UTS2024 Paediatrics Neurology I MC Student version-1 PDF

Paediatrics: Neurology 1 [email protected]; @poonamehta UTS GRADUATE SCHOOL OF HEALTH Learning Objectives On completion of this masterclass, you will be able to Understand theories of motor developmen...

Paediatrics: Neurology 1 [email protected]; @poonamehta UTS GRADUATE SCHOOL OF HEALTH Learning Objectives On completion of this masterclass, you will be able to Understand theories of motor development and analyse the implications of this information in relation to paediatric physiotherapy practice. Apply typical development from infancy to adolescence to identify atypical, or abnormal development. Identify and evaluate current research on management for children with cerebral palsy. Prep work Understand and be able to discuss: Developmental milestones at 6, 12, 24 months, 3-5 years, 7-10 years, 11years + Fine motor skills, Self-help skills, Personal-social, Speech and language, Cognitive skills Part 1 Developmental Milestones UTS CRICOS 00099F  GROWTH & DEVELOPMENT Physical maturation Functional/ Physiological maturation Though the two generally proceed concurrently, this may not always be so……… Source: Google images  Periods of Growth Prenatal Perinatal Postnatal Ovum (0-14 days) 22 weeks of gestation to 7 Young infant (3-6 months) days after birth Embryo (14 days to 9 Older infant (7-11months) weeks) Foetus (9 weeks to birth) Toddler (12-24 months) Pre-schooler (3-5 years) Primary school age (7-10 years) Preadolescent – adolescent (11 years +) UTS Graduate School of Health Age terminology  Classification by birth weight Organization WH. International statistical classification of diseases and related health problems, tenth revision, 2nd ed. World Health Organization; 2004. APGAR Score Apgar, V., et al.: Evaluation of the newborn infant – second report JAMA. 168( 15):1985-1988, Dec. 13, 1958  Gross Motor Development Milestones AGE MILESTONE 2-3 months Head in midline in supine/hold head upright when carried 3-4 months Rolling 6 months Sitting 7- 9 months Crawling 8-10 months Pull to stand/ Standing with support 10- 11 months Cruising around furniture 11 months Standing without support 12-18 months Independent walking 18 months Running 24 months Walking up and down stairs  Fine Motor Development AGE MILESTONE Birth Hand fisted, grasp reflex 2 months Hands open, may retain a placed rattle briefly 3 months Hands to mouth and midline 4 months 2 handed reach, can retain object in hand, shaking objects 5 months Bi-dextrous grasp- holds objects with 2 hands (e.g. bottle) 6 months Transfer object between hands 7 months Palmar grasp and thumb adducting, one handed reach 9 months Pincer grasp (pellets), pointing with index finger 11 months Takes object out of container, claps hands  Motor development milestone Young infant (3-6 months) Older infant (7-11months) Voluntary movement  Pivoting Reaching and grasping  Commando crawl  4 point crawl Rolling  Transfer from sitting  crawling Sitting  Pulling up into standing  floor Toddler (12-24 months) Pre-schooler (3-5 years)  Lateral cruising  pushing a walker  More complex GMS - Single leg stance, hopping,  Independent walking catch , drop kick, jump rope, hopscotch, ride bike,  Basic GMS – kicking, scoop catch, jump, run, ride scooter, ascend/descend stairs independently, step up and step down with railing faster running and agility Primary school age (7-10 years) Preadolescent – adolescent (11 years +)  Increased complexity of FMS and GMS  Increased complexity of FMS and GMS  Increased duration, speed and reaction time  Increased duration, speed and reaction time  Increased self-help and independence  Increased self-help and independence E.g. skiing, basket- ball, net ball, soccer, E.g. skiing, basket- ball, net ball, soccer, gymnastics gymnastics  Personal Social Development AGE MILESTONE 2 months Social smile 3 months Recognizes mother 6 months Smiles at mirror image, identifies familiar face/stranger 9 months Waves bye – bye, sociable/ chatty (babbles) 1 year Plays simple ball games, feeds self with a spoon Theories of motor development Neuro-maturational theories Functional behaviours appear as the nervous system matures. More complex behaviours being based on the activity of the progressively higher levels of the nervous system (Based on the work of Gesell, Shirley and others) Hierarchical maturation of neural control structures  Motor milestones  Stages of reflex development  Cephalo-caudal/ proximal-distal development Alternating dominance between flexion and extension Treatment of the child with CNS dysfunction focused on inhibition of primitive reflexes that were believed to exist and produce activity limitations, and facilitation of righting reactions that were supposedly the underlying coordinative structures for development of skilled voluntary motor behaviour  functional outcomes naturally follow Hierarchical maturation of neural control structures Cortex: The will & equilibrium Midbrain: Righting reactions Brain stem: Postural reflexes Spinal cord: Phasic reflexes Source: Google images  Primitive reflexes- Spinal reflexes Galant reflex Crawl reflex Rooting reflex Sucking reflex Moro (Startle) reflex Babinski reflex Flexor withdrawal Crossed extension Stepping reflex Grasp reflex  Primitive reflexes- Spinal reflexes Reflex Stimulus Response Time Significance Galant Crawl Rooting Sucking Moro Babinski Flexor withdrawal Crossed extension Stepping Grasp  Galant REFLEX: STIMULUS: Stroke the spine downward motion while the infant lies on the stomach RESPONSE: The infant will twitch their hips toward the touch in a dancing movement. TIME OF APPEARANCE: In utero (20 weeks) TIME OF DISAPPEARANCE: 3-9mnths.  CRAWL REFLEX : STIMULUS: Prone position (on the tummy). RESPONSE: Pull their legs under their body and kick them out in crawling motion. TIME OF APPEARANCE: At birth. TIME OF DISAPPEARANCE: By 12wks. Clinical significance?  ROOTING REFLEX : STIMULUS: Stroke/Press/touch corner of the mouth (cheek or lips). RESPONSE: Face turns towards the side. TIME OF APPEARANCE: At birth. TIME OF DISAPPEARANCE: By 12wks. Clinical significance?  SUCKING REFLEX: Stimulus: Introduce a finger into the mouth. Response: Sucking action of the lips and jaws. Time of appearance: At birth. Time of disappearance: 3-4months. Clinical Significance?  GRASP REFLEX (Palmar): STIMULUS: Press finger or other suitable object into palm from ulnar side. RESPONSE: Fingers flex and grip the object. TIME OF APPEARANCE: At birth. TIME OF DISAPPEARANCE: By 12wks. Clinical significance?  MORO (Startle) REFLEX (Vestibular/ auditory/ visual/ tactile): Position: Supine and back of head is supported above the table. Stimulus: Drop the head backwards associated with a loud sound. Response: Abduction and extension of arms followed by adduction of arms ( as in embrace) often accompanied by a cry. Time of emergence: 9 weeks in utero, fully present at birth. Time of inhibition: 3-4mnths. Clinical Significance?  BABINSKI REFLEX: Stimulus: Stroke the lateral aspect of foot from heel to the base of great toe. Response: Fanning of all 5 toes, extension of the hallux. Time of appearance: At birth. Time of disappearance: 1-2 year Clinical significance?  FLEXOR WITHDRAWL: POSITION: Supine or Sitting. STIMULUS: Noxious stimulus to sole of foot. RESPONSE: Uncontrolled flexion response of the stimulated leg. ONSET: At birth. INTEGRATION: 1-2 months. Clinical significance?  CROSSED EXTENSION REFLEX: POSITION: Supine, head mid position, legs extended. STIMULUS: Noxious stimulus to ball of foot. RESPONSE: Opposite lower extremity adducts and extends and foot goes in plantar flexion. Clinical significance?  STEPPING/ PLACING/WALKING REFLEX: STIMULUS: Support the infant by holding around their thorax and place their feet flat on a surface RESPONSE: Alternating steps forward are observed (hip/knee flexion, ankle DF) TIME OF APPEARANCE: At birth. TIME OF DISAPPEARANCE: 6mnths.  BRAINSTEM/ TONIC REFLEXES TLR : TONIC LABRINTHINE REFLEX ATNR : ASYMMETRICAL TONIC NECK REFLEX STNR: SYMMETRICAL TONIC NECK REFLEX  Tonic reflexes- Brainstem reflexes Reflex Stimulus Response Time Significanc e TLR Tonic Labyrinthine Reflex ATNR Asymmetrical Tonic Neck Reflex STNR Symmetrical Tonic Neck Reflex  TONIC LABYRINTHINE REFLEX: STIMULUS: Change of orientation of the head in space; position of head in relation to gravity while prone and supine. RESPONSE: Prone position- Flexion of all limbs as they try to lift head. Supine position- Extension of all limbs as the head is moved backward. TIME OF APPEARANCE: Birth. TIME OF DISAPPEARANCE: 2-4 months. Clinical Significance?  ASYMMETRICAL TONIC NECK REFLEX. POSITION: Supine lying, head in mid position, arms and legs extended. (fencing reflex) STIMULUS: Attract infant’s attention to tun head and look across one shoulder RESPONSE:  Increase in “extensor tone” on face side and  Increase in “flexor tone” on skull side. TIME OF APPEARANCE: At birth. TIME OF DISAPPEARANCE: 6mnths. Clinical Significance?  SYMMETRICAL TONIC NECK REFLEX POSITION: Supine lying, head in mid position. arms and legs extended. STIMULUS: Flexion or Extension the head. RESPONSE: Flexion of head: Arms flex, legs extend. Extension of head: Arms extension, legs flex TIME OF APPEARANCE: Emerges after ATNR phases out (6-9 months). TIME OF DISAPPEARANCE: (9-11mnths) Clinical Significance?  Midbrain/ Cortical reactions Righting reactions NOB (Neck on body) BOB (Body on body) BOH (Body on head) Labyrinthine Head Righting Optical righting reflex Equilibrium reactions Tilting Postural fixation Protective extension  Midbrain/ Cortical Reactions Reflex Stimulus Response Time Significance Righting Reactions NOB (Neck on body) BOB (Body on body) BOH (Body on head) Labyrinthine Head Righting Equilibrium reactions Tilting Postural fixation Protective Extension Righting reactions……… NOB- neck on body STIMULUS: Passive turning of the head to one side in supine RESPONSE: Log rolling towards the same side to align with head TIME OF APPEARANCE: 6 months. TIME OF DISAPPEARANCE: 5 years Clinical Significance? Righting reactions……… BOB- body on body STIMULUS: Passive turning of the trunk (upper/lower) to one side in supine lying position. RESPONSE: Log rolling of the corresponding (upper/lower) segment towards the same side. TIME OF APPEARANCE: 6 months. TIME OF DISAPPEARANCE: 5 years Clinical Significance? Righting reactions……… BOH- body on head STIMULUS: Positioning the baby either in supine or prone. RESPONSE: Baby tends to arrange by keeping head vertical and mouth horizontal. TIME OF APPEARANCE: 2 months. TIME OF DISAPPEARANCE: 5 years Clinical Significance? Righting reactions……… Labyrinthine head righting STIMULUS: Position the baby in supine with your hands around their thorax. Tilt them 30 degree in to flexion/extension/side-flexion, bringing them back to midline between positions. From 8 months- face a blank wall to avoid visual cuing. RESPONSE: The head should correct immediately back to the upright (vertical) position when tilted. TIME OF APPEARANCE: Birth. TIME OF DISAPPEARANCE: Normally persists. Equilibrium reactions…… Tilting STIMULUS: Alter the COG by shifting the surface by placing the baby in different- 2 positions. RESPONSE: Extension & adduction of supporting extremity Flexion & Abduction of the other side. TIME OF APPEARANCE: Prone 4-6 months. Supine 6-8 months Sitting 6-8 months Quadripod 10-12 months Standing 12-21 months TIME OF DISAPPEARANCE: Normally persists Clinical Significance? Equilibrium reactions….. Postural fixation STIMULUS: Alter the COG by slow force on the normal surface by placing the baby in different-2 positions (pushing to one side). RESPONSE: Extension & adduction of supporting extremity Flexion & Abduction of the other side. TIME OF APPEARANCE: Prone 4-6 months. Supine 6-8 months Sitting 6-8 months Quadripod 10-12 months Standing 12-21 months TIME OF DISAPPEARANCE: Normally persists Clinical Significance?  PROTECTIVE EXTENSION/ PARACHUTE REFLEX: STIMULUS: Hold the infant firmly with both hands around the trunk. Rapidly tip the child towards the floor. RESPONSE: Swift flexion of the shoulders, extension of elbows, wrist and fingers with slight shoulder external rotation. TIME OF APPEARANCE: 9 months. TIME OF DISAPPEARANCE: Normally persists Clinical Significance? Clinical Implications? Need to know typical development to be able to identify atypical development Clinical interventions in Physiotherapy were originally based on the developmental sequence for planning the intervention However, we must also consider that the child’s biological systems are not the only mechanism influencing motor performance. Motor performance is an outcome of the child, task and environment and these factors are constantly changing. Need to consider child-rearing practices, the role of family in the intervention and the impact of the environment.  Part 2- Neurological Conditions Cerebral Palsy Neuro-progressive disorders Spina Bifida Developmental Coordination Disorder UTS CRICOS 00099F  Cerebral Palsy “Umbrella term” “A group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing Foetal or infant brain” (Rosenbaum 2007) Cerebral Palsy ACPR. (2013). Australian Cerebral Palsy Register Report Birth Years 1993 – 2006 Cerebral Palsy- risks http://www.pathophys.org/cerebralpalsy/  Cerebral Palsy Pathophysiology Premature neonatal brain is susceptible to 2 main pathologies: 1. Intraventricular haemorrhage (IVH)- bleeding into the ventricles of the brain. The blood vessels around the ventricles develop late in 3 rd trimester, thus preterm infants have underdeveloped periventricular blood vessels, predisposing them to increased risk of IVH. The risk of CP increases with the severity of IVH. 2. Periventricular leukomalacia (PVL)- brain damage that adversely affects white matter, causing cell death, creating empty spaces in that part of the brain. The periventricular white matter sends nerve impulses that control motor function. Spasticity, cognitive impairment and vision issues often result from PVL. Approx. 60-100% babies with PVL will be diagnosed with CP. http://www.pathophys.org/cerebralpalsy/ Cerebral Palsy Classification Source: Cerebral Palsy Alliance  Spastic CP ‘hypertonia’ or ‘increased muscle tone’ Effect on the upper limbs (arms and Effect on the lower limbs (legs) hands)  Flexion at the elbow  Flexion at the hip  Flexion at the wrist  Adduction or ‘scissoring’ of the thighs  Flexion at the fingers  Flexion at the knees  Equinovarus foot posture Spasticity in these areas can lead to Spasticity in the muscles of one or both legs difficulties with tasks involving the hands may affect a person’s ability to: and the arms:  Stand upright  getting dressed  Sit upright  washing and toileting oneself  Transfer from one position to another  eating or drinking  Move and reposition in bed  writing  Walk and run  manipulating objects Cerebral Palsy- Motor symptoms http://www.pathophys.org/cerebralpalsy/  Ataxic CP Ataxic CP: ‘Without order’ or ‘coordination’ Unsteady, shaky movements or tremor Difficulties maintaining balance People with ataxia appear very unsteady and shaky because their sense of balance and depth perception is affected.  Dyskinetic CP Dyskinetic (Athetoid) CP: trouble controlling muscle movement- twisting, abrupt movements. dystonia: twisting and repeating movements that can be painful athetosis: slow, writhing movements chorea: irregular, abrupt movements Cerebral Palsy Signs (Babies) Low muscle tone (baby feels ‘floppy’ when picked up) Unable to hold up his/her own head while lying on their stomach or in a supported sitting position Muscle spasms or feeling stiff Poor muscle control, reflexes and posture Delayed development (can’t sit up or independently roll over by 6 months) Feeding or swallowing difficulties Prefers to use one side of their body Source: Cerebral Palsy Alliance  Cerebral Palsy Signs (Young children) Although the brain of young children with CP remains injured, the injury does not get worse as they develop. Depending on the level of severity of cerebral palsy, young children may experience difficulties with physical development such as: not walking by 12-18 months not speaking simple sentences by 24 months If your child is not reaching these milestones or they display some of the signs of cerebral palsy, you may need to speak to your early childhood nurse, general practitioner or paediatrician. In NSW, questions relating to developmental milestones are described in the Personal Health Record book (Blue Book) provided to families when their child is born. Source: Cerebral Palsy Alliance  Cerebral Palsy Severity Cerebral Palsy can vary in level of severity which can be classified by gross motor function, manual ability and communication. Gross Motor Function Classification System (GMFCS) Manual Ability Classification System (MACS) Communication Function Classification System (CFCS) Source: Cerebral Palsy Alliance Gross Motor Function Classification system Source: Cerebral Palsy Alliance Manual Ability Classification system Source: Cerebral Palsy Alliance Communication Function Classification system Source: Cerebral Palsy Alliance Cerebral Palsy Associated Impairments Source: Cerebral Palsy Alliance Source: Cerebral Palsy Alliance Assessment & Diagnosis To be continued in workshops………………………..