Assessment of Child with Motor Disorders (CP)

SAVE OFFLINE

Melbourne, November 2006

Assessment of the Child with motor disorders (CP) Florian Heinen

Dept. of Paediatric Neurology and Developmental Medicine Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Upper motor neurone pathways G. Sheean (1995) OTHERs • Rubrospinal tract • Corticospinal tract (pyramidal) • Corticoreticular tract (parapyramidal)

MAIN INHIBITORY TRACT • Dorsal reticulospinal tract (DRT)

• Tectospinal tract • Coerulospinal tract

MAIN EXCITATORY TRACTS • Medial and lateral reticulospinal tracts (MRT, LRT) • Vestibulospinal tract (VST)

Aus V. Dietz (2002) Proprioception and locomotor disease. Nat Rev Neurosci.

Neurological examination 6 Min (Orientation in a healthy child) 60 Min (55-85 Min)

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Type - severity - etiology

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Type •

Spastic cerebral palsy (CP) – Abnormal pattern of posture and/or movement – Increased tone (not necessarily constant) – Pathologic reflexes (increased, hyperreflaxia, pyramidal signs)

•

Bilateral – Limbs on both sides are involved

•

Unilateral spastic CP – Limbs on one side is involved

•

Dyskinetic CP – Dystonic – Choreo-athetotic

•

Ataxic CP SCPE. Dev Med Child Neurol 2000

Severity - GMFCS

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Etiology - e.g. Periventricular leucomalacia time of lesion: early third trimester

• MRI

• Sonography GMFCS I

GMFCS III

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Assessment tools – clinical examination

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Assessment tools – clinical examination Evaluation Scales

Clinical Tests

-

– – – – – – – –

Tardieu - Scale Modified Ashworth Scale - Range of motion (ROM) - Physician Rating scale

Thomas - Test Duncan Ely - Test Knee distance Phelps gracilis - Test Popliteal angle Pendulum - Test Silfverskjöld - Test Selective motor control of the foot

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Taskforce on childhood motor disorders ‘muscular hypertonia‘ Spasticity is a velocity-dependent resistance of a muscle to stretch. We therefore define spasticity as hypertonia in which one or both of the following signs are present: 1) resistance to externally imposed movement increases with increasing speed of stretch and varies with the direction of joint movement, and/or 2) resistance to externally imposed movement rises rapidly above a threshold speed or joint angle.

Sanger et al., in Pediatrics (2003)

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

1.

Tardieu-Test (‘catch‘)

–

gold standard to measure spasticity

–

velocitiy-dependent difference in slow vs. fast ROM

–

„catch“ and clonus

–

evaluation for almost every joint

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Tardieu-Test (‘catch‘) Popliteal angle

Triceps surae catch

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

2.

– –

Modified Ashworth Scale assessment of muscle tone velocity: 1 s per ROM

–

occurrence of resistance in the Range of Motion

–

increasing with severity and prevalence of fibrotic transformation

–

evaluation for every joint

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

3.

Range of Motion ROM

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

4.

Physician Rating Scale

–

during motion

–

standardized video documentation

Maathuis et al. J Pediatr Orthop Volume 25, Number 3, May/June 2005 Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Clinical Tests

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Hip flexion - Thomas Test

–

to assess shortening and increase in muscle tone of m. iliopsoas

–

supine position

–

hips and knees extended

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Hip rotation

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Rectus femoris - Duncan-Ely Test

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Adductor spasticity - Knee distance

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Adductor spasticity - pendulum test

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Adductor spasticity - Phelps gracilis test

–

to assess shortening & increased muscle tone of biarticular gracilis

–

prone position

–

maximal abduction of the hip with knee flexion

–

slow extension shows outer rotation and adduction of leg

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Knee flexion - sitting with feet in front Shortening of the medial hamstrings

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Knee flexion - popliteal angle shortening of the medial hamstrings

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Spastic equinus ...to obtain correct measurements for the ankle joint range of motion on passive dorsiflexion it is essential to redress the subtalar joint while performing the test. This realigns the axis of the foot and ensures that the joint range of motion is not overestimated...

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Silfverskjöld test • To assess shortening and increase in muscle tone of the triceps surae.

• Differentiation between soleus (dorsiflexion with the knee flexed) and gastrocnemius (dorsiflexion with the knee extended). Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Selective motor control

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Assisting Hand Assessment Test AHA (for unilateral CP)

Krumlinde-Sundholm L et al. Scan J Occup Ther 2003 10:16–26. Krumlinde-Sundholm L, Holmefur M, Eliasson AC. (2003) Assisting Hand Assessment Manual, Research Version 4.0. Stockholm: Karolinska Institutet, Neuropediatric Research Unit, Astrid Lindgren Children’s Hospital. Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Goal attainment scaling (GAS) • Decision about treatment strategy after the careful clinical examination, history and assessment of functional or structural deficits. • Therapy goals are individually set for each patient, and agreed on by all involved before starting therapy. • Goals that should be realistically achievable and appropriate for the patient's daily routine.

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany

Dept. of Paediatric and Developmental Neurology • Dr. von Hauner’s Children's Hospital Ludwig-Maximilians-University of Munich • Germany