Transcript Motor Disorders in Childhood - General Practice Specialty

Dr Valerie Orr
Consultant in Paediatric Neurodisability
RHSC, Yorkhill
Objectives
 To be able to identify and make appropriate referrals
for children with abnormal motor development
 To develop knowledge of current paediatric
management of children with 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 – median ages
Ref. Illustrated Textbook of Paediatrics
Gross motor milestones – median ages
Ref. Illustrated Textbook of Paediatrics
Early locomotor patterns
Ref. Illustrated Textbook of Paediatrics
Gross motor milestones – limit ages
Ref. Illustrated Textbook of Paediatrics
 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 e.g. early
hand preference
 Abnormalities of muscle tone
i.e. hypotonia (‘floppy’) or hypertonia (‘stiff’)
 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 - floppy & strong vs floppy & weak
Referral
 Paediatrician
(Urgent if feeding difficulties or poor weight gain)
Floppy infant – aetiology
Includes
 Prematurity, illness & drugs
 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%
 May occur in context of global developmental delay
 Consider CK in boys
Toe walking
Possible causes
 Idiopathic toe walking
 Muscle spasticity
e.g. cerebral palsy, spinal cord lesion, hereditary spastic paraparesis
 Muscle disease
e.g. Duchenne muscular dystrophy, Charcot Marie Tooth (HMSN)
Duchenne muscular dystrophy
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
Developmental Coordination Disorder
 ‘Dyspraxia’, ‘clumsiness’
 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
 Examine and ensure that there is no underlying
medical problem or refer to paediatrician for
further assessment
 Referral to Occupational Therapist
 Group interventions to promote motor skills and selfesteem e.g. Rainbow Gym
 Classroom support
Management of motor disorders
 Multidisciplinary team approach
 Holistic, child /family centred care
 Often need to access support from education
services, social services and voluntary agencies
WHO ICF Framework
Cerebral Palsy
‘A disorder of movement and posture due to defect
or lesion of the immature brain’
Incidence ~2 per 1000 live births
 Antenatal 80% e.g. prematurity, fetal & neonatal stroke, brain
malformations, maternal infection
 Perinatal 10%
e.g. neonatal encephalopathy
 Postneonatal events 10%
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 spasticity treatments
 Orthotics
 Botulinum toxin
 Oral medications e.g. Baclofen
 Intrathecal baclofen
 Orthopaedic surgery
Transition
 Children with motor disorders become adults with
ongoing and often complex health needs
 GP becomes key health professional for most young
people with cerebral palsy
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 References
 From Birth to Five Years. Mary Sheridan.
 Developmental assessment of children. Bellman M et al,
BMJ Jan 2013
 Managing common symptoms of cerebral palsy in children.
Sewell et al, BMJ Sep 2014
 NICE guideline 2012 Spasticity in children and young people
with non-progressive brain disorders
 NHS QIS ‘I still can’t tie my shoelaces…’ Quick Reference
Guide to Identification and Diagnosis of DCD’