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Abnormal Motor Development

Abnormal Motor Development. 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

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Abnormal Motor Development

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  1. Abnormal Motor Development Dr Valerie Orr Consultant in Paediatric Neurodisability RHSC, Yorkhill

  2. Objectives • To be able to identify abnormal motor development • To develop understanding of common motor disorders

  3. 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)

  4. How do we identify children with abnormal development? • Follow-up of ‘high risk’ infants • Screening • Listening to parents • Opportunistic recognition Ref. Hall 4

  5. 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

  6. 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

  7. 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

  8. Floppy infant – assessment History • Pregnancy and birth • Feeding • Development Examination • Weight & OFC ?thriving • Facial features ?dysmorphism • Movement ?antigravity mvts

  9. 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

  10. 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?

  11. Delayed walking (>18mths) • Normal variants • Associated with bottom shuffling • Cerebral palsy or minor neurological problems <10% • Consider CK in boys

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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!

  23. Useful sources of information • From Birth to Five Years. Mary Sheridan. • Health for All Children 4th Edition. Hall D. • Developmental delay: Identification and management. AustFam Phys 2005, Vol 34; 9:739-742 • Voluntary organisations e.g. Hemihelp, SCOPE, Contact a Family

  24. 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/programme_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

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