communicate successfully with others.
Communication for a child with cerebral palsy is
essential.Technology can be a substitute such as an
alternative and augmentative communication device
that provides vocal output for a child who cannot
communicate with her voice. This means that a child who cannot speak can push a button and
ask her mom for an apple. Or tell her sister her new dress is pretty. It means a child in school
can ask questions of his teacher or talk with her friends. It means a worker can converse with
others in his office. This communication can also be achieved through Communication
boards.

A number of pupils will

undoubtedly need various forms
of writing aids like grippers.The
writing materials - pencils,
crayons or chalks - should be
quite chunky and easy to hold,
and not easily breakable. Pencils may be made thicker by placing them in a rubber casing.
The grip on the pencil will not be as hard and forced and writer’s cramp may be avoided. A
simple hand grip may be fashioned for pupils with elastic
fastening to grip the hand for students who are unable to hold or
grip pencils or crayons by themselves. Writing materials should
be placed in such a way that they are accessible for the child
without assistance like pencils/crayons placed in holes in a
wooden boat etc.

To prevent books or sheets of paper from sliding about, they may be stuck to the desk with
tape, or fastened with elastic or some heavy objects. A non-slip pad which prevents books or
papers from sliding may be of help. If it is at all possible, the possible working posture,
writing support (desk) should be tilted to find the best position.

If the hands cannot be used when writing: a computer with special

keyboard for computer may be a solution. The keyboard may also be
operated by a stick fastened to the front of a helmet, - or held with the
mouth. Various types of mouse and keyboard alternatives are

available that can be adapted to the motor movement of the child. E.g. mouse button can be
big and round as shown in the picture that could be used by a child with CP Athetosis or
spasticity. The computer can be a tool for improved literacy, language development,
mathematical, organizational, and social skill development. AT can help in education and
activities of daily living.Assistive learning softwares are used for learning activities and
concepts as well as for communication purposes.

Learning to use the equipment may include education from a therapist or teacher, depending
on the technology. Assistive Technology may help children move more easily, control their
environment, perform activities of daily living with more independence or communicate
successfully.

Assistive Technology Options for Motor Function, Positioning, and Activities of Daily
Living
1. Motor Functions:
a. Braces (orthotics) and Splints
b. Mobility Devices like crutches, Canes and Walkers

c. Wheelchairs: manual or powered

d. Powered scooters

2. Positioning Devices:
Modified and adapted Seats, Standers, Sidelyers and Wedges

3. Adapted eating equipment

4. Electronic home aids (door openers, devices to turn on lights)

5. Vision aids (magnifiers, large text print books)
6. Hearing aids (telephone amplifiers)
Summary:

Children with CP need an Individualized Education Plan to realize their potential and work at
their own pace and ability. Since CP affects all developmental areas, IEP should target the
academic, socio emotional, communicative, self-help and motor areas.
The IEP is a written report that must containsthe child’s present levels of academic
achievement and functional performance and development, including how the child’s
disability affects his or her involvement and progress in the curriculum;his developmental
strengths and needs; A statement of measurable annual goals, including academic and
functional goals;A description of how the child’s progress toward meeting the annual goals
will be measured, and when periodic progress reports will be provided; and standards for
determining whether the goals of the educational programs are being met. A statement of
the special education and related services and supplementary aids and services to be provided
to the child, or on behalf of the child needs to be added. The projected date for the beginning
of the services and modifications, and the anticipated frequency, location, and duration of
those services and modifications are written.The behavior intervention programs, child’s
communication needs; and parent concerns are other aspects of IEP.
Education of children with CP requires special equipment and TLM. The TLM can be
concrete examples and 3 D objects, as they have difficulty in understanding abstractionslike
beads and blocks, garden tools. Certain TLM are made especially like flash cards, picture
cards, models or cut outs and charts. The TLM would include interactive computer softwares
that supplement the lessons. According to the NCERT handbook, provision is to be made for
adjustable furniture, special writing thick pen and improvised prosthetics/orthotics.
Assistive technology is enhanced the functional ability of a child with CP. It is any product,
or an item that facilitates independent functioning, assists communication or provides
information. The AT commonly used are communication aids like adapted computer
hardware, wirting aids, motor function facilitating aids like various types of wheelchairs and
crutches, positioning devices, adapted feeding aids like thick handle spoons and plates with
separators, electronic home aids etc.
Questions:

1. Answer in brief:

a. Suggest how you can prepare TLM from locally available materials for teaching
children with CP.
b. What are the essential components of an IEP?
c. List and explain the usefulness of five TLMs that would facilitate in the teaching
of a reading lesson in the classroom for a child with cerebral palsy. of each
d. What is assistive technology and how does various products help a child with
cerebral palsy. Explain briefly.

2. Fill in the Blanks:

a. What and how disabled children should be taught when they enter school, depends at
any given moment on the child’s ______________.
b. The IEP can be understood as _________, for the special education experience of a
child with a disability.
c. STG are the ____________ between the current performance levels of the student and
the LTG
d. If the child experiences problems in following a line when reading, the use of
___________ may be the simple solution.

3. Put a tick mark on the correct option of yes or no:

a. The IEP is developed by a multidisciplinary team. (Yes/ No)

b. A special educator is an integral part of the team. (Yes/ No)
c. The goals developed in the areas of reading, mathematics, language and
comprehension are included in the cognitive field. (Yes/ No)
d. The individual development reports showing the individual progress of the student
should be prepared at least once every three months. (Yes/ No)
e. Mrs.Patil , a teacher is using various services and devices that include communication
aids, alternative computer keyboards, and adaptive services technology in her
classroom to help children with CP.These are called TLMs.(Yes/ No)

References:
 http://kidshealth.org/parent/growth/learning/iep.html?tracking=P_RelatedArticle
 http://ucp.org/resources/education/
 http://www.parentcenterhub.org/repository/iepcontents/
 http://www.mychildwithoutlimits.org/understand/cerebral-palsy/cerebral-palsy-
treatment/assistive-technology/
 SarvaShikshaAbhiyan; Training Module onTraining of Resource Teachers under
SSAin Cerebral Palsy and Locomotor Impairments in www.ssa.nic.in/
 www.cp-pack.eu / Knowledge about CP
 PAPER B 9
INTRODUCTION TO LOCOMOTOR AND MULTIPLE
DISABILITIES

UNIT 2: Amputees, Polio, Spinal Cord Injuries Spina-bifida and Muscular

Dystrophy

Authors

MrsDeepshikhaMathur

DrShabnamRangwala

DrAminaMarkar
 2.1. Definition, Meaning and Classification

Objectives:

After studying this topic, you will be able to:

 Understand the definition, meaning and concept ofamputation,poliomyelitis, spinal cord

injuries, spina bifida and muscular dystrophy.

 Know their classifications and causes

Content:

In this topic, you would get to understand the meaning and features of locomotor and
neuromuscular disabilities of amputation,poliomyelitis, spinal cord injuries, spina bifida and
muscular dystrophy. The overview of each disability given below would also tell you how these
disabilities are classified into various types.

I. Amputation

Definition and meaning-

Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical

measure, it is used to control pain or a disease process in the affected limb, such
as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative
surgery for such problems. A special case is that of congenital amputation, a congenital disorder,
where fetal limbs have been cut off by constrictive bands.

In simple terms an amputation means cutting off or a surgical removal of all or a part of a limb.

Classification – Amputation can be classified as upper limb or lower limb amputation. They
can further be classified based on the part of the limb that has been cut or the level of the
amputation.
1) Amputation of lower limb or leg –
This can further be classified into the level of the amputation
 a) Hemipelvectomy: It is the amputation of half of
pelvis and entire lower extremity
b) Hip disarticulation: It is the amputation at the
hip joint and loss of the entire lower extremity.
c) Above-knee or transfemoral amputation (most
common) :amputation above knee at any level
on the thigh
d) Knee disarticulation: amputation at the knee
joint.
e) Below-knee or transtibialamputation (most common) :amputation below knee at any
level on the calf.
f) Complete tarsal: amputation at the ankle.
g) Partial tarsal: amputation of the metatarsals and phalanges.
h) Complete phalanges:amputation of toe (s)

2 )Amputation of the arm -

a) Forequarter: loss of clavicle, scapula and entire Upper
Extremity (UE)
b) Shoulder disarticulation:loss of entire upper extremity
c) Above-elbow (AE) or transhumeral (long or short):
above the elbow at any level on the UE.
d) Elbow disarticulation: amputation of the UE distal to
the elbow joint.
e) Below-elbow (BE) or Transradial (long or short):amputation below the elbow at any level of
the forearm
f) Wrist disarticulation: amputation distal to the wrist joint. Lost of the entire hand
g) Finger amputation: amputation of digit(s) at any level

3) Other amputation -.
a) Amputation of the ear, nose, breast etc.
Causes of amputation
Amputations of the upper limb are usually caused due to occupational injuries ie injures related
to your work. Diseases such as cancer or diabetes rarely require amputation of the upper limbs.
In case of leprosy there may be spontaneous loss of a body segment similar to amputation.
Leg (lower-limb) amputations result largely from an injury such as a motor vehicle crash or from
a surgical procedure to treat a complication of a disorder such as decreased circulation due to
diabetes. Cancer and leprosy may also cause amputation.

Symptoms of amputation

Pain:After an arm or a leg amputation, people may feel pain that seems to be in amputated
limb.The pain is real, but the location is wrong. Phantom pain is more likely if pain before
amputation was severe or lasted a long time. Phantom pain is often more severe soon after the
amputation, then decreases over time

Phantom limb sensation: Some people experience phantom limb sensation, which is not painful
but feels as if the amputated limb is still there. When people with an amputated leg have this
sensation, they may stand up (and thus fall back down).

II. Poliomyelitis

Definition- Poliomyelitis can be defined as an infectious viral disease that affects the peripheral
nervous system i.e the spinal nerves causing temporary or permanent paralysis of the muscles
that are supplied by those nerves.

Polio is a crippling and potentially fatal infectious disease. There is no cure, but there are safe

and effective vaccines. The strategy to eradicate polio is therefore based on preventing infection
by immunizing every child until transmission stops and the world is polio-free. In India we can
say that we have reached a Polio free India.
Who is at risk?

Polio can strike at any age, but it mainly affects children under five years old. Children living in
unhygienic conditions, where the chances of the virus multiplying are greater are at a greater
risk.

Symptoms

Initial symptoms include fever, fatigue, headache, vomiting, and stiffness in the neck and pain in
the limbs. This followed by wasting of decreasing in the size of the limb.

Cause and transmission

Polio is spread through person-to-person contact. When a child is infected with wild poliovirus,
the virus enters the body through the mouth,transmitted through contaminated food and water
and multiplies in the intestinefrom where it can invade the nervous system. It is then shed into
the environment through the faeces where it can spread rapidly through a community, especially
in situations of poor hygiene and sanitation. If a sufficient number of children are fully
immunized against polio, the virus is unable to find susceptible children to infect, and dies out.

Young children who are not yet toilet-trained are a ready source of transmission, regardless of
their environment. Polio can be spread when food or drink is contaminated by faeces. There is
also evidence that flies can passively transfer poliovirus from faeces to food.

Most people infected with the poliovirus have no signs of illness and are never aware they have
been infected. These symptomless people carry the virus in their intestines and can “silently”
spread the infection to thousands of others before the first case of polio paralysis emerges.

For this reason, WHO considers a single confirmed case of polio paralysis to be evidence of an
epidemic – particularly in countries where very few cases occur.
Types of Polio

Acute flaccid paralysis (AFP)

One in 200 infections leads to irreversible paralysis, usually in the legs. This is caused by the
virus entering the blood stream and invading the nervous system. As it multiplies, the virus
destroys the nerve cells that activate muscles. The affected muscles are no longer functional and
the limb becomes floppy and lifeless – a condition known as acute flaccid paralysis (AFP).

All cases of acute flaccid paralysis (AFP) among children under fifteen years of age are reported
and tested for poliovirus within 48 hours of onset.

Bulbar polio

More extensive paralysis, involving the trunk and muscles of the thorax and abdomen, can result
in quadriplegia. In the most severe cases (bulbar polio), poliovirus attacks the nerve cells of the
brain stem, reducing breathing capacity and causing difficulty in swallowing and speaking.
Among those paralysed, 5% to 10% die when their breathing muscles become immobilized.

Post-polio syndrome

Around 40% of people who survive paralytic polio may develop additional symptoms 15–40
years after the original illness. These symptoms are called post-polio syndrome which
includefurther progressive muscle weakness, severe fatigue and pain in the muscles and joints.

Risk factors for paralysis

No one knows why only a small percentage of infections lead to paralysis. Several key risk
factors have been identified as increasing the likelihood of paralysis in a person infected with
polio. These include:

a. immune deficiency
b. pregnancy

c. removal of the tonsils (tonsillectomy)

d. intramuscular injections, e.g. medications
e. strenuous exercise
f. injury.

III. Spinal Cord Injuries

Definition and meaning-A spinal cord injury (SCI) is an injury to the spinal cord resulting in a
change, either temporary or permanent, in the cord's normal motor, sensory, or autonomic
function.
Spinal cord is the central bunch of nerves that come out of the brain and run down the back
bone. These then split to run to the limbs. It is the main information connection area- movement,
sensation and temperature controls all pass through the spinal cord. When this is damaged, these
controls are affected.

Causes of Spinal Cord Injury

Injuries due to trauma are the most common cause. Damage to the spinal cord can occur due to
many reasons other than trauma. These include vehicle accident, fall from a height, infection,
stroke, tumour, inflammation, and several congenital causes. Each of these causes will produce a
differing pattern of nerve damage, resulting in differing patterns of sensory loss and paralysis.

Classification
Spinal cord injuries are classified based on the level of the spinal cord injurywhich is called the
level of the lesion. Generally it is accepted that the higher level of injury the greater the amount
of damage and therefore the increase in the severity of symptoms.
The spinal cord is organized with
different nerve tracts going to specific
places as shown in the picture above.
Sensory nerves travel in different
regions of the spinal cord from motor
nerves. This can lead to specific
patterns of sensory and motor loss
when the spinal cord is damage. The
levels of spinal cord injuries are listed
in picture above and include two
levels of tetraplegia/quadriplegia and
two levels of paraplegia.
Symptoms depend on the level of the injury the higher the level of the injury greater are the
symptoms.
In quadriplegia where the people are paralysed from neck down, the problems may include loss
of control from neck down, loss of bladder and bowel control, affect breathing, spasticity after
initial period of floppiness, and reduced sweating.
In paraplegia effects may include loss of control in the legs, partial or complete loss of bladder
and bowel control, and floppiness of legs or spasticity depending on the level of injury.
Secondary problems are very common in complete and incomplete SCI and include, pressure
sores, urinary infections, contractures (due to inability to move joints) and respiratory problems.

There is a system of classification for spinal cord injuries based on the recommendations of the
American Spinal Injury Association. This is the internationally accepted scale. An incomplete
spinal cord injury in which some feeling or movement remains, is classified as an AIS B, C, D or
E:
B = sensory sparing (may only be around the anus at first)
C = 50% of the muscles below the injury level are NOT working at "anti-gravity" i.e. they are
not strong enough for you to use them in a functional way.
D = 50% of the muscles below the injury level ARE working at "anti-gravity".
E = normal muscle strength in all muscle groups and a person with this degree of injury probably
won't need to be an inpatient in the spinal unit at all (but may have some bladder,bowel or sexual
dysfunction and may be seen in the outpatient department by one of the doctors).
The table below shows the level of independence achieved as the level of injury goes down from
the cervical to sacral areas of the spine. The lower the lesion, the more independent the person is.
Level of Spinal Cord Lesion FUNCTIONAL ABILITIES
Vertebrae
C1-3 Assisted breathing (with ventilator).
Inability to sit or stand without complete support
Use of motorised wheelchair with head control.
In C 4 level of lesion, the person needs the above
but can breathe independently.

C5 Use of motorised wheelchair for long distances

May be able to use manual wheelchair at home or
on flatground surfaces.
Independent in eating and drinking, typing, writing
and computer with the aid of splints/devices.
In C6 level of lesion, the person can do all the
above with more independence and may achieve
driving using hand-controls.

C7 Independent transfers, including in and out of car.

Independence with personal care (as noted above)
with aids/adaptations.
Driving using hand-controls,possibly including
lifting wheelchair in and out of car.

C8 Independent transfers, possibly including floor to

wheelchair.
Independent personal care, including managing
buttons and shoe laces.
Management of bowel care with or without use of
an aid.
Independence with food and drink preparation and
some household tasks.
Driving,including lifting wheelchair in and out of
car.

T1-6 Advanced Independent transfers: wheelchair to

floor and return.
Managing wheelchair up and down curbs, steps.
 Independent in all aspects of personal care and most
household activities.
transfers, possibly including floor to wheelchair.

T6-L2 Independent transfers, including floor to wheelchair.

Improved trunk stability and balance.
Advanced wheelchair skills.
Therapeutic walking with long leg braces and
crutches.

L3-S1 Increasing use of legs and therefore, walking with

varyingamounts of external support.

S2-5 Normal gait.

Increasing voluntary control over bladder, bowel,
and sexual functions.

IV. Spina bifida

Definition

Spina bifida is a general term for any neural tube defect (also called an NTD) that involves the
brain,spinal cord, and/or meninges (protective covering over the brain and spine).

Causes
Spina bifida occurs when the neural tube (area around the spinal cord) does not close during a
baby’s development. The exact cause of spina bifida is unknown. Spina bifida is most likely a
multifactorial birth defect meaning that multiple causes (including genetic, nutritional, and/or
environmental factors) contribute tothe development of spina bifida.

Classification and types

There are three major types of spina bifida
1) spina bifida occulta
2) meningoceles,
3) Myelomeningoceles

1) Spina bifida occultaoccurs when there is a small gap between the vertebrae(bones of the
spine); this gap is usually covered by skin or a tuft of hair. Because of this
coveringpatients with spina bifida occulta may not have a visible NTD.

2) Meningocelesoccur when the meninges comes through the opening in the spine. The
nerves of the spinal cord are usually not damaged or involved in meningoceles.
Meningoceles may or may not becovered by skin.

3) Myelomeningoceles, the most severe form of spina bifida, occur when the meninges and
the spinalcord nerves protrude from the opening in the spine. Children with either
meningocelesormyelomeningoceles often have nerve damage and disabilities, such as
problems with bowel or bladdercontrol, difficulty walking, or paralysis.
These names are a little difficult to remember. It is easier to rememberthe meaning. Meningo-
indicates the inclusion of meninges (the tissue that surrounds the spinal cord). Mylo- indicates
the inclusion of nerve fibres (or spinal cord).
Some problems that may occur with spina bifida are:
 Hydrocephalus- This literally means water in the brain. The collecting fluid makes the
head swell and puts pressure on the brain. This may result in damage leading to physical
or intellectual impairments Treatment may involve surgery to put in a shunt to drain the
fluid.
 Muscle weakness
 Loss of sensation
 Other deformities like dislocated hip, club feet or feet turning up and out are common
deformities.

V. Muscular dystrophy
Definition-

Muscular dystrophy is a group of diseases that cause progressive weakness and loss of muscle
mass. In muscular dystrophy, abnormal genes (mutations) interfere with the production of
proteins needed to form healthy muscle. The muscles weakness usually starts from thigh and feet
muscles and progressively involves other muscles including breathing and heart beat.

Causes-Certain genes are involved in making proteins that protect muscle fibers from damage.
Muscular dystrophy occurs when one of these genes is defective.

Risk Factors- Muscular dystrophy occurs in both sexes and in all ages and races. However, the
most common variety, Duchenne Muscular dystrophy, usually occurs in young boys. People with
a family history of muscular dystrophy are at higher risk of developing the disease or passing it
on to their children.
Complications- The complications of progressive muscle weakness include:

 Inability to walk: Some people with muscular dystrophy eventually need to use a
wheelchair.
  Shortening of muscles or tendons around joints
 Breathing problems: Progressive weakness can affect the muscles associated with breathing
 Curved spine (scoliosis): Weakened muscles may be unable to hold the spine straight.
 Heart problems: Muscular dystrophy can reduce the efficiency of the heart muscle.
 Swallowing problems: If the muscles involved with swallowing are affected

Classification or Types-

Duchenne muscular dystrophy

This is the more severe type of

muscular dystrophy. Although girls
can be carriers and mildly affected,
the disease typically affects boys,
signs and symptoms typically
appear between the ages of 2 and 3,
and may include:

 Frequent falls
 Difficulty getting up from a lying or sitting position
 Trouble running and jumping
 Waddling gait
 Walking on the toes
 Large calf muscles
 Muscle pain and stiffness
 Learning disabilities

There is no cure for DMD and no medicine that will stop the weakness from progressing.
Becker muscular dystrophy

Signs and symptoms are similar to those of Duchenne muscular dystrophy, but typically are
milder and progress more slowly. Symptoms generally begin in the teens but may not occur until
the mid-20s or even later.
Other types of muscular dystrophy

Some types of muscular dystrophy are defined by a specific feature or by where in the body
symptoms first begin. Examples include:

 Myotonic.
 Facioscapulohumeral (FSHD).
 Congenital.
 Limb-girdle.

Summary

In this topic you have learnt about the meaning, causes, symptoms and classification of the
locomotor and neuromuscular disabilities of amputation,poliomyelitis, spinal cord injuries, spina
bifida and muscular dystrophy. In all the disabilities, the person experiences loss of movement
and sensation in varying degree. The severity of symptoms depends on the location of the lesion
in amputation, polio, SCI and Spina Bifida. In muscular dystrophy, the whole body is affected
but the progress of the disease depends on its type. The cause for each disability is varied.Polio is
caused by a viral infection and muscular dystrophy has a genetic cause. Cause for spina bifida is
still not known. Among all disabilities mentioned here, Spina Bifida can result most often in
physical and intellectual impairments.

Questions

1. Fill in the Blanks

a. __________________ is a general term for any neural tube defect (also called an NTD)
that involves the brain,spinal cord, and/or meninges (protective covering over the brain
and spine).
b. ______________________ and ____________________ are two of the key risk factors
have been identified as increasing the likelihood of paralysis in a person infected with
polio.
c. _______________________ means water in the brain and occurs with spina bifida.
 d. Secondary problems are very common in complete and incomplete SCI and include
___________,_____________________,_________________and __________________.

2. Write Short answers:

a. What is phantom pain and phantom limb sensation?

b. Why does WHO considers a single confirmed case of polio paralysis to be evidence of an
epidemic?
c. Explain the types of Spina Bifida.
d. Which is the more severe type of Muscular dystrophy? Explain what syptoms are seen in
that.
e. Define spinal cord injuries. What happens in quadriplegia?

References:

1. Moroz,Alex;Rehabilitation after Limb Amputation in

http://www.msdmanuals.com/home/fundamentals/rehabilitation/rehabilitation-after-limb-
amputation
2. http://www.rah.sa.gov.au/hampstead/downloads/SASCIS/Chapter%202.pdf

3. http://www.kidshealth.org/kid/health_problems/birth_defect/spina_bifida.html

4. MedlinePlus Medical Encyclopedia in http://www.nlm.nih.gov/medlineplus/spinabifida.html

5. http://www.ninds.nih.gov/disorders/spina_bifida/detail_spina_bifida.htm

6. http://www.mayoclinic.org/diseases-conditions/muscular-dystrophy/basics/definition/con-
20021240

7. Norris (Mo), Meriel (2001); Rehabilitation Therapy Assistant Manual; Mobility India,
Banglore

8. Kieran, Shari Stokes; Connor, Frances Patridge; Saaz Von Hippel, Caren; Jones Sherry Harris;
(1980); Mainstreaming Preschoolers: Children with Orthopaedic Handicaps; US Department of
Health and Human Services, Washington D. C.
 2.2. Assessment of Functional Difficulties
Objectives:

After studying this topic, you will be able to understand

 the concept of functional assessment

 areas of functional assessments of people with amputation, polio, spinal cord injuries,
spina bifida and muscular dystrophy

Content:

What a Functional Assessment?

A functional abilityis the ability of the child with the above conditions to be able to be a
functional individual in his/her environment. Knowing what the child can do and cannot do is the
basis for a functional assessment. Limitations in physical functioning are important to consider
because of their link to: (1) decreased quality of life, (2) increased risk of disability, falls and
fractures, and depression, and (3) increased health care costs.

The focus in functional disability assessment is on the person's behavior rather than on the
performance of body parts or organ systemsand represents aberrations in an individual's usual
performance. Functional assessment assesses the physical, social and emotional function.
Walking, climbing stairs, performing housework, shopping, and preparing meals are all
examples of physical function while level of anxiety is an emotional function. It also includes
tasks concerned with fundamental daily activities, such as self-care or basic mobility, usually are
defined as "basic" activities of daily living.

Areas of functional assessment

A functional assessment of all types of locomotor and neuromuscular disabilities will be the
same. Functional assessment of cerebral palsy has been explained in the Unit 1, topic 2. The
same areas will apply for children with amputation, polio, spinal cord injuries, spina bifida and
muscular dystrophy. The assessment wouldinclude the following:
  Observations in different positions to assess the highest level of ability of the
child/person. The child is observed in different positions like supine (lying on back),
prone lying (lying on stomach), sitting, crawling and standing covered in section 1.2.
 In addition to observation of abilities, the functional assessment also includes some
clinical assessments such as assessment of range of motion/ROM and assessment of
muscle power/ MP. Also assessments of activities of daily living arerequired to be done.
The details of assessment of ROM, MP and ADL have been covered in section 1.2.

It is important that an accurate assessment is completed for each person and reassessment is done
at regular intervals. A brief recap of the points to be assessed (as also explained in detail in 1.2)
are:

1. History-
Level of damage and how the damage occurred,
treatment to date.
2. Muscle strength-
Full muscle grading should be done to ascertain
which muscles have any possible residual function
and if any improvement over time occurs
3. Sensation-
Using the body chart, you should mark the areas of
decreased or absent sensation. This will show which
areas need to be checked regularly as they are at risk
of pressure sores, burns etc.
4. Deformities-
Contractures and other deformities should be
marked on the body chart
5. ADL-
Problems of ADL activities and its reason should noted.
6. Bladder and bowel control and breathing difficulties
Other information can be added in the comments section. An example of the assessment form is
given in the attached illustration.

Most children/personswith amputation, polio and spinal cord injuries will require a greater in
depth assessments of muscle power using individual muscle testing and assessment of range of
motion. This is required to understand the prosthesis or caliper that is required to be given to
them.

Persons with polio and amputation are largely fully functional after they have worn their
prosthesis or caliper.

In case of polio and lower limb amputation, their greatest functional difficulty would be in the
area of mobility. As a teacher it is important to be aware of the donning or removal of the aid.
The details of the types of prosthesis/ aids are mentioned in the next section. For upper limb
amputation the greatest challenge is in the area of ADL’s and of selection of an occupation.
Detailed occupational assessments may need to be done to understand their residual functions.

Functional difficulties of a child with spina bifida and muscular dystrophy will largely depend on
the severity of the disability. They may vary from fully independent to fully dependent based on
the detailed grading covered in section 1.2.

A person with a spinal cord injury also requires a mobility assessment so that mobility training
may be done. Mobility training may be done with a walker, crutch or a wheelchair.

The Functional Assessment Team

Assessment is a team effort. Each team member sees the child from a different perspective.
Everyone works together to figure out what’s going is the best plan of action for the child. An
assessment team will include:

 Physical therapist
 Occupation therapist
 Orthotis/prosthetist

Summary
The functional assessment of children with amputation, polio, spinal cord injuries, spina bifida
and muscular dystrophy is done by a functional assessment team. The team assesses the abilities
of the child as to what he/ she can or cannot do in his environment and to what extent. These
include the muscle strength, range of motion, sensations, ADL activities, walking patterns and
bladder and bowel difficulties. The aids used by the child are also assessed by the orthotists /
prosthetist. Reassessment is important at regular intervals.

Questions

1. Which are the areas of functional assessments?

2. Why is an orthotist/ prosthetist an important member of the assessment team?

References

1. Norris (Mo), Meriel (2001); Rehabilitation Therapy Assistant Manual; Mobility India,
Banglore
2. Alan M. Jette and Paul D. Cleary;(1987); Functional Disability Assessment ; Physical
Therapy Journal, Volume 67 / Number 12, December 1987
(http://ptjournal.apta.org/content/67/12/1854)
 2.3. Provision of Therapeutic Intervention and Referral

Objective:

After studying this topic, you will be able to understand

 Importance of various types of therapeutic interventions relative to each of the locomotor

and neuromuscular disabilities mentioned
 different types of therapeutic interventions and referrals that are provided to children with
amputations, poliomyelitis, spinal cord injuries, spina bifida and muscular dystrophy.

Content:

The general principles of intervention for all types of disabilities remain the same and any
principle may be applied depending on the particular case. Each type of disability has some
specifics to its intervention which have been listed below:

I. Amputation: Therapeutic intervention and prevention

Before surgery, a surgeon, prosthetist, and physical therapist discuss the plans and goals with the
person who requires amputation. A prosthetist is an expert who fits, builds, and adjusts artificial
limbs (prostheses) and provides advice about how to use them. The exercises used in
rehabilitation may be started before the amputation.

A prosthesis for a limb (arm or leg) consists of a socket in a rigid frame (interface), components,
and a cover. The interface enables the prosthesis to be attached to the body. Components include
terminal devices (such as artificial hands, feet, fingers, or toes) and artificial joints.

Arm (UE) amputation:

Rehabilitation includes general conditioning exercises and exercises to stretch the shoulder and
elbow and to strengthen arm muscles. Endurance exercises may also be necessary. The specific
exercise program prescribed depends on whether one or both arms were amputated and how
much of the arm was amputated. People learn how to do activities of daily living using the
prosthesis, adaptive devices, or other parts of the body (such as the mouth and feet).

Leg (lower-limb) amputation

After leg amputation, most people are fitted for an artificial leg or LE prosthesis and intervention
includes exercises for general conditioning and exercises to stretch the hip and knee and to
strengthen all arm and leg muscles. The person is encouraged to begin standing and balancing
exercises. Endurance exercises may be needed. The specific program prescribed depends on
whether one or both legs were amputated and how much of the leg was amputated.

Prosthetic environment-

When people receive the prosthesis, they are taught the basics of using it:

 How to put the prosthesis on

 How to take it off
 How to walk with it
 How to care for the prosthesis and the skin of the stump

A physical therapist develops a program of exercises to improve strength, balance, flexibility,

and cardiovascular fitness. The therapist teaches people more about how to walk with a
prosthesis. Walking begins with direct assistance and progresses to walking with a walker, then
with a cane progress to independent walking.

Care of the stump

People must learn to care for their stump.Because leg prosthesis is intended only for walking,
people should remove it before going to sleep. At bedtime, the stump should be inspected
thoroughly (with a mirror if the person is inspecting it), washed with mild soap and warm water,
dried thoroughly, and then dusted with talcum powder.

If certain problems as given below occur they should be treated

  Dry skin: Apply lanolin to the stump
 Excessive sweating: Apply an unscented antiperspirant
 Inflamed skin: Remove the irritant immediately, and apply talcum powder or a low-
potency corticosteroid cream or ointment
 Broken skin: Not wear the prosthesis until the wound has healed and see a doctor

II. Poliomyelitis: Therapeutic intervention and prevention

There is no cure for polio, only treatment is to alleviate the symptoms. Heat and physical
therapy is used to stimulate the muscles and antispasmodic drugs are given to relax the muscles.
While this can improve mobility, it cannot reverse permanent polio paralysis.

Polio can be prevented through immunization. Polio vaccine, given multiple times, almost
always protects a child for life. During the acute phase of the infection, the intervention includes
antispasmodic drugs to relive pain and rest.After the acute phase, the intervention for polio
largely includes muscle strengthening exercises including selection of the right type of caliper.
Once caliper is selected gait (walking) training is done.

III. Spinal Cord Injuries: Therapeutic intervention

With its millions of nerves, the spinal cord is both a delicate and tremendously complicated
structure. While a nerve running in the arms or legs can regenerate [regrow] if severed, a nerve
in the spinal cord itself has very limited ability to regenerate. In most cases, immediately
following spinal cord injury, weakness and sensory loss is at its peak. Some of this loss may be
due to permanent injury, and some of the weakness may improve. Unfortunately, both permanent
and temporary weakness look the same, so only with time can we tell whether the weakness is
permanent or temporary.
The time for recovery to occur is variable, depending on the injury. In some cases most recovery
occurs within the first 3 months, while with others it can take as long as 18 months. Typically,
most recovery occurs in the first few months after SCI. As time goes by, fewer gains are seen.
It is very important to do all you can to help your body to heal. Your medical care helps,
certainly. Surgery, if necessary, is typically done to make the bony spinal column stable, reduce
compression to the spinal cord, and/or prevent further damage. Medications may be given at
certain periods following the SCI to attempt to minimize the nerve damage. Further medical
support is given to prevent serious complications, and allow the body maximum health and
nutrition for healing.
For higher level spinal cord injuries care of the skin is important as, if this is not done, it may
lead to pressure sores. Most spinal cord injuries have a long course of rehabilitation or
physiotherapy. An occupational therapist will do an assessment of hand function to give
guidance for school or work placement. A speech therapist will give guidance for feeding
intervention. Since a SCI is a traumatic incident the patient as well as his/her family may require
psychological support.

In the initial stage, prevention of secondary problems like contracture and pressure sores is the
most important goal. For that good positioning and passive or active movements for the limbs are
important. The therapist also may have to help the person to very slowly move to more and more
upright positions. Any muscles that have not been affected need to be strengthened as much as
possible. The therapist needs to teach independence in ADL, balance in both sitting and walking,
and transfers themselves independently.

IV. Spina Bifida: Therapeutic intervention

As soon as the baby is born there is an inspection of the health of the spine. An immediate
surgery is undertaken to close the spine if the spina bifida has caused the spine to be not fused.
The surgicalrepair only repairs the appearance of the spine.It cannot fix any damage to the
nerves. Treating spina bifida focuses on managing any problems with the spine, feet, or hips
whichmay be present, as well as preventing infection. Prevention of contractures is essential.
Care of the bowel and bladder for children with spina bifida is a must.
It may be possible to strengthen some muscles that are only partially paralyzed, so exercise are
indicated. If this is not possible, then walking aids like calipers, crutches and wheelchairs is
given.

V. Muscular Dystrophy: Therapeutic intervention

Several types of therapy and assistive devices can improve quality and sometimes length of life
in people who have muscular dystrophy.
  Range-of-motion and stretching exercises. Muscular dystrophy can restrict the flexibility
and mobility of joints. Range-of-motion exercises can help to keep joints as flexible as
possible
 Exercise. Low-impact aerobic exercise, such as walking and swimming, can help maintain
strength, mobility and general health. Some types of strengthening exercises also might be
helpful.
 Braces. Braces can help keep muscles and tendons stretched and flexible, slowing the
progression of contractures. Braces can also aid mobility by providing support for weakened
muscles.
 Mobility aids. Canes, walkers and wheelchairs can help maintain mobility and
independence.
 Breathing assistance. As respiratory muscles weaken, a sleep apnea device may help
improve oxygen delivery during the night. Some people with severe muscular dystrophy
may need to use a machine that forces air in and out of their lungs (ventilator). From an
early age, children with MD should be encouraged to sing, shout and do other activities that
involve deep breathing.

 Surgery.Surgery may be needed to correct a spinal curvature that could eventually make
breathing more difficult.

Summary

As with all disabilities, the treatment depends on the combination of problems, potential for
improvement and level of motivation of the person himself. A programme to be carried out for
therapy should be set after complete assessment and taught to the family. The rehabilitation
through therapeutic interventions is a long process. It should be continued through out life to
ensure that complications do not occur.

Almost all disabilities require strengthening of the residue muscle power and the training in ADL
activities. Besides this, a careful assessment of aids required would help the person in his
mobility and independence. Exercises are planned for endurance, strengthening and increasing
the range of motion.
 Questions:

i. Write True or False:

1. Rehabilitation for upper arm amputations includes general conditioning exercises,
endurance exercises and exercises to stretch the shoulder and elbow and to strengthen
arm muscles.
2. Heat and physical therapy can be used to reverse permanent polio paralysis.
3. People can keep the leg prosthesis attached whenen when they go to sleep
4. The surgical repair in spina bifida only repairs the appearance of the spine and does not
fix any damage to the nerves.
5. Low-impact aerobic exercise, such as walking and swimming, can help maintain
strength, mobility and general health in MD.
ii. Complete the sentence
1. After leg amputation, intervention includes exercises for
______________________________________________________________________

2. Treating spina bifida focuses on managing any problems with

______________________________________________________________________

3. In muscular dystrophy, braces can help

______________________________________________________________________

4. After the acute phase, the intervention for polio largely

includes______________________________________________________________________
_______

References:

b. Moroz,Alex;Rehabilitation after Limb Amputation in

http://www.msdmanuals.com/home/fundamentals/rehabilitation/rehabilitation-after-limb-
amputation
2. http://www.rah.sa.gov.au/hampstead/downloads/SASCIS/Chapter%202.pdf

3. http://www.kidshealth.org/kid/health_problems/birth_defect/spina_bifida.html
4. MedlinePlus Medical Encyclopediain http://www.nlm.nih.gov/medlineplus/spinabifida.html

5. http://www.ninds.nih.gov/disorders/spina_bifida/detail_spina_bifida.htm

6. http://www.mayoclinic.org/diseases-conditions/muscular-dystrophy/basics/definition/con-
20021240

7. Norris (Mo), Meriel (2001); Rehabilitation Therapy Assistant Manual; Mobility India,
Banglore

8. Kieran, Shari Stokes; Connor, Frances Patridge; Saaz Von Hippel, Caren; Jones Sherry Harris;
(1980); Mainstreaming Preschoolers: Children with Orthopaedic Handicaps; US Department of
Health and Human Services, Washington D. C.
 2.4: Implications of Functional Limitations for Education and Creating Prosthetic
Environment in School and Home: Seating Arrangements, Positioning and Handling
Techniques at Home and School

Objective:

After studying this topic, you will be able to:

 understand the factors that influence the learning process

 identify educational implication of children with amputation, polio, Muscular Dystrophy,

Spinal Cord Injuries and Spina Bifida

 understand what prosthetic equipments and seating arrangements to use with different
disability at school and home.

Content:

Every child possesses the potential for learning substantially despite his/ her disability. You must
understand and prepare for the wide range of needs that may require accommodation and
adaptation by giving special attention to the factors that affect the individual child’s learning.
The educational implications mentioned below are found in all the disabilities related to this unit.
An exception to the general implications or particular feature of a disability are mentioned within
the content.
Children with amputation, polio, Muscular Dystrophy, Spinal Cord Injuries and Spina
Bifidaexperience limitations imposed by the disability in the form of moving, sitting for long
duration, writing (if their hands are affected) taking care of their daily need such as toileting and
participation in physical activities.

Due to the difficulties in movement, you may observe the child havingall or some of the
following difficulties in class and at home:

1. Motor weakness, paralysis

2. Deformities

3. Sensory Loss
4. Pressure Ulcers

5. Spasticity

6. Urinary and Faecal Incontinence, Urinary Retention

7. Pain etc.

Very often complete or partial loss of sensation accompanies motor weakness. Found in spinal
injuries and Spina Bifida, all or some of the modalities of sensation can be affected e.g. pain,
temperature and position sense, vibration, pressure. The child may feel less or no pain when
he/she is wounded or would not be able to make out how hot a particular surface is. Motor
activity is also affected. Thus co-ordination, initiation of voluntary movements and muscle tone
are impaired. Thus in the class, the child may have difficulty in physical activities requiring
moving about in the class to access materials like books, writing and colouring equipments,
changing classrooms for extra curricular activities, coordination of two activities like holding a
notebook and at the same time draw a diagram using various drawing materials. Children with
MD may need some support like grippers or velcro to hold the pencil/ pen in their hands.

For MD, the muscles for retaining posture begin to deteriorate. The child’s seating and posture
will require assistance. The child’s problem in moving will require support and eventually the
use of special equipment such as wheelchairs.

Children with spinal injury or Spina Bifida especially may have additional problems of not
having proper control over their urination and bowel control.For Muscular dystrophy too,
schedule bathroom breaks or allow student to leave class a bit early to maneuver through the
building.

Communication and speech is usually similar to that of other children without disabilities unless
the disability is severe.

A child with polio, amputation, SCI, MD and Spina Bifida may have inhibitions about his/ her
body. The child’s own feelings may make him/ her feel deformed, unattractiveor the object of
 curiosity. The teacher needs to help the child use all parts of the body with emphasis on
developing the gross and fine motor skills. The prosthetic fitted to the child’s limb may require
adjustment from time to time and can cause soreness and pain in the remaining part of the limb.

Above difficulties arising out of disability of moving subsequently limit the function of the child
in his various activities of daily living (ADL) that are required in the classroom and home. For
example, difficulties are found in

1. Mobility and ambulation

2. Transfers

3. Self care activities like toileting, bathing, grooming and feeding.

4. Social and leisure activities

5. Work place activities.

Many aids are available like wheelchairs, walkers, canes and crutches that would help children
get around the building. Also braces, helmets, artificial limbs and specific self help aids like
adapted feeding aids like modified plates and cups help a particular child to eat, communicate,
play and perform other activities of daily living.

Spatial and perceptual difficulties may arise due to limited exploration of the environment at an
early age (e.g. unable to crawl independently). This will have an impact on learning, reading,
writing and Mathematics in the student’s education. This may not occur in children with polio
and amputation as they may have more movement than other disabilities mentioned here.
Many children cannot participate in normal activities because they cannot walk for long
distances or not walk at all. Providing with necessary aids like braces, walker or wheelchair
could increase participation. However, students may tire easily. You will have to monitor
fatigue.

Students would need emotional support from time to time. Students may experience feelings of
frustration as they become increasingly dependent on others at a time when their peers are
enjoying more freedom and independence. Be alert to signs of depression or isolation and deal
with it accordingly – contact parents, talk with student, talk with counselor and other
supports.Encourage active classroom participation to help boost self-confidence. In order that
students do not develop a sense of “learned helplessness”, emphasis must be placed on the
students’ abilities, strengths and talents and their capacity to develop independent skills. As
students may experience a sense of social isolation of school, you must emphasize on developing
friendships with peers. A counselor / psychologist would help to promote emotional well being
in children.

The important things to be kept in mind by the teachers are:

1. The children using an aid or appliance should be taught how to use them properly so that
they can walk and function in a better way with minimum energy consumption.
2. In the classroom a child with difficulty in moving may not need so much attention. In
case of severe disability, they might need extra physical assistance. This problem can be
solved by pairing such a child with a child having no disability and asking him to assist
the disabled child. If it is not possible, then you may have to seek the help of a volunteer
from the community to which the child belongs to.
3. While teaching in the class, make sure that the children can see you and hear you when
you teach or write something on the blackboard. Some children may have problem of
weakness of the hands due to which they are either slow in writing or not able to write
themselves. You have to identify such children and provide them either extra time or
arrange for a volunteer to write for him/her.
4. The teacher should always encourage physical activities. It may be that disabled children
are not able to participate fully in a particular physical activity. Adaptations in this
activity should be made.
5. Since lack of coordination and balance is a result of the disability, children should also be
taught how to prevent accidents at home, in the school and when outside (e.g. taught
about traffic rules and to cross the roads) and teach how to be careful to prevent injuries.
6. Some children who have sensation loss in the hands or feet, like the children with spina
bifida or muscular dystrophy should be taught about the role of sensation and feeling of
pain and how they can prevent them from injuring their senseless part of the body.
7. Some children who are not able to hold the ordinary pencil or pen because of weakness
of grip may be provided with some adaptation so that they can hold it and write
themselves.
 8. Regular interaction with the parents of a child with locomotor impairment in order to
have a regular feed back from them regarding his/her competence in the activities of daily
living, behavior at home and participation in the social activities.
9. Watch every child carefully and find out about the child’s behavior in the class, so that if
any child is having unwanted behavior, you can correct it.

The majority of children with locomotor and neuromuscular impairments do not require special
schools. They can participate and benefit from general education in regular school. But the
school needs to be made barrier free. Class Room should be located on the ground floor so that
the children can reach their class room with a minimum of difficulty. If that is not feasible the
school should have ample elevator service and /or inclined ramps specially for children who use
wheel chair for their mobility, built environment needs to incorporate level access, ramps,
lifts/elevators, handrails and grab bars, larger toilet cubicles, adequate wide paths, doors,
entrances etc. Desk and chairs should be comfortable for the children with physical disabilities.
The height of the chair and table needs to be adjusted as described in the earlier topic on
positioning of child with CP such that the child is least restricted in his movements as well as
finds himself in a comfortable physical environment.

Undertaking the above precautions, you will be able to overcome the problems of children with
polio, muscular dystrophy, spina bifida, spinal injury, and amputation and assist them in
achieving their educational goals so that they can become independent adults and are able to go
for work and earn for themselves. They will also be able to learn as to how to get along with
others, how to behave and how to make friends. In this way they can become useful members of
the community.

Creating Prosthetic Environment in School and Home: Seating Arrangements, Positioning

and Handling Techniques at Home and School

Children with polio, muscular dystrophy, spina bifida, spinal injury, and amputation need
prosthetic aids and modified and adapted equipments to meet their needs seating, positioning and
handling at home and classroom. These are similar to those needed by children with cerebral
palsy and have been discussed in chapter 1.4. In addition, a brief overview is given below.
Modifications in the tables and chairs and buying bolsters, wedges and lap trays would help to
position the child appropriately and increase his participation in the activities.
Children with poor sitting balance would need some chair modifications. Sometimes the arms
need to be high so that the child does not fall to one side. A high backed chair too would help to
keep the child’s head upright and his trunk supported. Sometimes propping small pillows at the
side helps to prop him up.
For activities on the floor a seat with back rest and without legs can be placed on the floor. A
seat belt fastened at hip level is often useful. A corner seat could also serve the purpose.
When sitting or standing is too
difficult or tiring, the child can lie
on his stomach with his chest and
arms over a bolster so that his arms
are free for play or academic
activities.
A tray can be fitted in front of the
chair which would hold the
educational material or any other material like feeding aids/ drawing material etc. This allows for
easy access. It can also be used for placing the communication boards.
Prosthesis is an artificial replacement for a missing body part; an orthosis is a device that
replaces a function no longer present in a part of person’s body. An adaptive device for daily
living includes a variety of adaptations of ordinary items found at home, or school that make
performing the task for self care, school or leisure activity easier. Even if any of these are used, it
is important to learn to use the residual function and not to rely totally on the
prosthesis or orthosis.
For polio,spinal cord injuries and spina
bifida, the orthosis used are the calipers
as a form of external support for a weak
limb. There are three kinds of calipers-
Ankle foot orthosis (AFO), Knee ankle
foot orthosis (KAFO) and Hip, knee, ankle and foot orthosis (HKFO).The parents and teachers
need to be aware of the care of calipers and that it should be worn regularly or there is a risk of
contractures occurring.
For children with amputation the prosthesis used may be

Above elbow and

below elbow prosthesis
 Finger prosthesis

Shoulder prosthesis

Various other walking aids too can be used like walkers, crutches and sticks. All these are
equipments to increase a persons ability to balance, relieve his partial/ full weight from a
weakened or missing limb. It aids the person to walk independently. Some children may also
need to use wheelchair. After fitting the orthosis parents and teachers must take care of the gait
of the person.
Handling and positioning of these children demand attention to support the child’s body at
various points and how various postures influence muscle tone and ability to move. Good
positioning for limbs help to prevent contractures and pressure sore development. Suitable
positions are shown in the diagram below. The pictures are taken from the book disabled village
children.

For spinal injuries, amputatation and polio, the

child should very slowly helped to move to an
upright position. This may take weeks.
Good positioning and handling is important for amputees also, to prevent contaractures. An
artificial limb is not appropriate for all amputees, Here other form of mobility aids can be
considered.
An independence in ADL activities of sitting, feeding, toileting and grooming is needed with the
help of modified and adapted equipments. They have been described in detail in the section on
cerebral palsy. Adding Velcro straps to toothbrush, alternative ways of holding a pen, plates with
sections, shirts with Velcro all help in becoming independent.
For giving pressure relief, appropriate seating materials like cushions, rolled towels can be used.
Regular change in the position to relieve pressure areas, regular good hygiene, lifting from sitting
after every few minutes would ensure maintenance of good skin health and protection from
injury.
For a person with prosthesis or orthosis of the lower limb, getting on and off the floor , stairs etc
too is important. A prosthesis / orthosis for upper limb may enable the child to hold glasses but
very fine finger action may not be possible. Parents should ensure care of stump and its removal
at night.
Summary

The disability often interferes with a youngster’s attempts to gain independence such as taking
care of toileting needs, feeding himself, writing and turning pages in a book. Teachers must
continue to stress cognitive aspects of learning because their mind is not affected. Students may
need extra time to take tests and encourage use of a tape recorder in class for note taking when
writing becomes too difficult. Occupation and Physical Therapist can recommend exercises that
will continue to maintain flexibility and strength while taking into consideration adaptive
equipment that may be helpful in the school setting.Prosthic and orthotic aids help in mobility,
ADL, and seating.
Questions

c. Answer in brief:
a. What are the difficulties experienced due to muscle weakness in the classroom?
b. Suggest some chair modifications for children with poor sitting balance.
d. Choose the correct answer:
 a. Very often complete or partial loss of sensation accompanies ___________ ( motor
weakness/ deformities).
b. Spatial and perceptual difficulties may arise due to ______________ ( injury to the body
parts /limited explorationof the environment) at an early age.
c. Since _______________ (lack of coordination and balance/ loss of sensation) is a result
of the disability, children should also be taught how to prevent accidents at home, in the
school and when outside.
d. A ____________ ( table /tray) can be fitted in front of the chair which would hold the
educational material or any other material.
e. Good positioning for limbs in polio. SCI and spina bifida help to prevent
_____________(contractures and pressure sore development/ falls and injuries)

References:

1. Norris (Mo), Meriel (2001); Rehabilitation Therapy Assistant Manual; Mobility

India, Banglore
2. Kieran, Shari Stokes; Connor, Frances Patridge; Saaz Von Hippel, Caren; Jones
Sherry Harris; (1980); Mainstreaming Preschoolers: Children with Orthopaedic
Handicaps; US Department of Health and Human Services, Washington D. C.
3. http://www.snagroup.ie/index.php/physdis2
4. https://www.region10.org/r10website/assets/File/musculardystrophy.pdf
 2.5. Facilitating Teaching-Learning: IEP, Developing TLM; Assistive technology

Objective:

After studying this topic, you will be able to:

 Develop an IEP for children with Amputation, Polio, Spinal Cord Injuries Spina-bifida
and Muscular Dystrophy
 Know what types of equipment and TLM are needed for children with various
disabilities.
 Know about assistive devices for these children

Content:

In the last unit, in topic 1.5 you have learnt the meaning, importance and the components that
comprise an effective IEP. The principles for developing an IEP for children with Amputation,
Polio, Spinal Cord Injuries Spina-bifida and Muscular Dystrophy are same and can be reviewed
in 1.5. However the specific difficulties associated with each condition and the corresponding
educational interventions needed for each are incorporated while designing the IEP for each
child.

The nature and severity of the disability of the child may limit the child's ability to learn in the
ordinary way. Curriculum adaptations are a specific modification that relates to instruction or
content of a curriculum. These adaptations could be done by making adjustments or carrying out
modifications to the environment in which a student learns. The teaching and learning techniques
are required to be changed so that they suit the needs of the children. You have to provide
support through teaching and through learning material to enhance the student’s performance or
at least allow partial participation in learning activities, learning programs and in the assessment
of learning having taken place.
It is important for children to have the opportunity to learn by doing, to involve actively in
problem solving and in developing language and communication skills. Thus, encouraging
participation of children with special needs is an important strategy and must be appropriately
employed by you.

S/he may need accessible reading material, special aids and appliances and motivation to
optimize her/his learning. Children’s impairments, may also call for adaptation of teaching
strategies, provision of special reading materials, teaching of plus curriculum skills or use of
special assistive devices. All of these would be reflected in the IEP.

As far as the children with locomotor impairmentsare concerned, they suffer from three major
problems loss of limb, deformity of the limb and weakness of the limb. These problems may
hinder in his activity of daily living, in terms of, moving, lifting object etc. As far as their other
faculties are concerned, like hearing, speaking and mental abilities they are normal. Therefore,
they do not require any adaptation in the training learning material.

A review salient points of IEP that you have learnt earlier about IEP in Unit 1

An Individualized Education Plan (IEP) is a written plan of action prepared for a student who
requires modifications of the regular school program or accommodations. It contains

• Present levels of academic and functional performance

• Annual goals
• Measurements of progress and how progress will be shared
• What special education and related services will be provided » how often they will be provided
(frequency) » how long they will be provided (duration) » where they will be provided (location)
» who will provide the services
An IEP is usually in place at the beginning of the school year and the IEP is reviewed
periodically by the IEP team to determine whether goals are being achieved. The IEP team must
revise the IEP when expected progress fails to meet annual goals or when a reevaluation deems it
appropriate. Additional requirements for an IEP ensure that records must be kept confidential.

Specific inputs in IEP required for various conditions:

a) Amputation:
Children who have lost a part of their body through amputation can have general
difficulties in using their bodies. And need encouragement to use the remaining parts.
Adjustments to use of an artificial limb may cause soreness and pain. The IEP needs to
allot some time to occupational therapist wherein he/she can help in symmetry in the
overall body posture and proper fit of the artificial limb. The IEP needs areas to
encourage the use of all limbs and you as a teacher will need to device various sessions to
increase the child’s social interaction where he uses maximum number of body parts.
An amputation creates a sudden change in the body and in the child’s ability to use that
part. As a result the child may naturally feel many emotions including feeling of loss,
frustration, anger etc. The child may wish to hide the remaining part of the limb.Some
children need to be helped to cope with these related feelings to gain a healthy sense of
self. Hence, the psychologist/ counselor plays a very important part in the IEP team and
needs to be allotted some sessions with the children. Also emphasis should be on gross
motor and fine motor skills. The amputee’s thought process and language are like other
children.
b) Polio: Polio can cause paralysis by destroying nerve cells that make the muscles work.
Hence the child is unable to move a limb or a part of it. Deformities due to fixed
positions of the limb can cause difficulty in dressing, grooming, toileting etc. For the
child with polio , these areas of ADL, and special care of the affected limb have to be
included as well as services of occupational therapist have to be put in. A child’s normal
physical and social activity would help to prevent deformities. For very young children
special attention would be on play activities and social interaction with children of his
age group in his environment.
A child with polio is just like all other children except for loss of movement. A child’s
intelligence is not affected by polio and he can do all activities like other children except
those that involve movement of the particular limb. He can do activities that require
thinking. The child is able to communicate in the same way as other children.
c) Spinal Cord Injuries and Spina Bifida:
When the spinal cord is damaged through accident, illness or as a result of a congenital
condition, such as spina bifida, loss of sensation may occur in certain regions which
 variesfrom child to child. You need to put in the IEP, the special equipment that would be
required to keep the paralyzed parts of the body in correct position and aid gross motor
movements e.g. special chair or table or adapted keyboard. The children with Spina
Bifida would need sessions on understanding body position and body image. You can
help the child through putting in these areas in the IEP with activities that include body
parts like puzzles, songs and other games. They may not have had as many or as varied
experiences as other children due to their restricted mobility. For example the children
may have heard of the ‘Mall’ but have not gone to actually shopping in the Mall. Hence
outdoor activities need to be weaved into the IEP. You may also need to include sessions
on learning to cooperate, share and take turns as they may have had less experience to
interact with others. Children with lack of sensation in parts of the body cannot sense
pain so they would not know if they get sores or rubbing against furniture may cause
injury. To avoid this situation, you may like to keep activities in the IEP that would be
short and require him to change position from time to time. Children with Spina Bifida
who do not have bladder control would need frequent toileting breaks. Children with
Spinal cord injuries exhibit similar cognitive abilities as found in the general population.

d) Muscular Dystrophy (MD):

Students with complex physical disability typically require a number of related services
as well as special education. As physical ability is lost, it becomes increasingly more
difficult for a child with MD to perform many activities and the need for assistance will
increase. There may also be learning deficiencies or speech impediments that require
specialized programs. While educatorsand parents want their students to succeed, without
the proper tools and guidance many will struggle and not receive an appropriate
education.
Considering child's current level of ability, measurable annual and interim goals are
written outlining what the child is expected to learn and achieve in the coming school
year. Since MD is a genetic disorder that causes the muscles in the body to gradually
weaken and eventually stop working, these goals must be designed to meet the
progressing difficulties and needs resulting from this disability, to enable the child to be
involved in and make progress and to meet other educational needs. Short goals are
 recommended. Updates of measured progress should be provided to the parents
periodically through the school year.

Symptoms can vary among students with MD, as can the severity of related problems.
Exhausting care routines and health care appointments can take up big chunks of time
and energy and have to be taken into account while designing the IEP.

Hence for children with polio, spinal cord injuries and amputation, curriculum and educational
goals are similar to non disabled children. In addition, special instructions may be needed in
mobility skills, daily living skills and vocational skills also special instructions are needed on the
use of the mechanical devices that would help them to perform the task. Educational tasks for
spina bifida and muscular dystrophy are related to their functioning in the everyday community.

Developing TLM

TLMs are special tools which make use of the senses of the students for effective teaching –
learning process in the classroom. They may also be called teaching aids as they are materials
used by teachers to help in better communication, good class interaction and effective teaching
and learning. They facilitate the different learning style of the students. Learning and teaching
methodology has progressed from the earlier method of Response Strengthening to Knowledge
Acquisition and a paradigm shift to Construction of Knowledge has been made. The duty of the
teacher is to provide appropriate environment where the child will construct his/ her knowledge
by interacting with his/ her physical environment.

In the general scenario, most often classroom teaching is dominated by the lecture method of the
teacherand teaching becomes very monotonous as students have to mostly rely on rote
learning.Except for some essential aids like chalk, duster, blackboard, teaching- learning material
(TLM) are hardly used in the classroom. When used, it may not be specific to the context of the
subject taught. There is a need to orient teachers and develop appropriate context specific TLM
that are useful to enhance the quality of teaching learning process.

The development of teaching materials should have a significant impact on the instruction.
Materials may use print or electronic format. TLM can make learning much more effective and
fun in the classrooms.For most children particularly those with severe disabilities, considerable
amount of equipment and special TLM are required. Without them no effective teaching will be
possible. The purpose of this topic is to indicate what types of equipment and TLM are needed
for children with locomotor and neuro muscular disabilities.

While using teaching aids for disabled children, you should keep the following points in mind:

 The TLM should be related to the lesson and supplement oral lecture.

 It should be made keeping in mind the previous experience and grasping ability of
thechild.

 It should stimulate thinking and activity.

 Preference should be given for real life objects than charts or models like instead of
showing the picture of a flower, the teacher should get a real flower in the class.

In addition to specially designed classrooms and special furniture as shown above, specially
designed instructional equipment should be provided such as large crayons or pencils to easily
manipulate for those children who find difficulty with standard sizes. A disabled child who can
not manage to write with pencil or pen may be provided the use of computers.

Children with polio, amputation and spinal injuries would show cognitive development similar to
non disabled children. Children with muscular dystrophy and spina bifida may show some
perceptual and spatial difficulties. For all the children TLM would provide advantages in
learning as they utilize as many senses as possible. The TLM are attractive and help to hold the
attention. They are also motivating force for learning.

TLM for the disabilities mentioned can be both two dimensional and three dimensional.
Textbooks, picture books and blackboard too are the oldest teaching aids. You can use two
dimensional aids like magnetic boards, flannel board, charts, flip charts, diagrams, picture cards,
flash cards, puppets effectively to teach concepts and supplement the lessons taught in the
textbooks.

To provide direct experience for the student, real 3 D objects are very important. Objects like
rock, soil and different types of leaves, fruits, etc. can be shown in the classroom. It immediately
connects the student with the outside world and motivates him to further
investigate and explore. Specimens of real objects also have great
 educational value. Different types of models provide knowledge
of the external and internal parts of the things which children with
locomotor and neuromuscular disability may not have the
opportunity to experience. Like a model of a fort would help the
child to clearly understand the construction design. Model of a
solar system would give an actual feel of the shape, size and space
making learning about the concept relevant to the student or a model of a heart or a brain. Some
models can be functional like the model of a water pump.
Since children with locomotor and neuromuscular
disability have restricted experience of outside world,
models present reality of things as they are three
dimensional.

Technology and multimedia are great support to teaching.

Motion pictures are the most popular and effective audio visual aids as it satisfy the visual and
auditory senses. These would include, basic educational
teaching films, documentaries and even feature films.
Besides making a topic interesting, it provides realism,
and keeps the students’ attention. Nowadays, you can
extensively make use of internet to download relevant
short films or film clips to make the lesson interesting.
Films also help in enhancing social interaction and can
be used as an aid to achieve social and communication Source: www.at4learning.com
goals in the IEP.

Computers allow the students to learn to learn materials at their own pace. They will provide the
disabled students with learning experiences that can stimulate real life problems , both in and out
of class. You can use e learning software available in the market for every subject area that could
provide interactive individual drill and practice sessions, tutorials or simulations. Many
interactive perceptual exercises are available on many internet sites that will make the sessions
interesting.
When you use TLMs in the class, you immediately catch the attention and interest of the child,
make the lesson interesting and provide the child with a peg to remember the lesson. TLMs are
multisensory in nature. Hence, for children with muscular dystrophy and spina bifida who may
experience some perceptual difficulties, TLMs are tools that will help to make sense of what they
are learning. You can use any objects in your surroundings and with your creative and innovative
skills, make effective TLMs relevant to the lesson you are teaching.

Assistive Technology

Assistive technology used for amputees, spinal cord injuries, spina bifida, muscular dystrophy,
polio is any item, piece of equipment, software or product system that is used to increase,
maintain, or improve their functional capabilities. It includes products and services to help with
difficulty in ADL, writing, remembering, learning, typing, walking, etc.

Loss of use of any or all limbs severely affects all areas of daily living. Weakness of hand
causes complex disabilities like impairment in dexterity, hand writing, grasp, hold, pinch and
proprioception. Weakness of lower limbs causes varying degree of difficulty or inability to
walk. Various types of AT can be used including electronic devices, wheel chairs, walkers,
braces, educational software, pencil holders, eye-gaze, and head trackers. Colour-coding
systems (highlighters, pens, coloured paper), colour transparency overlays, stress-ballsrequire
low level technology and are easily available.Common types of software like Speech to text, text
to speech, writing organizers, symbols to text, modified keyboards, adapted mouse (roller ball,

Source: www.astechnz.com http://.joycegodwingrubbs2.wordpress.co

m
trackball, joystick, switch access),wheelchairs
also assist in skill enhancement or replacement. Communication AT would include equipments
like On-screen keyboards, A.A.C. communication devices, voice recognition software.
Appliances like calipers, standing frames and splints etc., may be required to prevent deformity
due to muscle imbalance, stabilize unstable joints affected by the motor weakness, provide relief
from weight bearing, facilitate walkingand maintain a stable posture and gait. Standing frames
allow nonambulatory students to continue to bear weight on their legs, promoting healthier
bones, better circulation and a straighter spine. Transfer boards and mechanical lifts make it
easier and safer to move a nonambulatory student. Walkers, wheelchairs and foot, ankle and leg
braces keep children safely mobile and part of the social scene.Appliances used to prevent or
correct deformities are called orthoses. They are named according to the joints they stabilize.
E.g. for ankle, ankle foot orthosis (AFO). These are used for students with poilio and prevent
deformities.

As the students with Muscular Dystrophy get older, they lose the control on muscles. Here AT
can be low tech like communication boards made of cardboard or high tech such as special
purpose computers. They would also need prosthetics and positioning devices. Special switches,
keyboards, and pointing devices specially for muscular dystrophy and spina bifida where there is
progressive muscular weakness and perceptual difficulties would assist in functional activities.
Assistive equipment and communication
devices allow students with weak speech
muscles to convey their needs and thoughts.
Computer adaptations and software allow
those with limited movement to type and
surf the Internet. Small adaptations help with
everyday tasks: special feeding utensils and
cups, straws, a foam rubber cylinder for
grasping pens and pencils, tape recorders,
etc.

Children with spina bifida will have difficulty with mobility. In lower-level lesions, children are
expected to ambulate to some degree, but acquisition of this mobility is delayed. Therefore,
mobility devices such as manual or power wheelchairs may be used. In addition, students with
spina bifida may have altered sensation, and a number of patients will have
hydrocephalus. They can benefit from a range of equipment, including Orthotics (lower
extremity and possibly trunk), Standing devices (mobile or stationary), Ambulation aids
(crutches, walker, gait-trainer), Wheeled mobility device (ultralightweight manual wheelchair or
power wheelchair), Pressure re-distributing seat cushion to reduce risk of skin breakdown.

Though assistive devices facilitate and enhance the communication, mobility, education and
quality of life of the student there are also many barriers encountered with use of assistive
technology. Many people may lack of access to computers and software at school and home, to
technical aids for leisure time, and to mobility devices. Some may not receive adequate technical
support, information, and training to effectively use assistive technology independently. This
results in a continued need for personal assistance from parents or aides. Cost of maintenance
may also be high.Selection and maintenance of AT needs an integrated consultation with a
multidisciplinary team.

Summary

IEP for the children with polio, amputation, spinal cord injuries, spina bifida and muscular
dystrophy follows the same procedure as for other disabilities. However, the major consideration
is to help the children become independent and self sufficientindaily activities, , to provide basic
academic skills, and prepare the child for acquisition of advanced vocational skill. Teaching
learning material used in fulfilling the educational goals for these children are varied and can be
either 2 dimensional like picture books or flash cards or 3 dimensionals like models and real
objects. Nowadays, with the internet explosion, computers are being used as effective teaching
aids using various academic softwares, interactive interactive sites for teaching and films to
convey a lesson. However, while choosing a teaching aid, the teacher needs to consider the
appropriateness, attractiveness, cost effective and handling ease for children with disabilities.
Complex interactions between physical, functional, psychosocial, and quality-of-life variables all
contribute to technology use.Assistive technology assists the disabled child to maintain or
enhance a particular function of daily activity. Hence, they can be mobility aids like wheelchairs,
walkers, orthosis like calipers or they can be communication aids like computer based
communicators, or adapted keyboards, mouse, joystick or headpointer. All products that enhance
and contribute to making the person independent in daily life activities can be considered to be
assistive technology be it low tech products like communication board and pencil grippers or
high tech product like electronic wheelchairs and sophisticated softwares. The positive benefits
 of enhanced function afforded by assistive technology may not outweigh dissatisfaction with its
appearance, difficulties with maintenance, cost, and other factors.

Questions:

1. Answer briefly:
a. What are the features that should be considered while making an IEP for a child with
muscular dystrophy?
b. How do computerbased TLM assist in teaching a lesson. Explain with example.
c. Assistive technology is helpful in maintaining and enhancing functional abilities. Explain this
statement.
2. True and False
i. Curriculum adaptations are a specific modification that relates to instruction or content of a
curriculum
ii. IEP need not reflect provision of special reading materials, teaching of plus curriculum skills
or use of special assistive devices.
iii. The psychologist/ counselor plays a very important part in the IEP team and needs to be
allotted some sessions with the children.
iv. The children with Spina Bifida would not need sessions on understanding body position and
body image.
v. For children with muscular dystrophy short educational goals are recommended.

Reference:
1. Norris (Mo), Meriel (2001); Rehabilitation Therapy Assistant Manual; Mobility India,
Banglore
2. Kieran, Shari Stokes; Connor, Frances Patridge; Saaz Von Hippel, Caren; Jones Sherry
Harris; (1980); Mainstreaming Preschoolers: Children with Orthopaedic Handicaps; US
Department of Health and Human Services, Washington D. C.
3. http://www.parentprojectmd.org/site/PageServer?pagename=Care_educational_iep_devel
op_components#sthash.BkbQdyFX.dpuf
4. http://www.educateautism.com/
 PAPER B 9
INTRODUCTION TO LOCOMOTOR AND MULTIPLE
DISABILITIES

Unit 3: Multiple disabilities and other disabling conditions

Author
MrsSonaliSaini

1
 3.1 Multiple Disabilities: Meaning and Classification
Objectives-
After going through this chapter you will be able to know and understand:

1. Definition of multiple disabilities

2. Common Characteristics of multiple disabilities
3. Prevalence of Multiple Disabilities
4. Causes and types of Multiple disabilities

Content:

Children who have a combination of severe disabilities are called “Multiply Disabled”. Caring
formultiple and severely disabled children is never easy and they need an enormous amountof time,
patience and love.

DEFINITION OF MULTIPLE DISABILITIES

As per the National Trust Act, “Multiple Disabilities” means a combination of two or more
disabilities asdefined in clause (i) of section 2 of the Persons with Disabilities (Equal Opportunities,
Protectionof Rights and Full Participation) Act, 1995. Disabilities under the National Trust Act are in
fact Developmental Disabilities caused due to insult to the brain and damage to the central nervous
system. These disabilities are Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities.
These are neither diseases nor contagious nor progressive. They cannot be cured by drugs or surgery,
but early detection and training improve outcome. This is done using the services of Physio-
Occupational, Speech Therapists, Community Based Rehabilitation Workers and Special Educators.

The combination of disabilities and degree of severity is different in each child. The time at which
the disability occurs in the child, what is known as the ‘age of onset’, may also range from birth to a
few days after birth, from early childhood till late teens. Sometimes children are born with one
disability but acquire the second or third disabling conditions during childhood. The characteristics
and the needs of the children depend on the nature of combination of the disabilities, the age of onset
and the opportunities that have been available to a child in his environment.

Multiple Disability refers to: a combination of two or more disabling conditions that have a
combined effect on the child’s communication, mobility and performance of day-to-day tasks.

2
Multiple disabilities according to IDEA is concomitant [simultaneous] impairments (such as
intellectual disability-blindness, intellectual disability-orthopedic impairment, etc.), the combination
of which causes such severe educational needs that they cannot be accommodated in a special
education program solely for one of the impairments.

The term multiple disabilities is general and broad. From the term, you can’t tell:

 how many disabilities a child has;

 which disabilities are involved; or
 how severe each disability is.

We can say that just as every child is different, similarly every child with MD is different.

However there are some things that these groups of children have in common.

 It affects the all-round development of the child

 Communication with the world around is most severely affected
 Opportunities to interact with the environment becomes very limited
 Ability to move around in the environment is restricted
 Need regular help in simple day-to-day activities such as wearing a shirt, opening a
door,finding a chair to sit down etc.
 A highly structured educational / rehabilitation program helps in their training.

CHARACTERISTICS OF CHILDREN WITH MULTIPLE DISABILITIES

Children with MD show all or some of the following characteristics:

Vision difficulties: As children grow, some of them appear to always squeeze their eyes togetherto
look at something closely, or keep looking at their moving fingers/paper, bump into things while
walking, complain of too much light all the time. Their eyes may also look different from ‘normal’
eyes.

Hearing difficulties: A child with a hearing problem may respond to only particular sounds.
Theymay take a long time and repeated training to develop speech. And mostly they may only
repeatwhat they hear. They may also learn to adapt to their routine environment by ‘guessing’
theconversations going around, but may actually face a lot of difficulty in a new place with
unknownpeople. Sometimes deaf children also show difficulty in balancing their body or walking in

3
a straight line.

Learning difficulties: Due to the combined loss due to two or more disabilities, the rate and speed
oflearning of the children is very slow. Learning often becomes repetitive and meaningless,
unlessspecial care is taken to make the child feel safe about exploring the world around him.
Multiple disabled children also have very limited ideas to play with toys or things around them.

Communication: Communication is probably the one area that is most significantly affected
inchildren with multiple disabilities. The children are unable to see or hear or follow the
differentways in which their brother and sister play with each other, elders are greeted, standing in a
line to get a ticket or passing a bottle of water around a dining table.

Posture and Mobility: Our sight, hearing and body movements help us to move around,
withoutbumping into things, remember the way to reach places or even to use our own hands to hold
andlook at things. Presence of Cerebral Palsy, locomotor disabilities and balance difficulties makes
ithard for the child to manage his own body movements sometimes and so it becomes very difficultto
use his body to move from one place to another. Similarly a combination of Intellectual disability
and CP or CP and Autism would result in similar postural and mobility difficulties.

Odd Behaviours: Most children with multiple disabilities show strange behaviours that are called
‘self-stimulating’ behaviours. Some of these are moving one’s body repeatedly, shaking head side to
side, moving fingers in front of eyes, hitting or slapping the ears. The children mostly do this due to
lack of anything else to do. Sometimes it is important for them to continue doing it from time to time
as it helps them get some information about the world around them in their own special way.
Sometimes these children also show disturbed sleep patterns.

Medical Conditions: Most multiple disabled children also suffer from other medical conditionssuch
as epilepsy, frequent eye and ear infections, respiratory disorders, muscular degeneration,frequent
surgeries and so on. Such medical conditions lead to frequent hospitalizations and thechild again
misses out on a lot of exposure and learning from the environment.

PREVELANCE:

The percentage of students having severe multiple disabilities is very low.Approximately 0.1 to 1
percent of the general school-age population and approximately 2 percentof the total population of
school age students have severe and multiple disabilities. It is not likelythat more than one student
with severe multiple disabilities would be enrolled in a general classroom at any given time.

4
CAUSES OF MULTIPLE DISABILITIES

There are several factors that cause severe and multiple disabilities & can be divided as follows:

Prenatal causes which include:

 Chromosomal abnormalities
 Viral infections
 Drug and Alcohol use during pregnancy
 Mother’s malnutrition
 Physical trauma to the mother

Perinatal causes which include:

 Lack of oxygen supply to the baby’s brain

 Physical injury to the baby’s brain at birth
 Contracted infections during birth

Postnatal causes which include:

 Childhood infections such as meningitis & encephalitis

 Traumatic brain injury from an accident or abuse
 Lead poisoning
 Reactions to medication
 Exposure to toxins or other environmental conditions

As with other disabilities, the severity and complexity of the disability depends on the
geneticabnormality, the amount of damage to the brain and the environment in which the child is
raised.

TYPES OF MULTIPLE DISABILITIES

Children with multiple disabilities will have a combination of various disabilities that may include:
speech, physical mobility, learning, mental retardation, visual, hearing, brain injury and possibly
others. Along with multiple disabilities, they can also exhibit sensory losses and behaviour and or
social problems. There are many educational implications for these students.
Children with multiple disabilities may constitute a highly diversified group of disabled population,
each often having a combination of two or more obvious and not so obvious disabilities.

5
In spite of the diversity multiple disabilities may, be grouped as below on the basis of their generic or
causative evaluation (Waldraut, Rath, 2001)

1.Coinciding disabilities which are inevitably casually linked: The children may be affected with
such coinciding disabilities in which one disability (the primary disability) may be a natural cause for
the evolution or eruption of another disability (the secondary or consequent disability) e.g. deafness
results in speech disorders, CP may also result in speech, and intellectual difficulties.

2. Coinciding disabilities which are not linked by a causal relationship: The children may be
affected with such coinciding disabilities in which none of these disabilities is a result of the other,
e.g. blindness and deafness, CP and autism or CP and Intellectual disability or deafness and autism.

3.Coinciding disabilities which are not inevitably linked: The children may be affected with such
coinciding disabilities in which one disability may or may not be the result of another. Actually here
very often, it is not easy to conclude about any existing causal relationship between the coinciding
disabilities, e.g. learning disabilities and emotional disturbance or other behavioural disorders.
Cerebral Palsy is itself sometimes considered to be a multiple disability.

Questions:
1. Define Multiple disability.
2. Describe some characteristics present in a child with multiple disability.

Reference:
https://en.wikipedia.org
http://www.who.int

http://www.cdc.gov/
http://www.nlm.nih.gov/medlineplus/medlineplus.html
Mangal, S.K. (2014) Educating Exceptional Children: An Introduction to Special Education. Delhi:
PHI Learning Private Limited.

6
3.2: Various combinations of Multiple Disabilities and Associated conditions such as Epilepsy,
Motor and sensory conditions.

Objective-

After going through this chapter you will be able to know and understand:

1. Definition of Multiple Disabilities

2. Common Combinations of multiple disabilities
3. Cerebral palsy and associated conditions
4. Autism and associated conditions
5. Sensory Impairment and associated conditions

Content:

Multiple disabilities according to IDEA is concomitant [simultaneous] impairments (such as

intellectual disability-blindness, intellectual disability-orthopedic impairment, etc.), the combination
of which causes such severe educational needs that they cannot be accommodated in a special
education program solely for one of the impairments.

The term multiple disabilities is general and broad. From the term, you can’t tell:

 how many disabilities a child has;

 which disabilities are involved; or
 how severe each disability is.

Many combinations of disabilities are possible. For example, one child with multiple disabilities may
have an intellectual disability and deafness. Another child may have cerebral palsy and autism.

Some of the common combinations of multiple disabilities are as follows-

 Cerebral Palsy + Mental Retardation/ Hearing/ Speech/ Visual problems

 Visual Impairment + Hearing Impairment + Intellectual Deficits

 Autism + Intellectual Deficits

7
Cerebral Palsy and associated conditions –

You have already read in detail about cerebral palsy in unit 1. A brief overview of the condition is
presented here. Cerebral palsy is a neurological condition. The cause of cerebral palsy is either brain
injury or brain malformation occurring during fetal development, at birth, or after birth while the
brain is still developing. The actual brain damage does not progress, which differentiates cerebral
palsy from similar conditions. The brain damage occurs in parts of the brain that affect muscle tone,
gross and fine motor functions, balance, control, reflexes, and posture. These are mainly orthopedic
in nature and are considered primary conditions of cerebral palsy.

Primary conditions can lead to secondary conditions. For example, 86 percent of those with
cerebral palsy have oral motor dysfunction, an inability to control facial muscles. Oral motor
dysfunction can result in difficulty in swallowing, breathing, or communicating; these are considered
secondary conditions of cerebral palsy.

Associative conditions (such as intellectual impairment, epileptic seizures, hearing impairment, or

vision impairment) do not result from the same brain injury that caused cerebral palsy, but do occur
frequently in those with the condition. In fact, research shows these conditions occur alongside
cerebral palsy so frequently that parents of children diagnosed with cerebral palsy are advised to
have their child evaluated for associative conditions upon diagnosis.

An individual may also have health conditions, called co-mitigating factors, which co-exist with
cerebral palsy but are unrelated to it. Unlike associative conditions, researchers have not concluded
these conditions have a high correlation with cerebral palsy, but the multidisciplinary treatment team
will take co-mitigating factors into consideration when forming a comprehensive treatment plan for a
child with cerebral palsy.

To explain the terminology further-

Primary condition – These are a direct result of the brain lesion or brain malformation. Primary
conditions affect motor coordination, motor control, muscle tone, posture and balance. Gross motor,
fine motor, and oral motor functioning are also considered primary conditions of cerebral palsy.

8
Secondary condition – Primary conditions, in turn, may lead to secondary conditions such as
inability to chew, inability to swallow, breathing difficulties, bladder and bowel control issues, and
communication difficulties. If the brain lesion or malformation that caused cerebral palsy did not
exist, these secondary conditions would not be present.

Associative conditions – Research has shown that individuals with cerebral palsy often have
associative conditions not caused by the same brain injury or malformation which caused cerebral
palsy, but proven to be common with individuals who have cerebral palsy. If the brain injury or
malformation that caused the cerebral palsy did not occur, these conditions may still be present in the
individual. Associative conditions include intellectual impairment, epileptic seizures, hearing
impairment, and vision impairment.

Co-mitigating factors – An individual may also have health conditions separate from cerebral palsy.
Unlike associative conditions, researchers have not concluded that these conditions have a high
correlation to cerebral palsy. Co-mitigating factors exist regardless of cerebral palsy. Examples of
co-mitigating conditions of cerebral palsy include autism, attention deficit hyperactivity disorder,
and asthma.

Autism and associated conditions:

Autism spectrum disorder (ASD) is a complex developmental disability; signs typically appear
during early childhood and affect a person’s ability to communicate, and interact with others. ASD is
defined by a certain set of behaviors and is a “spectrum condition” that affects individuals differently
and to varying degrees. There is no known single cause of autism, but increased awareness and early
diagnosis/intervention and access to appropriate services/supports lead to significantly improved
outcomes. Some of the behaviors associated with autism include delayed learning of language;
difficulty making eye contact or holding a conversation; difficulty with executive functioning, which
relates to reasoning and planning; narrow, intense interests; poor motor skills’ and sensory
sensitivities.

Autism with Intellectual Impairment-

Approximately 75% of people with autism have a non-verbal Intelligence Quotient (IQ) below 70 -
autism can also occur in individuals of normal, or even superior intelligence.
Autism and Seizures:

9
One in four children with ASD develops seizures, often starting either in early childhood or
adolescence. Seizures, caused by abnormal electrical activity in the brain, can produce a temporary
loss of consciousness (a “blackout”), a body convulsion, unusual movements, or staring spells.
Autism and ADHD-

Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms that include
inattentiveness, hyperactivity and impulsiveness.

Common symptoms of ADHD include:

 a short attention span or being easily distracted

 restlessness, constant fidgeting or overactivity
 being impulsive

The symptoms of attention deficit and hyperactivity disorder (ADHD) create significant problems
for over half of all children with autism.

Autism and Visual Impairment/Hearing Impairment:

Children with poor vision or a hearing loss are more likely to be diagnosed with autism than are
those in the general population, reports a large published epidemiological study.The study, published
in Disability and Health Journal, looked at more than 230,000 children in Atlanta who reached the
age of 8 years between 2000 and 2008. It found that 6 percent of children with hearing problems and
7 percent of those with visual impairments have autism, compared with 1 percent of the general
population.
Autism diagnosis in these children is also complicated by the fact that many diagnostic evaluations
for the disorder rely on visual or hearing cues, such as making eye contact or responding to one's
name
Sensory Impairment and associated conditions:

Sensory Impairment with Intellectual Disabilities:

The prevalence of sensory impairment (visual and hearing) is much greater in adults with intellectual
disability than in the general population. Difficulty in accessing generic services and the deficits
inlanguage and communication skills found in this population make the assessment of
sensoryimpairment a challenge.

10
The prevalence of hearing impairment is at least 40 times higher in people with intellectual disability
compared with the general population.The prevalence of visual impairment is approximately 0.5–2%
in the general population but is at least 8.5 times higher in people with intellectual disability.

Sensory Impairments and different syndromes-

 Down syndrome

Down Syndrome is a congenital condition in which intellectual disability accompanies many typical
facial features and body structure. Structural anomalies of sensory organs (e.g. narrow ear canals,
keratoconus) are common in people with Down syndrome. As a result, sensory impairments may
occur several decades earlier in people with Down syndrome than in the general population.

 Usher syndrome

Usher syndrome is the most common cause of deaf-blindness in adults, causing 5–10% of cases of
congenital hearing loss, 18% of cases of retinitis pigmentosa and over 50% of cases of deaf-
blindness. Usher syndrome causes gradual loss of vision due to progressive retinitis pigmentosa.
Most of the patients had intellectual disability.

 Congenital rubella syndrome

Rubella can cause sensorineural congenital hearing loss, central auditory imperceptions, visual
impairment and developmental delay, all of which may be underdiagnosed in people with intellectual
disability.
Summary:

Multiple disabilities according to IDEA is concomitant [simultaneous] impairments), the

combination of which causes such severe educational needs that they cannot be
accommodated in a special education program solely for one of the impairments.Many
combinations of disabilities are possible. Multiple disabilities will have primary condition
along with associative and/or associative conditions. Cerebral palsy, Autism and Intellectual
disabilities come under multiple disabilities.

Questions-

11
State if the following statements are True or False; justify.

1. The term multiple disabilities indicates how severe the disability is.

2. Cerebral palsy is a neurological condition.

3. Cerebral Palsy is a multiple disability.

4. Children with Autism do not display other associated conditions like epilepsy, ADHD.

5. Children with poor vision or a hearing loss are more likely to be diagnosed with autism than are
those in the general population.

References:
 http://cerebralpalsy.org/
 http://www.parentcenterhub.org/
 https://en.wikipedia.org
 http://www.ninds.nih.gov/
 http://www.miriamfoundation.ca/
 http://www.autism-society.org/
 www.autismspeaks.org
 http://sfari.org/
 http://apt.rcpsych.org/
 http://apt.rcpsych.org/

12
 3.3: Other disabling conditions such as Leprosy cured students, Tuberous Sclerosis and
Multiple Sclerosis.

Objective:

After going through this chapter you will be able to know and understand:

1. Leprosy and its implications

2. Tuberous Sclerosis and its implications
3. Multiple Sclerosis and its implications

Content:

Leprosy is an infectious disease that causes severe, disfiguring skin sores and nerve damage in the
arms and legs.

Leprosy is actually not that contagious. You can catch it only if you come into close and repeated
contact with nose and mouth droplets from someone with untreated leprosy. Children are more likely
to get leprosy than adults.

Leprosy is caused by a slow-growing type of bacteria called Mycobacterium leprae. Leprosy

primarily affects the skin and the nerves outside the brain and spinal cord, called the peripheral
nerves. It may also strike the eyes and the thin tissue lining the inside of the nose.
The main symptom of leprosy is disfiguring skin sores, lumps, or bumps that do not go away after
several weeks or months. The skin sores are pale-colored.

Nerve damage can lead to:

 Loss of feeling in the arms and legs

 Muscle weakness

13
Leprosy can be cured. In the last two decades, 16 million people with leprosy have been cured. The
World Health Organization provides a Multidrug therapy (MDT) treatment free for all people with
leprosy.

Without treatment, leprosy can permanently damage your skin, nerves, arms, legs, feet, and eyes.

Complications of leprosy can include:

 Blindness or glaucoma.
 Disfiguration of the face (including permanent swelling, bumps, and lumps).
 Erectile dysfunction and infertility in men.
 Kidney failure.
 Muscle weakness that leads to claw-like hands or an inability to flex the feet.
 Permanent damage to the inside of the nose, which can lead tonosebleeds and a chronic, stuffy
nose.
 Permanent damage to the nerves outside the brain and spinal cord, including those in the arms,
legs, and feet.
Nerve damage can lead to a dangerous loss of feeling. A person with leprosy-related nerve damage
may not feel pain when the hands, legs, or feet are cut, burned, or otherwise injured.

The implications of leprosy in relation to multiple disabilities -

Variety, multiplicity and worsening are the main features of leprosy-related impairments and
disabilities. They vary widely, and include different degrees of loss of skillful use of the hands due to
muscle paralysis, ulceration, digital shortening and stiffness of fingers, loco-motor disability due to
plantar ulcers, foot-drop, chronic infection of the foot and tarsal disorganization, and ocular
morbidity. A significant proportion of affected persons have multiple body part involvement. Most
commonly, both upper and lower extremities are affected. Impairments are not static; they are often
mild to begin with and worsen in course of time, over a few months to a few years, either on their
own or because of development of secondary impairments. The worsening occurs in spurts, due to
injury, infection or inflammation. Unless disability prevention measures are taken, the worsening is
inevitable, in spite of the cure of the disease, surgical correction of deformities, or vocational
rehabilitation. The presence and a combination of more than one type of impairment results in
leprosy being classified under multiple disabilities.

Tuberous Sclerosis

14
Tuberous sclerosis is a rare genetic disorder that causes benign tumors to grow in the brain as well as
in other vital organs. TSC is caused by a mutation of either of two genes, TSC1 and TSC2. The
aspects of TSC that most strongly impact quality of life are generally associated with the brain:
seizures, developmental delay, intellectual disability and autism.

About 50% of people with TSC have learning difficulties ranging from mild to significant, and
studies have reported that between 25% and 61% of affected individuals meet the diagnostic criteria
for autism, with an even higher proportion showing features of a broader pervasive developmental
disorder. Other conditions, such as ADHD, aggression, behavioral outbursts and OCD can also
occur.

Lower IQ is associated with more brain involvement on MRI.

Due to a range of multiple conditions associated with tuberous sclerosis it clearly has implications
under multiple disabilities affecting various aspects of development and impairments.

Multiple Sclerosis-

Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. It
damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage
slows down or blocks messages between your brain and your body, leading to the symptoms of MS.

They can include-

 Visual disturbances
 Muscle weakness
 Trouble with coordination and balance
 Sensations such as numbness, prickling, or "pins and needles"
 Thinking and memory problems

No one knows what causes MS. It may be an autoimmune disease, which happens when your
immune system attacks healthy cells in your body by mistake. Multiple sclerosis affects women
more than men. It often begins between the ages of 20 and 40. Usually, the disease is mild, but some
people lose the ability to write, speak, or walk. MS can affect an individual’s work, relationships,
sleep, diet and ability to exercise.

Common symptoms include:

15
  Vision problems, including double vision, blurriness, partial color blindness, eye pain, partial
or complete loss of vision in one eye
 Thinking and memory problems
 Fatigue
 Muscle weakness, dizziness or tremor
 Numbness or weakness on one side or the bottom half of your body
 Trouble with coordination and balance
 Loss of bowel or bladder control
 Sensations such as numbness or tingling, "pins and needles"
 Electric-shock sensations caused by moving your head in a certain way

As multiple sclerosis affects sensory a well as motor functioning it can be classified under multiple
disabilities.
There is currently no cure for multiple sclerosis. A combination of medicines, physical, speech and
occupational therapies may help the patient cope with and relieve symptoms, slow the progress of
the disease and maintain a good quality of life.

Summary

Leprosy is an infectious disease that causes severe, disfiguring skin sores and nerve damage in the
arms and legs. Leprosy primarily affects the skin and the nerves outside the brain and spinal cord,
called the peripheral nerves. It may also strike the eyes and the thin tissue lining the inside of the
nose. Leprosy can be cured.

Tuberous sclerosis is a rare genetic disorder that causes benign tumors to grow in the brain as well as
in other vital organs. TSC is caused by a mutation of either of two genes, TSC1 and TSC2.

Multiple sclerosis (MS) is a nervous system disease that affects your brain and spinal cord. Some
people with MS can lose the ability to write, speak, or walk. MS can affect an individual’s work,
relationships, sleep, diet and ability to exercise.

Questions:

Sate if the following statements are True or False; justify.

1. You can catch leprosy it only if you come into close and repeated contact with nose and mouth
droplets from someone with untreated leprosy.

16
2. Tuberous sclerosis is a rare genetic disorder

3. Autism is not associated with Tuberous sclerosis.

4. Leprosy cannot be cured.

5. The causes of Multiple Sclerosis are unknown.

Answer the following questions in brief-

1. What is leprosy?

2. What are some of the symptoms of leprosy, state some of the complications that can occur?

3. What is the cause of Tuberous Sclerosis?

4. What are some of the symptoms of multiple sclerosis?

5. Explain some of the interventions/treatments for leprosy, tuberous sclerosis and multiple sclerosis.

References:

http://www.who.int/en/

http://www.dinf.ne.jp/

https://www.nlm.nih.gov

http://familydoctor.org/

http://psychcentral.com/

http://www.tsalliance.org/

https://en.wikipedia.org

17
3.4 Implications of Functional Limitations for Education and Creating Prosthetic Environment
in School and Home: Seating Arrangements, Positioning and Handling Techniques at Home
and School

Objectives:

After going through this chapter you will be able to know and understand:

 Implications of Functional Limitations for Education

 Creating Prosthetic Environment in School and Home through Seating Arrangements
 Positioning and Handling Techniques at Home and School

Content:

Multiple disabilities present functional limitations in all areas of motor, communication, social,
behaviour and learning. These are manifested in activities of daily living, academic and nonacademic
areas as well as daily routines of the child. Details of functional limitations of children with CP,
muscular dystrophy, spina bifida are discussed in Unit 1 and 2 of this paper and you must have read
about the functional limitations of children with Autism and intellectual disability in other units.
Children with multiple disabilities have a combination of these limitations as per their co existing
conditions. The effect of these limitations on quality of life and activities of life are interactive and
not only additive in education and home environment.

While developing age-appropriate adaptive skills is a challenge for students with multiple disabilities,
their ability to learn can help provide them with some level of independence in a number of life skills
areas.Individuals with severe disabilities and multiple disabilities are highly diverse in both their
abilities and disabilities. What they share is a capacity to learn and a lifelong need for support.

Deficits in motor development can impact independence in self-care areas and can also force

18
limitations on mobility and access to the environment. These deficits may be a result of poor muscle
tone or an unavoidable aspect of the specific condition. Motor coordination involves simple gross
muscular activities like running, dancing, throwing and kicking, walking, crawling, or fine muscular
activities like fastening lace, sewing, buttoning, unbuttoning, stitching, tracing or writing.Multiple
disabilities has an impact on motor coordination and this is visible directly in the routine orage
appropriate motor activities holding a pencil and writing etc. Thesedifficulties are seen despite
average or above average general intellectual abilities in the child.
However, primary conditions like Mental retardation, cerebral palsy, muscular dystrophy, ADDs,
PDDs, sensory impairments and neurological conditions abet the situation. The
developmentalhistory of these cases show delays in motor milestones (such as neck holding, turning
over ,crawling , creeping , sitting, standing , walking and so on ) , their motor co-ordination problems
are
evident in simple tasks. The teacher will need to provide assistant in most tasks like taking the books
or tiffin out of the bag, writing, changing classrooms etc.
Socialisation
Socialization is an active process of learning. Social development occurs as we interactwith one
another and become acquainted with the social world in which we live. This is how we acquire
languageand learn the fundamentals of our culture. It is also when much of our personality takes
shape. Children with multiple disabilities who may have motor difficulties, or communication
difficulties or intellectual difficulties would not be able to interact with their environment optimally
and this shows in their lack of effective social interaction and communication.
Cognitive Development
Multiple disabilities have interactional, rather than additive effects, making instruction and
learningcomplex.The cognitive abilities of individuals with multiple disabilities are challenging to
assess due to their frequent limitations in controlled movement, vision,hearing, communication, or
cooperative behaviour. We need to be careful in assessing the intellectual abilities as sometimes
accurate assessments is not possible due to inability to express appropriately or motor difficulties.

Sensory System

Sensory impairments may also be present in students with multiple disabilities, and knowing the
specifics of their hearing and/or visual impairment is absolutely essential to the development of an
appropriate instructional program. Refer to the specific category sections on these impairments for
more detailed information on the potential impact on learning caused by sensory impairments.

19
Perhaps most importantly, students with multiple disabilities have deficits in the area of
communication, making it difficult for them to communicate their wants, needs, and pains to those
around them. This limitation can be devastating to the emotional and intellectual development of the
child, but can be addressed through the use of assistive technology and augmentative communication
systems.

Learning
Human learning may occur as part of education, personal development, or training. Or it mayoccur
as a result of activities such as play. Play has been approached by several theorists as thefirst form of
learning. Children play, experiment with the world, learn the rules and learn to interact.In fact play is
pivotal for children’s development, since they make meaning of their environmentthrough play. For
children with multiple disabilities, play is not a natural activity due to various reasons like motor
impairments or Autism characteristics. These students may have difficulty attaining and
remembering skills and or transferring these skills from one situation to another. Support is usually
needed beyond the confines of the classroom.

When compared to their peers, most students with severe and multiple disabilities learn more slowly,
forget more readily, and experience problems generalizing skills from situation to situation. These
characteristics are best addressed when educators follow accepted practices. First, education of these
students must start early and continue at some level throughout life. Second, all students typically
need speech and language intervention, while many others will need physical and occupational
therapy. Students with sensory impairments may need interpreters and mobility trainers, while some
with medical needs may require nursing services or supervision. Third, The benefits of integrating
therapy into natural activities is widely accepted over the traditional practice of isolated, or pull-out,
therapy.

Fourth, curriculum for these students tends to be functional in nature, reflecting skills needed in
everyday life across domestic, leisure, school, community, and vocational domains. Students are
taught to make choices, communicate in functional ways (which may include AAC methods such as
signing, use of pictures, etc.), develop useful skills that reduce their dependence on others, and learn
social skills suited to their chronological age.

Emotional Support

20
The following emotional disturbances are usually seen in children with MD
 Disruptive to classroom activity or any activity.
 Impulsive.
 Inattentive, distractible.
 Appears pre-occupied.
 Extreme resistance to change and transitions (familiar to unfamiliar environment).
 Low self esteem.
 Unable to work in groups.
 Engages in self injurious behaviour.
 Has no regard for personal space and belongings.
 Persistently tries to manipulate situations.

Children with multiple disabilities or severe disabilities often have significant needs relating totheir
healthcare, personal care and educational needs. As a teacher, it is important to keep yourmind
focused on the educational aspect of your work with these children. Your job is to TEACH, aswell as
to link in as best you can with therapists, doctors, nursing staff and caregivers who mayprovide
support and care to the child. As such, you need to consider how your teaching practicerelates to the
goals which have been established in the IEP document for each student and worktowards achieving
those goals. Students with multiple disabilities study the Core Curriculum along with their
classmates, with accommodations such as tactile aids, alternate formats, and assistive technology. In
addition, students with blindness or visual impairment will require the Expanded Core Curriculum,
with subjects unique to their needs: Orientation & Mobility skills, social interaction, leisure, and
independence skills.

Activities of Daily Living

The basic activities of daily living consist of these self-care tasks:
 Personal hygiene
 Dressing and undressing
 Eating
 Transferring from bed to chair and back
 Voluntarily urinary control
 Elimination
 Moving around (as opposed to being bedridden).

21
It is difficult for children with MD to fulfill these tasks on their own. Ramps and adaptive toilet
facilities in the school should be made compulsory as well as proper lighting facilities inside the
premises should be provided. There should be barrier free architecture while reaching for the ADL
activities and there should be a caregiver to provide service during the ADL activities. There are
many adaptations needed for ADL for a Child with MD that would have to be used and taught to the
child.

Positioning and Handling

Positioning refers to the use of appropriate body positions. Due to abnormal pull of muscles,children
with cerebral palsy and MD spend a lot of time in abnormal positions. These abnormalpositions can
lead to increased tightness and other contractures and deformities and should beavoided whenever
possible. Proper positioning should be used in all routines throughout the child’sday. Try to
encourage proper positing appropriate to the child’s motor development.
Handling refers to the techniques and methods that are used to move a child or assist a child tomove
as independently as possible from one position to the next. It relates to how the child ispicked up, put
down, carried, held etc through movement transitions (e.g.: laying to sitting). Actually,handling is
not done only with therapist’s hands, but with his/her entire body. Specific handling,lifting and
carrying techniques will vary according to the child’s individual needs. Support can begradually
decreased as the child learns to support himself.
Most of the seating arrangements, positioning and handling techniques have been discussed in detail
in Unit 1 and 2. Same concepts apply to children with multiple disability.
Seating
_ Corner sitting: lap boards to be provided, so that the child can engage in activities
_ Corner stools: Can be used when the child has some amount of head control. It providestrunk
support to the child. Lap boards to be provided.
ModifiedChair for seating of children with CP
 Make sure that, the hips, knees and ankle are at 90 degree angle.
 The feet should always rest on the floor. If not, provide a small foot rest.
 The hips should always be kept apart. This can be done by keeping a roll between the legs.
 Height of the back should depend on the child’s trunk control.
 If the child does not have head control, provide support for that also.
 A lap board should be provided, so that the child can do activities on it.
 If the child bends his trunk to one side while sitting, it will lead to deformities. Trunk blocks

22
 can be added to prevent this.
 If the child is not mobile, wheels can be attached to the chair, so that it will be easier for the
parents to move the child around the house.
Standing
 On a Standing frame. Helps in the reduction of tone throughout the body. Child can also see
what is happening in the class room as well and engage in activities
Positioning a Child with CP/ MD in Class room
When the child does not have adequate head control or trunk control
In prone
 Position the child on a wedge
 Head and neck should be off the wedge
 Child can weight bear on flexed or extended elbows
 Place a roll between the legs
 A small roll can be placed under the chest as well
Positioning a child in prone will help the child to develop head control and some amount of trunk
control.
Side lying
 Place a small roll under the head such that the neck is slightly laterally flexed
 Long roll in front extending from chest to legs
 One leg to be kept on the top of the roll
 Position the child on both sides
Carrying Techniques (Details are given in Unit 1 and 2)
While carrying the child or shifting the child from one position toanother the following techniques
can be used
_ Carry across the teacher’s hips with the child’s hips and kneesbent and knees separate and not over
the shoulders
_ Carrying the child with the child facing forwards, with bent hips and knees and knees separate
_ Using a wheel chair.

Summary:

This chapter explains the effect of functional limitations on education. It also explains the products
and process of creating a prosthetic environment for seating arrangement ,postioning and handling at

23
school and education. Functional limitations result from disabilities and are restrictions in an
individual’s functioning that hinder the ability to perform tasks or activities.

Problems faced by individuals with physical impairments with coexisting sensory or neurological
disability include poor muscle control, weakness and fatigue, difficulty walking, talking, seeing,
speaking, sensing or grasping (due to pain or weakness), difficulty reaching things, and difficulty
doing complex or compound manipulations (push and turn). Cognitive impairments are varied.
Memory problems include difficulty getting information from short-term storage, long term and
remote memory. This includes difficulty recognizing and retrieving information. Perception
problems include difficulty taking in, attending to, and discriminating sensory information.
Language impairments can cause difficulty in comprehension and/or expression of written and/or
spoken language.

Positioning and handling techniques will be mainly applied to children having motor impairments as
one of the disability like in cerebral palsy. Detailed explanation has been provided in unit 1 and 2 for
the same and is applicable to multiple disabled children.

Questions:

1. How does motor impairment in a multiple disabled child affect his learning?
2. Write a short note on sensory imitations.

References:

 http://www.perkinselearning.org/scout/curriculum-students-multiple-disabilities
 SSA Module on Training of Resource Teachers under SSA on Multiple Disabilities
 Severe and Education of individuals With Multiple Disabilities - Definition and Types of
Severe and Multiple Disabilities - Students, Mental, Retardation, and Services -
StateUniversity.com http://education.stateuniversity.com/pages/2415/Severe-Multiple-
Disabilities-Education-individuals-With.html#ixzz3lAnxy7CH

3.5 Facilitating Teaching-Learning: IEP, Developing TLM, Assistive technology

Objective-

After going through this chapter you will be able to know and understand:

24
The importance, content and process of IEP
Curricular Approaches for Children with Multiple Disabilities
Need and types of TLMs for multiple disability
Meaning and types of assistive devices required for Multiple disabilities

Content:
This Unit is divided in three sections-
A] Individualized Educational Plan (IEP)
B] Teaching Learning Materials (TLM)
C] Assistive Technology (AT)

You have already studied about the concept, meaning and process of IEP in Unit 1 and 2. An
overview of the same is presented below with reference to multiple disabilities.
A] Individualized Educational Plan (IEP)
Introduction
An IEP is an Individualized Education Program developed for students with disabilities to ensure
their educational goals are achieved. An Individualized Education Program (IEP) is a required step in
the process of receiving special education services. A student's parents, teachers, and other service
providers meet to come to a consensus about the educational accommodations necessary to assist the
student in meeting the objectives. This group of professionals and parents are known as the IEP
Team.
What is an IEP?
• A summary of the student’s strengths, interests, and needs, and of the expectations for a student’s
learning during a school year that differ from the expectations defined in the appropriate grade level
of the School based curriculum;
• A written plan of action prepared for a student who requires modifications of the regular school
program or accommodations;
• A tool to help teachers monitor and communicate the student’s growth;
• A plan developed, implemented, and monitored by school staff;
• A flexible, working document that can be adjusted as necessary;
• An accountability tool for the student, his or her parents, and everyone who has responsibilities
under the plan for helping the student meet his or her goals and expectations; an ongoing record that
ensures continuity in programming; and
• A document to be used in conjunction with the provincial report card.

25
An IEP is not...?
• A description of everything that will be taught to the student;
• An educational program or set of expectations for all students;
• A means to monitor the effectiveness of teachers; or
• A daily plan.
Important information to be Included in an IEP
 Student’s strengths and needs as recorded on the statement of decision received from
the authorized body
✓ Relevant medical/health information
✓ Relevant formal (standardized) assessment data
✓ Student’s current level of educational achievement in each program area
✓Annual goals and specific expectations for the student
✓ Program modifications (changes to the grade-level expectations in the Ontario curriculum)
✓ Accommodations required (supports or services that will help the student access the
curriculum and demonstrate learning)
✓ Special education and related services provided to the student
✓ Assessment strategies for reviewing the student’s achievements and progress
✓ Regular updates, showing dates, results, and recommendations
✓ Transition plan (if required)

Development of an the IEP

Many factors — physical, intellectual, educational, cultural, emotional, and social — influence a
student’s ability to learn. Understanding these factors can help the IEP team develop statements of
strengths and needs. The student’s strengths can be used to address his or her weaknesses. Writing
goals and expectations provide the student with a focus and motivation for his or her learning and
help teachers develop learning activities that are specific to the strengths, interests, and needs of the
student. The goals set out in the IEP should be based on the strengths and needs of the student. They
constitute the best prediction of what the student should be able to accomplish in a program area by
the end of the school year. Goals for multiple disabled child can be written to address specific
subject areas, such as language arts, mathematics, science, social studies, and fine arts, or skill areas,
such as vocational skills, gross motor development, perceptual motor skills, and social skills.

26
 Examples of goal statements include the following:This student willdisplay appropriate on-task
behaviour during independent work periods; dress himself or herself independently; use correct
spelling, grammar, and punctuation conventions with the support of print and electronic resources.
Strategies and resources for helping the student achieve his or her goals and expectations should be
based on the information gathered and recorded in the IEP.
The strategies and resources section of the IEP should identify the specific accommodations, human
and material resources, and teaching methodologies and strategies required to facilitate the student’s
ability to acquire, store, and retrieve knowledge and skills. It should also indicate the intensity of the
support required, and who is responsible. Monitoring the student’s progress in meeting the
expectations and achieving the goals will be most effective if it occurs on a regular cyclic basis.

Process and Implementing the IEP

I. Share the IEP with the Student, Parents, School Staff, and Other Professionals
Once the IEP is developed, the IEP team should ensure that everyone involved with the student is
aware of its contents. The team should meet with appropriate staff to discuss implementing the
activities described in the IEP, the responsibilities associated with the plan, and monitoring the plan;
and meet with the parents and the student to explain and discuss the contents of the IEP and the
monitoring plan, and to discuss parental involvement in support of the plan.
II. Put the IEP into Practice
Appropriate members of the team should implement the IEP by translating the IEP into daily plans
for learning, considering the student’s individual interests, strengths, needs, and achievement levels.
They should follow the monitoring plan to evaluate the student’s achievements and progress towards
meeting the goals and expectations specified.
III. Continuously Evaluate the Student’s Progress
Aa formal review and update of the IEP should take place at least once every reporting period.
However, team members should continuously monitor, assess, and evaluate the student’s progress to
determine if program and teaching adjustments are necessary.
IV. Adjust Goals, Expectations, and Strategiesas Necessary
If the student is not meeting the expectations and goals, the plan may need to be adjusted.
Template for development of the component of identification of strengths and need inan IEP

27
 Students Name: _________________________________ Age: _______________
School: _________________________________
Monitoring Cycle: __________________________
Please fill the template below based on observations and informal assessment-
Communication-
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Expectations with accommodations/modifications (Grade level):
Motor and Perceptual Skills:
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Independence in Daily living skills:
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Oral Language:
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Reading:
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Math:
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Comprehension:
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Behavior:
The student demonstrates a significant strength in:
The student requires significant instruction/support to:
Support:

Sample of IEP Goals

28
Annual Goal: The child will enhance his English Language Skills
Objective: At the end of 12 hours,Jatin will be able to accurately identify at least 80 words out of
100 words taught.
1 session = 1 hour

Curricular Approaches for Children with Multiple Disabilities

The Functional Curriculum
According to Erin (1995) the most important skills for children with Multiple disabilities to learn are
functional skills. These are the skills that enable such children to do ordinary daily activities and
functions. These may be as simple as grasping a spoon or as complex as travelling to a new job
independently. It also includes functional academics. Some children who are not intellectually can be
taught grade level academics with adaptations and modifications while others may need a modified
curriculum.

Content Task Analysis Duration Method Material Evaluatio Remarks

n
Dolch Sight The child will be 12 hours VAKT Flash Oral via Revision
words. able to 2 hrs each in method, Cards, 4 game in every
Example: 1. Match the June 2015, July Drill books of third
and, big, word ‘and’ 2015, and1hour and 25 words session
blue, can, with the flash each in August practice each followed
come card 2015, September by
2. Discriminate 2015, October evaluation
the words 2015, November
from other 2015, December
words 2015, January
3. Repeat steps 1 2016, February
and 2 for all 2016, March
the other 2016
words
4. Read the word

29
Environmental/physical accommodations/modifications in arrangement of the classroom
 Providing preferential seating
 Altering physical arrangement of classroom
 Reducing distractions
 Providing quiet corner/room
 Modifying equipment
 Adapting writing assignments
 Allowing use of study carrel
 Providing assistance in maintaining uncluttered space
 Providing space for movement or breaks.

Evaluation-Accommodations
 Allowing answers to be dictated
 Allowing frequent rest breaks
 Allowing additional time
 Allowing oral testing/using sign language
 Giving no timed tests
 Giving choice of test (multiple-choice, essay, true-false)
 Accepting short answers
 Allowing open book or open note tests
 Shortening test
 Reading test to student
 Providing study guide prior to test
 Highlighting key directions
 Giving test in alternative site
 Allowing calculator, word processor.
For children with multiple disabilities, their functional limitations and the interactive effect of the
disabling conditions will determine the development of the IEP. However the components of IEP and
the process of development will remain the same.

B] Developing Teaching Learning Materials (TLM)

30
Definition:
In the field of Education, TLM is a commonly used acronym that stands for "teaching/learning
materials." Broadly, the term refers to a spectrum of educational materials that teachers use in the
classroom to support specific learning objectives, as set out in lesson plans.

Students tend to learn better when they are interested which can be achieved through the use of
through different teaching aids. Multisensory TLM’s are more effective. Teaching aids also aid in
experiencial learning leading to better understanding and retention.

Areas where TLM can help-

 Language & Communication
 Sensory development
 Orientation & Mobility training
 Cognitive & Social skills
 ADL
 Subject/topic teaching
The choice of TLM for multiple disability involves as many 3D concrete objects as possible. Also all
TLMs that are simple, reduce or break learning material to simple tasks or learning units and are
interactive are applicable to children with multiple disabilities.
Examples:
 story books
 manipulative learning toys and material
 blocks
 videos
 games
 flashcards
 model clay
 overhead projector transparencies

Selection of TLM

 TLM have to be carefully selected as per the age and combination ofdisability of the children

 TLM can be ready made charts, flashcards or models which are relevant to the lesson.

31
 TLM should follow all safety standards like not using sharp or pointed objects, use of non toxic
paints etc.

 Subjects also determine the use of TLM’s E.g Geography can be best taught with globes, maps,
models etc. Science can be taught through internet, models, experiments etc.

Types of Teaching Aids

There are many aids available these days.

We may classify these aids as follows-

1) Visual Aids- Eg. Charts, flash cards
2) Audio Aids- Audio stories, noice makers, voice recordings
3) Audio - Visual Aids- Films, videos, video games
4) Tactual aids- 3-d/tactual maps, diagrams, textures
5) Multisensory aids- Talking and touching books, manipulates

Audio Visual Aid

Visual Aid

Audio Aid

Multisensory Aids

Tactual Aid

32
C] Assistive Technology (AT)

There are two types of Assistive technology:

Assistive
technology

Assistive Assistive
Technology Technology
Device Service

You must have read in other units about the various assistive devices that are used by children with
CP, Intellectual Disability and Autism. This section would again review some devices that make the
child functionally independent.

Assistive technology devicesare any item, piece of equipment or product system, whether acquired
commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve
the functional capabilities of children with disabilities.
The term does not include a medical device that is surgically implanted, or the replacement of such
device. Assistive technology is any tool or device that a student with a disability uses to perform a
task that he or she could not otherwise do or any tool the student uses to do a task more easily, faster,
or in a better way. It may be a simple “low tech” device such as a pencil grip or an expensive “high
tech” device such as an iPad.
Academic and Learning Aids: Electronic and non-electronic aids such as calculators, spell
checkers, portable word processors, and computer-based software solutions that are used by students
who has difficulty achieving in the educational curriculum
Aids for Daily Living: Self-help aids for use in activities such as eating, bathing, cooking, dressing,
toileting, and home maintenance
Assistive Listening Devices and Environmental Aids: Electronic and non-electronic aids such as
amplification devices, closed captioning systems, and environmental alert systems that assist
students who are hard of hearing or deaf with accessing information that is typically presented
through an auditory modality

33
Augmentative Communication: Electronic and non-electronic devices and software solutions that
provide a means for expressive and receptive communication for students with limited speech and
language
Computer Access and Instruction: Input and output devices, alternative access aids, modified or
alternative keyboards, switches, special software, and other devices and software solutions that
enable students with a disabilities to use the classroom computer
Environmental Control: Electronic and non-electronic aids such as switches, environmental control
units, and adapted appliances that are used by students with physical disabilities to increase their
independence across all areas of the curriculum
Mobility Aids: Electronic and non-electronic aids such as wheelchairs (manual and electronic),
walkers, scooters that are used to increase personal mobility
Pre-vocational and Vocational Aids: Electronic and non-electronic aids such as picture-based task
analysis sheets, adapted knobs, and adapted timers and watches that are used to assist students in
completing pre-vocational and vocational tasks
Recreation and Leisure Aids: Electronic and non-electronic aids such as adapted books, switch
adapted toys, and leisure computer-based software applications that are used by students with
disabilities to increase participation and independence in recreation and leisure activities
Seating and Positioning: Adaptive seating systems and positioning devices that provide students
with optimal positioning to enhance participation and access to the curriculum
Visual Aids: Electronic and non-electronic aids such as magnifiers, talking calculators, Braille
writers, adapted tape players, screen reading software applications for the computer, and Braille
note-taking devices that assist students with visual impairments or blindness in accessing and
producing information that is typically present in a visual (print) modality
The following devices are used for individuals with multiple disabilities with physical
impairments-
Adapted Furniture:Adapted chair, CP chair, corner stools, lapboards and standing frame.
Non-computer assistive technologies Computer assistive technologies

 Portable CCTV system  Virtual Magnifying glass

 GPS system w/ audio voice  audio playback
 Intelligent gesture pendant to control  On-screen keyboards
objects within a household e.g. lights,  Eye-gazers cameras
doors, alarm system  Voice recognition software
 Smart Wheelchairs  Memory & Brain games
 Intelligent walkers
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Mobility Aids
Mobility aids are appliances used to help people who have difficulty in walking. They enable some
of the body weight to be supported by the upper limbs.
1. Scooters
a. Prone scooters
Require the use of the arms and the ability to lift the head while moving

b. Caster carts
Offer children with upper-extremity function, such as those with spina bifida,another means of
mobility

c. Mobile stander
When the child has upper-extremity function to push and maneuver wheels.
These devices allow for lower extremity weight bearing in a standing position.
Indoor mobility is achieved using large hand held wheels for self- propulsion

e. Parallel bars
Parallel bars are used when the patient is unstable, or to correct a gait
pattern. They are rigid and support the child right through the length of
the bars.

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e. Walkers
Children who have the ability to pull to a standing position and maintain a
grip may be ableto use a hand held walker. These walkers are designed for
use either in front of or behind the child. One disadvantage is that it is
difficult to climb stairs with the help of a walker.

f. Crutches
Crutches are used to give additional support where strength is inadequate and
balance is imperfect. The three basic types of crutches are auxiliary crutches,
elbow crutches and gutter crutches.

g. Wheel chairs

Wheel chairs are either manual or powered. Manual wheel chairs

depend on the user or an assistant for propulsion whereas
powered devices depend on a motorized unit that the individual
accesses using a switch or a joystick.

Orthosis
An orthosis is a mechanical device fitted to the body to maintain it in an anatomical or functional
position.Purposes of orthosis is to
 Support a painful joint
 Immobilize for healing
 Protect tissues
 Provide stability
 Restrict unwanted motion
 Restore mobility
 Substitute for weak or absent muscles
 Prevent contractures
 Modify tone
Various types of orthosis are:
- Callipers
Lower limb orthoses are called as callipers. Various types of callipers are as follows:

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1. Foot orthosis: modifications made in the foot wear. Usual modifications are medial arch
support for a flat foot and heel elevation for limb length discrepancy.
Ankle- Foot Orthosis (AFO)
AFO is prescribed for-
 Muscle weakness affecting the ankle
 Prevention or correction of deformities of the foot and ankle
 Reduction of inappropriate weight bearing forces

Knee- Ankle- Foot Orthosis (KAFO)

It provides stability to knee, ankle and foot. Used when the child walks with
bent knees

Hip- Knee- Ankle- Foot Orthosis (HKAFO)

The HKAFO is prescribed whenever the muscles controlling the hip and
its stability are strained or weak. It provides support to the hip in addition to knee, ankle
and foot.

- Splints
An upper limb orthosis is called as a splint. Children who have one or more of the following
problems may benefit most :
- Sustained abnormal posturing
 Increased tone
 Limited movement of the hand
 Limitations in functional skills secondary to problems with hand functions.

Splints can be static or dynamic. Static splints have no moving parts, prevent motion and are used to
rest or rigidly support the splinted part. Dynamic splints have moving parts to
permit, control or restore movement.

Some common types of splints used in children with MD are as follows:

Cock-up splint
Immobilizes or stabilizes wrist in extension with volar or dorsal support.

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Opponens splint
Used when the child cannot bring his thumb out and against other fingers.

Resting hand splints

Keeps the forearm, wrist, thumb and fingers in functional
position.Worn during night and rest to reduce tone and to prevent
deformity.

Other assistive devices to help in ADL:

Commode Chair or Toilet Stool
Commode chair or toilet stool is needed for a child who cannot squat and use Indian toilets. It can be
made by cutting a hole over the seat of a plastic chair for children. Other options are to place a tyre
over the toilet on which the child can sit comfortably.
Other modifications in the toilet
 Side bars near the toilet will help a child with poor sitting balance to maintain his balance.
 Hose pipe for a child who cannot hold a mug with water and clean himself.

Each student’s IEP team should consider the student’s need for assistive technology devices and
services and any required assistive technology should be addressed in the student’s IEP and provided
to a student in a timely manner.

Questions:
1. Ennumerate the processes for development of an IEP for child with multiple disability with
an example.
2. Name some of the assistive devices and their use.
3. What kind of TLM would help child with multiple disability?

References:
http://study.com
https://www.edu.gov.on.ca
www.education.com
www.nasdse.org

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www.uk.sagepub.com
www.indiastudychannel.com
www.teachersofindia.org

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