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 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’