Motor Disorders in Childhood - General Practice Specialty
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Transcript Motor Disorders in Childhood - General Practice Specialty
Dr Valerie Orr
Consultant in Paediatric Neurodisability
RHSC, Yorkhill
Objectives
To be able to identify abnormal motor development
To develop understanding of common motor disorders
Does early detection matter?
Parents value early diagnosis
Improved outcome
Improved quality of life for child and family
Access to educational and social services
‘Early detection is of little value unless parents subsequently
experience a well-organised service with a clear referral
pathway to definitive diagnosis and management’
Ref: Health for all Children 4th Edition (Hall 4)
How do we identify children with abnormal
development?
Follow-up of ‘high risk’
infants
Screening
Listening to parents
Opportunistic
recognition
Ref. Hall 4
Gross motor milestones – when to refer
Head control
4 months
Sits unsupported
9 months
Stands independently 12 months
Walks independently 18 months
*Remember to adjust for prematurity until 2yrs
Features that may suggest underlying motor
disorder
Delayed motor milestones
Asymmetrical movement patterns
Abnormalities of muscle tone
Persisting primitive reflexes
Other difficulties
e.g.
feeding difficulties
unexplained irritability
respiratory problems
Worrying signs / Red flags
Not reaching & grasping objects by 6 months
Hand preference before 1 year
Hypertonicity
e.g. closed hand posture, extensor posturing, scissoring
Hypotonia
Loss of previously acquired motor skills at any age
Floppy infant – assessment
History
Pregnancy and birth
Feeding
Development
Examination
Weight & OFC ?thriving
Facial features ?dysmorphism
Movement ?antigravity mvts
Floppy infant - causes
Prematurity, illness & drugs - transient hypotonia
‘Benign congenital hypotonia’
Global developmental delay
Evolving cerebral palsy
Genetic syndromes
e.g. Downs, Prader-Willi syndrome
Neuromuscular problems (rare!)
e.g. congenital myotonic dystrophy,
spinal muscular atrophy
Clinical scenario
A mother brings her 18mth old son to the
surgery with a minor illness. She mentions that
she is concerned that he is not yet walking.
What particular points would you look for in the
history and examination?
What action might you take?
Delayed walking (>18mths)
Normal variants
Associated with bottom shuffling
Cerebral palsy or minor neurological problems <10%
Consider CK in boys
Toe walking
Causes
Idiopathic toe walking
Muscle spasticity
e.g. cerebral palsy, spinal cord lesion
Muscle disease
e.g. Duchenne muscular dystrophy, Charcot Marie Tooth
Treatments depend on cause
e.g. physiotherapy, casting, orthotics, surgery
Cerebral Palsy: a multi-system disorder
Description not diagnosis!
Primarily a motor disorder
Other impairments often associated
Vision
Cognition
Hearing
Feeding
Manual dexterity
Seizures
Speech & language
Behaviour problems
Aetiology of cerebral palsy
Incidence ~2 per 1000 live births
Antenatal ~70%
e.g. prematurity, fetal & neonatal stroke, brain
malformations, maternal infection
Perinatal 10-15%
e.g. neonatal encephalopathy
Postneonatal events ~15%
e.g. trauma, meningoencephalitis, stroke
Cerebral Palsy: Interventions
Aims
Maximise potential
Prevention of secondary
dysfunction
Promotion of improved function
and participation in society
Examples of tone management
Orthotics
Botulinum toxin
Oral medications e.g. Baclofen
Intrathecal baclofen
Orthopaedic surgery
Duchenne Muscular Dystrophy
X-linked disorder
High rate of new mutations
Incidence 1 in 3500 male live births
Mutation of dystrophin gene Xp21
8-10% of female carriers have some manifestations of
disease
Loss of ambulation at mean age of 9yrs
Average life expectancy now mid-20s
Duchenne muscular dystrophy: Diagnosis
Check CK in boys:
not walking by 18 months
4-6 months behind in general development at 2
years
awkward or clumsy gait under 4 years
unable to run or jump by 4 years
painful hips or legs under 4 years
Ref.
Mohamed K et al. Delayed diagnosis of Duchenne muscular dystrophy.
Eur J Pediatr Neurol 2000
Duchenne muscular dystrophy: Management
Multidisciplinary team approach
Use of steroids
Prolongation of ambulation
Reduction in complications e.g. scoliosis
Improvement in respiratory function
Increased use of non-invasive ventilation
Cardiac surveillance every 2yrs
Spinal surgery
Developmental Coordination Disorder
Male : Female
3:1
Impaired motor control & planning
difficulties with dressing and toileting
messy feeding
poor handwriting and drawing skills
poor ball skills
Can become socially isolated
Poor self esteem and schooling difficulties
Developmental Coordination Disorder:
DSM-IV diagnostic criteria
Marked impairment of the development of motor
co-ordination
Impairment significantly interferes with academic
achievement and activities of daily living
Problem not due to a recognised medical condition
Not a pervasive developmental delay
NHS QIS publication: ‘I still can’t tie my shoelaces...’
Quick Reference Guide to Identification and Diagnosis of DCD
Developmental Coordination Disorder:
Management
Reassure the child that there is no medical disease
process or refer to Paediatrician for assessment
Referral to Occupational Therapist
Classroom support
Group interventions to promote motor skills and
self-esteem e.g. Rainbow Gym
Summary
‘Limit ages’ can guide need for referral
Neurological examination should identify worrying
signs
Be alert to motor disorders that might present later in
childhood
Listen and respond to parents concerns!
Useful sources of information
From Birth to Five Years. Mary Sheridan.
Health for All Children 4th Edition. Hall D.
Developmental delay: Identification and management.
Aust Fam Phys 2005, Vol 34; 9:739-742
Voluntary organisations
e.g. Hemihelp, SCOPE, Contact a Family
Developmental Coordination Disorder:
useful references
‘I still can’t tie my shoelaces...’
Quick Reference Guide to Identification and Diagnosis of DCD
www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/pro
gramme_resources/dcd_review_response.aspx
Why every office needs a tennis ball: a new
approach to assessing the clumsy child
Cheryl Missiuna et al. CMAJ August 29, 2006; 175 (5)
www.cmaj.ca/content/175/5/471.full