UTS Paediatrics: Neurology 1 Workshop PDF

Paediatrics: Neurology 1 Workshop 1&2 UTS GRADUATE SCHOOL OF HEALTH LESSON OBJECTIVES On completion of this workshop, you will be able to: 1) Apply appropriate motor assessments to evaluate children’s motor development and condition 2) Analyse how ch...

Paediatrics: Neurology 1 Workshop 1&2 UTS GRADUATE SCHOOL OF HEALTH LESSON OBJECTIVES On completion of this workshop, you will be able to: 1) Apply appropriate motor assessments to evaluate children’s motor development and condition 2) Analyse how child’s motor performance differs from others 3) Formulate systemic approach to assess children with CP based on present and past medical history 4) Discuss possible support services which may benefits the child and their family SUBJECTIVE ASSESSMENT ❖ Main concerns What When they started Intermitted/constant Worsening/plateauing/improving ❖ Medical history Pregnancy and Neonatal history Birth complications (birth weight, premature, APGAR, O2 support necessary, NVD/C-Section) Relevant Past Medical History (Respiratory, Cardiac, surgical history, # history etc.) Medications Hearing assessment Vision assessment SUBJECTIVE ASSESSMENT ❖ Developmental History (Age appropriate) Gross Motor Functions ❑Rolling ❑Sitting ❑Standing ❑Crawling ❑Walking Fine motor functions Speech Cognition ❑Smiling ❖ Pain ❖ Other health professionals involved (GP, OT, Speech pathologist, Genetic counsellor etc.)  RED FLAGS Age Milestones 6 months Not rolling; Not holding head and shoulders up when on tummy 9 months Not sitting without support; Not moving 1.e. creeping or crawling motion Does not take weight well on legs when held by an adult 12 months Not crawling or bottom shuffling; Not pulling to stand Not standing holding on to furniture 18 months Not attempting to walk without support Not standing alone 2 years Unable to run; Unable to use stairs holding on Unable to throw a ball 3 years Not running well; Cannot walk up and down stairs Cannot kick or throw a ball Cannot jump with 2 feet together 4 years Cannot pedal a tricycle; Cannot catch throw or kick a ball Cannot balance well standing on one leg 5 years Awkward when walking, running, climbing and using stairs Ball skills are very different to their peers Unable to hop 5 times on each foot  RED FLAGS Age Milestones 6 months Not reaching for and holding (grasping) toys Hands frequently clenched 9 months Unable to hold and/or release toys Cannot move toy from one hand to another 12 months Majority of nutrition still liquid/puree Cannot chew solid food Unable to pickup small items using index finger and thumb 18 months Not holding or scribbling with a crayon Does not attempt to tower blocks 2 years No interest in self care skills e.g. feeding, dressing 3 years Difficulty helping with self care skills (feeding, dressing) Difficulty manipulating small objects e.g. threading beads 4 years Not toilet trained by day Unable to draw lines and circles 5 years Concerns from teachers about school readiness Not independent with eating and dressing Cannot draw simple pictures (e.g. stick person) SUBJECTIVE ASSESSMENT ❖ Family structure/supports ❖ Home Environment Indoor (internal steps, surfaces e.g floorboards/carpet, room for wheelchair manoeuvrability) Outdoor (Steps, Ramp, Hilly yard, rails) ❖ Home Mobility Fatigue Participation ❑ Daily/weekly routine ❑ ADLs- feeding/toileting, dressing, self-help skills ❑ Sleep Activities (Rhyme time at local library, swimming lessons, daycare) Cultural/family traditions you need to be aware about Goals of family  OBJECTIVE ASSESSMENT (AGE APPROPRIATE) ❖ Observation- Gross Motor functions Head Control Supine/ Prone Rolling / Sitting / Standing Posture Gait: forwards, backwards, sideways, tip toes, heel walking Gallop, skip, star jumps Running Stairs Jumping / hopping / Climbing Ball skills: kicking, catching, throwing, bouncing Transitions: Sit to stand, floor to standing, chair to chair, bed to chair  OBJECTIVE ASSESSMENT (AGE APPROPRIATE) ❖ Observation- Fine Motor Functions Grasp Hand to hand Transfer ❖ Respiratory Breathing pattern Cough Sputum Airway Clearance Routine ❖ Neurological Tone, Spasticity, Clonus Deep Tendon Reflexes Atypical movement patterns Tremor Infant patterns (if relevant) OBJECTIVE ASSESSMENT (AGE APPROPRIATE) ❖ Skeletal ROM limbs, neck (Passive and active) Head shape, Hip dysplasia, foot deformities Spinal palpation Asymmetries, side preference ❖ Muscular Strength Unusual positioning of limbs Movement against gravity Endurance of postural muscles Sit to stand, on/off floor ❖ Sensory Vision/ Hearing Tactile (sensitivities)/ Proprioception Vestibular  OBJECTIVE ASSESSMENT (AGE APPROPRIATE) ❖ Balance Parachute / protective responses Tandem walking Balance reactions Single Leg Stance: Eyes open, eyes closed ❖ Socialisation Eye contact Attachement Verbal communication Non-verbal communication ❖ Cognition Play skills, interests in toys / environment Babbling / language ❖ Participation Imaginative play/ Turn taking* Modified Ashworth Purpose: A measure of hypertonicity in a limb (independent of velocity) https://www.youtube.com/watch?v=46V8p1VtMzU Modified Tardieu - spasticity Definition: Tardieu is a scale for measuring spasticity that takes into account resistance to passive movement at both slow and fast speed. Purpose: A measure of limb spasticity 1. Quality of muscle reaction (scored 0-5); 0 is no resistance throughout passive ROM 1 slight resistance but no clear catch 2 clear catch followed by a release 3 fatigable clonus 10 sec 5 indicating joint is immobile Modified Tardieu - spasticity 2. Velocity of Stretch V1 is slow as possible (minimising stretch reflex) V2 speed of limb falling under gravity V3 moving as fast as possible (faster than the rate of the natural drop of the limb segment under gravity) 3. Joint angles The angle of muscle reaction (R1) is defined as the angle in which a catch or clonus is found during a quick stretch (during either V2 or V3) The angle of full ROM (R2) is taken at a very slow speed (V1). R1 is then subtracted from R2 and this represents the dynamic tone component of the muscle. (Boyd 1999) https://www.youtube.com/watch?v=b_ss3TWwfiw Other- Babinski 1. Babinski Reflex A reflex used to determine adequacy of the higher (central) nervous system. The Babinski reflex is obtained by stimulating the outside of the sole of the foot, causing extension of the big toe while fanning the other toes https://www.youtube.com/watch?v=bT91_y4hSkk Other- Clonus 2. Clonus Definition- Clonus is a rhythmic sustained involuntary muscular contractions... Hyperreflexia in Upper Motor Neuron Lesion (UMNL) https://www.youtube.com/watch?v=SNZ5-t0Y96E  Other- DTR 3. Deep tendon reflexes Deep tendon reflex (DTR) a brisk contraction of a muscle in response to a sudden stretch induced by a sharp tap by a finger or rubber hammer on the tendon of insertion of the muscle. Absence of the reflex may be caused by damage to the muscle, peripheral nerve, nerve roots, or spinal cord at that level. Increased response can indicate UMNL involvement. https://www.youtube.com/watch?v=bJH6hwqH1kM Muscle Strength https://www.niehs.nih.gov/research/resources/assets/docs/muscle_grading_and_testing_procedures_508.pdf Range of Movement ❖ Normal vs shortened ❖ Test position ROM normative data: https://www.cdc.gov/ncbddd/jointrom/  Reference Values for Normal Joint Range of Motion Age 2–8 Age 9–19 Motion Females Males Females Males Hip extension 26.2 (23.9 – 28.5) 28.3 (27.2 – 20.5 (18.6 – 18.2 (16.6 – 29.4) 22.4) 19.8) Hip flexion 140.8 (139.2 – 131.1 (129.4 – 134.9 (133.0 – 135.2 (133.0 – 142.4) 132.8) 136.8) 137.4) Knee flexion 152.6 (151.2 – 147.8 (146.6 – 142.3 (140.8 – 142.2 (140.4 – 154.0) 149.0) 143.8) 144.0) Knee extension 5.4 (3.9 – 6.9) 1.6 (0.9 – 2.3) 2.4 (1.5 – 3.3) 1.8 (0.9 – 2.7) Ankle 24.8 (22.5 – 27.1) 22.8 (21.3 – 17.3 (15.6 – 16.3 (14.9 – dorsiflexion 24.3) 19.0) 17.7) Ankle plantar 67.1 (64.8 – 69.4) 55.8 (54.4 – 57.3 (54.8 – 52.8 (50.8 – flexion 57.2) 59.8) 54.8)  Reference Values for Normal Joint Range of Motion Age 2–8 Age 9–19 Motion Females Males Females Males Shoulder flexion 178.6 (176.9 – 177.8 (176.7 – 171.8 (169.8 – 170.9 (169.1 – 180.3) 178.9) 173.8) 172.7) Elbow flexion 152.9 (151.5 – 151.4 (150.8 – 149.7 (148.5 – 148.3 (146.8 – 154.3) 152.0) 150.9) 149.8) Elbow extension 6.8 (5.2 – 8.4) 2.2 (0.9 – 3.5) 6.4 (4.7 – 8.1) 5.3 (3.6 – 7.0) Elbow pronation 84.6 (82.8 – 79.6 (78.8 – 81.2 (79.6 – 79.8 (77.8 – 86.4) 80.4) 82.8) 81.8) Elbow supination 93.7 (91.4 – 86.4 (85.3 – 90.0 (88.0 – 87.8 (85.7 – 96.0) 87.5) 92.0) 89.9) Objective assessment – standardised assessments Discrimination (normal / abnormal) Alberta Infant Motor Skills (AIMS) Movement Assessment Battery for Children (ABC), Prediction Movement Assessment for Infants (MAI), Prechtl’s General Movement Assessment (GMA), Hammersmith Infant Neurological Examination (HINE) Developmental Assessment of Young Children (DAYC) Evaluation Paediatric Evaluation of Disability Inventory (PEDI), Gross Motor Function Measure (GMFM) > Construct: norm vs criterion referenced  DISCRIMINATION ALBERTA INFANT MOTOR SKILLS (AIMS) Type of Test: performance HTTPS://WWW.YOUTUBE.COM/WATCH?V=HM5KEMW-RME based, norm-referenced observational measure Target Population and Ages: Infants 0-18 months or until child is able to independently walk 58 items, including 4 positions: prone (21 items), supine (9 items), sitting (12 items) & standing(16 standing) Sensitivity: 90.9% Specificity: 95.6% Knorr 2017  DISCRIMINATION ALBERTA INFANT MOTOR SKILLS (AIMS)  ALBERTA MOTOR INFANT SCALE (AIMS) Target population Purpose Advantages & Interpretation of Disadvantages results Infants from birth to Gross Motor Advantages: Add scores and plot independent walking assessment Observational, so minimal against norm handling require (0-18 months) Discrimination reference curves for Quick to administer infants age to Outcomes easily able to be communicated to parents determine percentile Detects deviations from the rank norm Guides intervention Disadvantages: Is not a neurological examination so does not explain cause of deviation Doesn’t look at symmetries Ceiling effects have been shown in infants over 9 months GMA is a non-invasive and cost effective way to identify neurological issues which may lead to cerebral palsy and other developmental disabilities. The assessment can be completed between birth to 20 weeks of age corrected. Infants have typical and distinct spontaneous "general movements" from before birth through until 20 weeks post term or corrected age. Those infants whose general movements are absent or abnormal are at higher risk of neurological conditions in particular CP. Therefore before 3 months of age, we can predict those at high risk of CP and provide early intervention. It is assessed with the infant awake lying on their back when they are calm and alert. They should not be stimulated or interacted with, have toys or dummies to use. The child is videoed for 3-5 minutes and then scored by an assessor trained in General Movement Assessments. This video can be taken by the parent or a clinician. The baby moves app is an app designed by RCH Melbourne which allows their patients to video their children at home and send to the clinicians for scoring. Meaning they do not need to some in for an assessment. The best age to perform the video is 12-14 weeks after the baby's due date. It is less reliable the closer the child gets to 20 weeks post due date.  GENERAL MOVEMENTS ASSESSMENT Target Population Purpose Advantages & Interpretation of Disadvantages results Infants Birth-20 weeks Identify infants at high Advantages: Writhing period: corrected age risk of cerebral palsy Video assessment- Normal/Abnormal Predictive Quick and easy to Fidgety movement perform period: Normal/ Videos can be sent Abnormal/ Absent from remote locations High sensitivity and sensitivity Disadvantages: needs consensus scoring Regular practice to maintain accuracy Does not inform an intervention plan Training expensive Short time period for assessment  Prediction Hammersmith Infant Neurological Examination- HINE Criterion referenced Infants between 2-24 months of age Three parts: A neurological examination (scored), ❖ Cranial nerve function, ❖ Posture, ❖ Quality and quantity of movements, ❖ Muscle tone, and ❖ Reflexes and reactions Developmental milestones and Behaviour (not scored)