Lecture 3

1. Lecture 3 Impairments and Cen Guide 6

2. The levels of disability linked to three different levels of intervention.

3. Impairments • Sensory impairments • Physical impairments • Developmental impairments • Cognitive impairments • Learning impairments • Mental Health impairments

4. National Disability Survey

5. Prevalence of each type of disability

6. Visual Impairments • Visual impairment represents a continuum, from people with very poor vision, to people who can see light but no shapes, to people who have no perception of light at all. • For general discussion it is useful to think of this population as representing two broad groups: those with low vision and those who are legally blind. • About 51,000 have impaired vision About 1.2% of the population • 21,000 “a lot of difficulty”, 2,300 cannot see at all • There are an estimated 8.6 million people with visual impairments (3.4% of the U.S. population). • In the elderly population the percentage of persons with visual impairments is very high.

7. Visual Impairments • A person is termed legally blind when their visual acuity (sharpness of vision) is 20/200 or worse after correction, or when their field of vision is less than 20 degrees; in the best eye after correction. • Low vision includes problems (after correction) such as dimness of vision, haziness, film over the eye, foggy vision, extreme near- or farsightedness, distortion of vision, spots before the eyes, colour distortions, visual field defects, tunnel vision, no peripheral vision, abnormal sensitivity to light or glare, and night blindness. • There are approximately 1.8 million people in the U.S. with severe visual impairments who are not legally blind.

8. Visual Impairments • Some of the more common difficulties a person with sight loss may experience include: • Judging the position and depth of steps • Reading standard print • Seeing the time on their watch • Using the telephone • Identifying money • Carrying out everyday routine tasks at home such as writing a shopping list • Crossing the road during the day or at night • Recognising faces

9. Visual Impairments • Many diseases causing severe visual impairments are common in those who are aging (glaucoma, cataracts, macular degeneration, and diabetic retinopathy). • With current demographic trends toward a larger proportion of elderly, the incidence of visual impairments will certainly increase

10. Causes of Sight Loss Causes of Sight Loss • A person with sight loss is seeing much less or may see nothing at all. • Different eye conditions create different difficulties. • Very few people are totally blind. A few have perception of light only; some have a loss of vision in the centre of their eye, others have no side vision. Some see everything as a blur while others have blank spots. • Some people with sight loss have enough vision to read but may have difficulty with night vision. Don’t assume that a person, who has enough vision to do one thing, can see enough to do everything. • In Ireland, some of the most common eye conditions are macular degeneration, glaucoma, detached retina, diabetic retinopathy and cataracts.

11. Macular degeneration This condition causes a loss of vision in the centre of the eye. Reading, writing and up-close work can become difficult. Sometimes the person may experience a problem with recognising colours. Daylight vision may be affected so increased lighting may be required. The person may have some side vision so they usually will be able to see to move about. It is a more common cause of sight loss among older people.

12. Glaucoma A person with glaucoma may experience loss of side vision. • Early onset glaucoma causes a subtle loss of contrast, for example, difficulties with seeing steps on a stairs or the herb on the pavement. • For a person with advanced glaucoma, moving around can be difficult, especially at night when vision is more reduced. • There may be a small central area where the person can still see to read and do up close work but side vision has been lost. This is also called tunnel vision. • You are more at risk of developing glaucoma if a member of your family has this condition, or if you are shortsighted or if you are of African or Asian origin.

13. Detached Retina • Detached retina will result in a loss of vision where the retina has been damaged. A person’s retina may detach for many reasons. • Retinal detachment is more common among middle aged people and short sighted people. • Detached retina may appear like a dark shadow over part of the eye or the person may experience bright flashes of light or showers of dark spots called floaters. • In many cases, the damage can be repaired.

14. Diabetic Retinopathy • This condition causes a partial blurring of vision or patchy loss of vision. Near vision may reduce and a person may have difficulty with up close reading. Vision levels may vary on a daily basis. • Diabetic retinopathy is a complication of advanced diabetes. Not all people with diabetes will develop this condition. • Damage to the back of the eye can often be repaired if detected at an early stage.

15. Cataracts • Cataracts make things look blurred and misty. Some people may have double vision. • As a cataract develops its centre becomes more and more yellow, giving everything the person sees a yellowish tinge. • Colours may become dulled and the person may see little detail. People with cataracts can be very sensitive to light and glare, light scatters and produces a ‘halo’. • Bright light or very sunny days can dazzle the person while too little light can make it difficult to see

16. Hearing impairment • Hearing impairment means any degree and type of auditory disorder, while deafness means an extreme inability to discriminate conversational speech through the ear. Deaf people, then, are those who cannot use their hearing for communication. • People with a lesser degree of hearing impairment are called hard of hearing. Usually, a person is considered deaf when sound must reach at least 90 decibels (5 to 10 times louder than normal speech) to be heard, and even amplified speech cannot be understood

17. National Disability Survey • About 58,000 with hearing impairments • About 1.4% of population • 21,000 “ a lot of difficulty”, 1,800 can’t hear • About 95% of onset is in adulthood, at older ages

18. Hearing impairments Hearing impairments can be found in all age groups, but loss of hearing acuity is part of the natural aging process. 23% of those aged 65 to 74 have hearing impairments, while almost 40% over age 75 have hearing impairments. The number of individuals with hearing impairments will increase with the increasing age of the population and the increase in the severity of noise exposure.

20. Hearing impairments • Hearing impairment may be sensorineural or conductive. Sensorineuralhearing loss involves damage to the auditory pathways within the central nervous system, beginning with the cochlea and auditory nerve, and including the brain stem and cerebral cortex (this prevents or disrupts interpretation of the auditory signal). • Conductive hearing loss is damage to the outer or middle ear which interferes with sound waves reaching the cochlea. Causes include heredity, infections, tumors, accidents and aging (presbycusis, or "old hearing")9

21. Ear

22. Conductive hearing loss Cholesteatoma (noncancerous tumour in the middle ear caused by an ear infection) Chronic middle ear fluid (otitis media with effusion) Middle ear infection (otitis media) Obstruction of external ear canal (for example, with wax, a tumour, or pus from an infection) Otosclerosis (bony overgrowth of the ossicles) Perforated eardrum Sensorineural hearing loss Aging Brain tumors Certain drugs Childhood infections (mumps, meningitis) Congenital infection (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis) Congenital abnormality Demyelinating diseases (diseases that destroy the myelin sheath covering nerves) Genetic Loud noise Meniere's disease Sudden pressure changes caused by flying, diving, and strenuous exercise Viral infection of the inner ear (labyrinthitis) Causes of Hearing Loss

23. What Is a Cochlear Implant? • A cochlear implant is a surgically implanted device that helps overcome problems in the inner ear, or cochlea. The cochlea is a snail-shaped, curled tube located in the area of the ear where nerves are contained. • Its function is to gather electrical signals from sound vibrations and transmit them to your auditory nerve (or hearing nerve). The hearing nerve then sends these signals to the brain, where they're translated into recognizable sounds.

25. Measurement of Loudness • Loudness is measured on a logarithmic scale. This means that an increase of 10 decibels (dB) represents a 10-fold increase in sound intensity and a doubling of the perceived loudness. Thus, 20 dB is 100 times the intensity of 0 dB and seems 4 times as loud; 30 dB is 1,000 times the intensity of 0 dB and seems 8 times as loud.

26. DecibelsExample 0 Faintest sound heard by human ear 30 Whisper, quiet library 60 Normal conversation, sewing machine, typewriter 90 Lawnmower, shop tools, truck traffic (8 hours per day is the maximum exposure without protection) 100 Chainsaw, pneumatic drill, snowmobile (2 hours per day is the maximum exposure without protection) 115 Sandblasting, loud rock concert, automobile horn (15 minutes per day is the maximum exposure without protection) 140 Gun shot, jet engine (noise causes pain, and even brief exposure injures unprotected ears; injury may occur even with hearing protectors) 180 Rocket launching pad

27. Hearing Devices

28. Physical Impairments • Problems faced by individuals with physical impairments 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). • Individuals with spinal cord injuries may be unable to use their limbs and may use "mouthsticks" for most manipulations. • Twisting motions may be difficult or impossible for people with many types of physical disabilities (including cerebral palsy, spinal cord injury, arthritis, multiple sclerosis, muscular dystrophy, etc.).

29. National Disability Survey • 160,000 have walking difficulties • 83,000 use walking aids • 31,000 use wheelchairs • 160,000 can’t walk for 15 minutes • About 80,000, nearly 2% of the population, have problems using hands or fingers • About half of these are aged over 65 • About 31,000 have a lot of difficulty and about 14,000 can’t use their hands at all • Practical difficulties in everyday activities like cooking, dressing, writing, opening doors, turning taps

30. Nature and Causes of Physical Impairments • Neuromuscular impairments include: • paralysis (total lack of muscular control in part or most of the body), • weakness (paresis; lack of muscle strength, or pain), and • interference with control, via spasticity (where muscles are tense and contracted), • ataxia (problems in accuracy of motor programming and coordination), and • athetosis (extra, involuntary, uncontrolled and purposeless motion). • http://www.neuromuscular-disease.com/neuromuscular-disorders/ • Skeletal impairments include joint movement limitations (either mechanical or due to pain), small limbs, missing limbs, or abnormal trunk size.

31. Physical Impairments • A major causes of these impairments are: • Arthritis. Arthritis is defined as pain in joints, usually reducing range of motion and causing weakness. • Rheumatoid arthritis is a chronic syndrome. Osteoarthritis is a degenerative joint disease. 31.6 million people in the U.S. suffer from rheumatic disease. • The incidence of all forms of arthritis is now estimated at 900,000 new cases per year

32. Cerebral Palsy (CP). • Cerebral palsy is defined as damage to the motor areas of the brain prior to brain maturity (most cases of CP occur before, during or shortly following birth). • CP is a type of injury, not a disease (although it can be caused by a disease), and does not get worse over time; it is also not "curable." Some causes of cerebral palsy are high temperature, lack of oxygen, and injury to the head. • The most common types are: (1) spastic, where the individual moves stiffly and with difficulty, (2) ataxic, characterized by a disturbed sense of balance and depth perception, and (3) athetoid, characterized by involuntary, uncontrolled motion. • Most cases are combinations of the three types

33. Neurological disorder • A neurological disorder is a disorder that involves the nervous system, by definition. A neurological disorder can be caused by either a disease, such as multiple sclerosis, or a trauma or injury to the nervous system. Neurological disorders can be remarkably difficult to treat and are often debilitating

34. Symptoms of neurological disorders can include the slow loss of coordination, balance, or ability to speak clearly. Often symptoms start with a mild and intermittent twitching or numbness in one extremity. Tremors, rigid muscles, slowed motion, difficulty swallowing, loss of automatic movements such as blinking, swinging the arms, and unconscious acts, and eventually dementia.

35. Diagnosing some neurological disorders may very well depend on symptoms evaluation alone. Parkinson’s for example, has no definitive test and is more likely to be diagnosed through physical examination well after the initial onset of symptoms.

36. Acquired Neurological Conditions • Motor Neurone Disease • Parkinson’s Disease • Multiple Sclerosis • Spinal Cord Injury • Stroke • Traumatic Brain Injury • Head & Neck Cancer

37. Spinal Cord Injury . Spinal cord injury can result in paralysis or paresis (weakening). The extent of paralysis/paresis and the parts of the body effected are determined by how high or low on the spine the damage occurs and the type of damage to the cord. • Quadriplegia involves all four limbs and is caused by injury to the cervical (upper) region of the spine; • paraplegia involves only the lower extremities and occurs where injury was below the level of the first thoracic vertebra (mid-lower back). • In the US, 47% of spinal cord injuries result in paraplegia; 53% in quadriplegia. Car accidents are the most frequent cause (38%), followed by falls and jumps (16%) and gunshot wounds (13%).

38. Spinal Cord

39. Levels of Injury in SCI • Cervical SCI's usually cause loss of function in the arms and legs, resulting in quadriplegia. • The first thoracic vertebra, T-1, is the vertebra where the top rib attaches. Injuries in the thoracic region usually affect the chest and the legs and result in paraplegia. • The vertebra in the lower back between the thoracic vertebra, where the ribs attach, and the pelvis (hip bone), are the Lumbar Vertebra. The sacral vertebra run from the Pelvis to the end of the spinal column. Generally result in some loss of functioning in the hips and legs. Paraplegia • http://www.spinalinjury.net/html/_spinal_cord_101.html

40. Specific Loss of Body Functions • Injuries above the C-4 level may require a ventilator for the person to breathe. • C-5 injuries often result in shoulder and biceps control, but no control at the wrist or hand. • C-6 injuries generally yield wrist control, but no hand function. • Individuals with C-7 and T-1 injuries can straighten their arms but still may have dexterity problems with the hand and fingers. Injuries at the thoracic level and below result in paraplegia, with the hands not affected. At T-1 to T-8 there is most often control of the hands, but poor trunk control as the result of lack of abdominal muscle control.

41. Specific Loss of Body Functions • Lower T-injuries (T-9 to T-12) allow good truck control and good abdominal muscle control. Sitting balance is very good. • Lumbar and Sacral injuries yield decreasing control of the hip flexors and legs. • Besides a loss of sensation or motor functioning, individuals with SCI also experience other changes. E.g., they may experience dysfunction of the bowel and bladder,. Sexual functioning is frequently with SCI may have their fertility affected, while women's fertility is generally not affected. • Very high injuries (C-1, C-2) can result in a loss of many involuntary functions including the ability to breathe, necessitating breathing aids such as mechanical ventilators. Other effects low blood pressure, inability to regulate blood pressure effectively, reduced control of body temperature, inability to sweat below the level of injury, and chronic pain

42. National Disability Survey • About 153,000 people experience chronic pain • About 3.6% of population • Fairly common among those of working age • About 78,000 experience a lot of or extreme difficulties in performing normal, everyday activities

43. Head Injury (cerebral trauma). • The term "head injury" is used to describe a wide array of injuries, including concussion, brain stem injury, closed head injury, cerebral haemorrhage, depressed skull fracture, foreign object, anoxia, and post-operative infections. • Like spinal cord injuries, head injury and also stroke often results in paralysis and paresis (partial), but there can be a variety of other effects as well. • Currently about one million Americans (1 in 250) suffer from effects of head injuries, and 400,000 - 600,000 people sustain a head injury each year. However, many of these are not permanently or severely disabled

44. http://www.emedicinehealth.com/head_injury/article_em.htm#overviewhttp://www.emedicinehealth.com/head_injury/article_em.htm#overview

45. US figures re Head Injuries

46. National Disability Survey Memory/Concentration • 113,000 people, about 2.7% of population • About 55,000 have moderate difficulty • Difficulties include: • remembering important things • concentrating for ten minutes • performing normal daily activities

47. Stroke (cerebral vascular accident; CVA). • The three main causes of stroke are: thrombosis (blood clot in a blood vessel blocks blood flow past that point), haemorrhage (resulting in bleeding into the brain tissue; associated with high blood pressure or rupture of an aneurysm), and embolism (a large clot breaks off and blocks an artery). • The response of brain tissue to injury is similar whether the injury results from direct trauma (as above) or from stroke. In either case, function in the area of the brain affected either stops altogether or is impaired

48. What are the risk factors of stroke? • high blood pressure • diabetes • heart disease • cigarette smoking • history of transient ischemic attacks (TIAs) • history of cerebrovascular accident (CVA) • high red blood cell count • high blood cholesterol and lipids • lack of exercise, physical inactivity • obesity • excessive alcohol use • drug abuse (certain kinds) • abnormal heart rhythm • cardiac structural abnormalities • age • race • history of prior stroke • heredity/genetics • where a person lives • temperature, season, and climate • socioeconomic factors

49. MD and MND • Motor Neuron disease (MND) is a fatal degenerative disease of the central nervous system characterized by slowly progressive paralysis of the voluntary muscles. • The major symptom is progressive muscle weakness involving the limbs, trunk, breathing muscles, throat and tongue, leading to partial paralysis and severe speech difficulties. • This is not a rare disease (5 cases per 100,000). It strikes mostly those between age 30 and 60, and men three times as often as women. Duration from onset to death is about 1 to 10 years (average 4 years). • Muscular Dystrophy (MD). Muscular dystrophy is a group of hereditary diseases causing progressive muscular weakness, loss of muscular control, contractions and difficulty in walking, breathing, reaching, and use of hands involving strength. About 4 cases in 100,000 are reported

50. Motor Neurone Disease (MND) • Degenerative disease involving motor neurones of the brain and spinal cord • 75% of people are unable to speak by the time of their death • 14-39% of patients survive for 5 years from first symptoms, 10% for 10 years. • Patients who present with bulbar symptoms (speech, swallowing) have rapid progression with average 2.2 years survival rate from first symptoms