Abnormal body movement in children

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Abnormal body movement Maryam abdulwahid Hawar jarjees Hedy hameed supervised by: Tanya muhammad

description

"abnormal body movements in children" Hawler medical university, college of medicine Erbil, Iraq

Transcript of Abnormal body movement in children

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Abnormal body movement

Maryam abdulwahid Hawar jarjees Hedy hameed supervised by: Tanya muhammad Dr. Dler

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Content

• Introduction• Types• Pathophysiology• Approach• Convulsion• Types• Cause• Management

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Introduction

• Movement disorders are a group of diseases and syndromes affecting the ability to produce and control bodily movements.

• They are generally the result of abnormalities of the extra pyramidal system or the basal ganglia.

• Can be the primary or secondary manifestation of numerous neurologic disorders

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Classification

involuntary movements

• rhythmic • Non –rhythmic

Convulsive disorders

• Epileptic• Non- epileptic

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Slide TitleMOVEMENT DISORDERS

PYRAMIDAL SYMPTOMS

BASAL GANGLIA DISORDERS

CERBELLAR DISORDERS

SPASTICITYATAXIA

HYPOKINESIAS HYPERKINESIAS MOTOR-SENSORY BEHAVIOUR

AKINESIA RIGIDITY

TREMOR DYSTONIA MYOCLONUS CHOREA/

ATHETOSISTICS/ STERIOTYPIES

COMPULSION

MANNERISM

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Chorea

• Irregular, rapid, purposeless, uncontrolled, involuntary movements, Worsen on rest, but remain or improve with involuntary movement.

• muscle tone is decreased.• May be Congenital, familial, metabolic,

vascular, toxic, infectious or neoplastic.

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Athetosis

• Slow, coarse, writhing, irregular movement.• More found over distal parts of limbs and

face.• non propositional and predominate over

postural.• Muscle tone may be increased.• Main cause is encephalopathy.• Its frequently seen with chorea

(choreoathetosis)• It present in many cases of mixed form of

cerebral palsy.

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Dystonia

• Syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures

• It has many causes and neurological sign• Causes: Perinatal asphyxia Kernicterus Drugs

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Tremor

• Rhythmic oscillations of a part of the body around the central point

• In children is usually due to psychological, familial, or cerebral origin.

• Associated with other diseases like thyrotoxicosis, hypoglycemia, wilson disease.

• Drugs (bronchodilators, amphetamine& TCA)

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Myoclonus

• Very brief, abrupt, involuntary, non-suppressible, jerky contraction involving a single muscle or muscle group- "shock like"

• Presence in normal (associated with sleep, exercise, anxiety) and numerous pathologic situations.

• May be epileptic or non epileptic,• Its distinguished from tremor in that it’s a simple

contraction of an agonist muscle, while tremor is simultaneous contraction of agonist and antagonist muscle.

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Tics • Repetitive semi-purposeful movements as blinking,

winking, grinning or screwing up of the eyes. Distinguished from other involuntary movements by the ability of the patient to suppress their occurrence. Most of them disappear at adolescent.

• Tourettes syndrom is a chronic tic disorder that begin before 7 year of age , unknown cause but 50% have FH. consists of motor and vocal tics and associated with ADHS or OCD,

• RX: clonidine &haloperidol• Has good px 2/3 have complete remission.

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Ataxia

• Inability to make smooth, accurate and coordinated movements

• Due to disorder of cerebellum, sensory pathway in posterior column of spinal cord)

• Generalized • primarily affect gait or hands and arms

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Stereotypies

• are intermittent, involuntary, repetitive, purposeless, patterned movements that are usually rhythmic.

• Such as arm flapping, rocking, licking, mouth opening, and hand waving.

• associated with mental retardation, autism, Rett syndrome, and blindness,

• but they also occur in otherwise normal children.

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APPROACH

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Key questions:

● Is the pattern of movements normal or abnormal?

● Is the number of movements excessive or diminished?

● Is the movement paroxysmal (sudden onset and offset), Continual (repeated again and again), or continuous?

● Has the movement disorder changed over time?

● sleep?

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• Do environmental stimuli or emotional

states modulate the movement disorder?● Can the movements be suppressed

voluntarily?● Is there a family history of a similar or related

condition?

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HX:

• Age at onset-• full term neonate : jitteriness• Infant : myoclonus, athetosis, transient

dystonia• Older child : chorea• Sex- • female: Sydenham’s chorea, thryrotoxicosis• male : tics, tremors

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• Type of movement-• rapid jerky: chorea• slow movement : athetosis• sustained: dystonia• Involvement of body parts:• distal limb : athetosis• all body parts : chorea• hand : focal dystonia • Presence of movements in sleep : seizure disorder , nocturnal myoclonus

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HX:

• Aggravated with stress: tremor, tics, Tourette synd , Generalised primary dystonia, Nocturnal myoclonus, Syndenham’s chorea.

• Relieving factors.• H/o intake of drugs• Antipychotic, antiepileptic, amphetamine,

cocain& lithium • Perinatal history/ Dystonia- Asphyxia, Jaundice Athetosis- Asphyxia, jaundice and prematurity

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EXAMINATIONS

• General exam.• Vital signs• Motor, tone, gait • Systemic examinations • Presence of primitive reflexes- cerebral

palsy• Signs of meningeal irritation?• any cerebellar signs?

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Rx• Hypokinetic - dopamine decreased -

treat with dopamine replacement or anticholinergic drugs.

• Hyperkinetic - dopamine increased and acetylcholine decreased -

treat with a dopamine antagonist or cholinergic drug.

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Convulsion

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Convulsion Convulsion is defined as a transient, involuntary alteration of consciousness, behavior, motor activity, sensation, or autonomic function caused by an excessive rate of discharges from a group of cerebral neurons leading to a sudden biochemical imbalance at the cell membrane.

Seizures are the most common pediatric neurologic disorder, the incidence is highest in children younger than 3 years of age.

Could be either acute symptomatic or remote symptomatic

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Causes 1. Infectious: brain abscess, encephalitis, febrile seizure,

meningitis.

2. Neurologic or developmental: Birth injury, congenital anomalies, hypoxic-ischemic encephalopathy, Ventriculo peritoneal shunt malfunction.

3. Metabolic: hypocalcemia, hypoglycemia, hypomagnesemia, hypoxia, inborn errors of metabolism, pyridoxine deficiency.

4. Traumatic: child abuse, head trauma, intracranial hemorrhage .

5. Toxicologic: Drugs like(amphetamines, theophyline),Lead, lithium, organophosphates and withdrawals ( anticonvulsants).

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Febrile convulsion

• Are the most common seizure disorder in childhood, affecting 2 - 5% of children between the ages of 6 months _5 years, are usually benign.

• Criteria for diagnosis :1. major: age<1 year, fever of<24 hours,

fever(38_39)2. Minor : +family history (febrile seizure

and epilepsy), complex partial seizure , male gender.

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• Simple:1. generalized2. <15 minutes3. 1time/day complex:4. partial5. Prolonged >15minutes6. Frequent attacks in 24 hours

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Epilepsy Is the occurrence of recurrent seizure(2

unprovoked seizure >24 apart) not caused by fever or an acute illness. could be generalized or partial,

Recurrent seizure in epilepsy despite treatment could be due to:

1.Wrong diagnosis.2.Incorrect type or improper dose of drug.

3.Underlying structural lesion.4.Metabolic disorders.

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Classification

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Status epilepticus

• Seizures that persist without interruption for more than 30 minutes

or recurrence of serial convulsion where the patient is unconscious in

between. is usually of generalized tonic clonic

type and commonly occurs in children with epilepsy.Conditions in which SE is common:

1.Complex febrile seizure(>30 mins) is the most common

2.Sudden withdrawal of anticonvulsant.3.Sleep deprivation.

4.Intercurrent infection.

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Differential diagnosis

• 1.Psuedoseizure: could be differentiated from true seizure by:

conscious a lack of coordination of movements. talking during the episode, the absence of incontinence or body injury EEG is usually normal.

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2.Disorders with altered consciousness( no postictal phase +rapid recovery)

• Syncope(brief, sudden loss of consciousness usually preceded by a feeling of light headedness.)

• Breath-holding spells(crying +breath holding+cyanosis+twitching of extremities)

3. Sleep disorders• Narcolepsy(sudden fall into sleep )• Cataplexy(sudden fall into sleeep +loss of muscle

tone)• Night terrors( preschool-aged child, with a sudden

awakening fromsleep,followedbycrying,screaming.

4.Psychologic disorders

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Approach

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Case

• 1yr old female presented with abnormal body movement of 5 minutes duration , generalized tonic clonic, with high grade fever, frothy mouth and rolled up eyes, preceded by FBM 2times,

• Temperature 38.8c, PR 102 b/min, RR 24breath/min

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HX

Preictal phase : any triggering factor like; fever, sleep disturbance ,any illness, stress, trauma.Ictal phase : during which the patient could have :Repetitive purposeless movement, Falling down without cause, perioral cyanosis, Stiffening of any or all extremities, Rhythmic shaking of any or all extremities, deviation of the eyes ,bladder or bowel incontinence, diminished level of consciousness or unresponsive and unconscious.Postictal phase: sleepy, headache or confusion and gain of consciousness, hyperthermia..

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Other questions

• HX of seizures • FH of seizures, PMH • developmental history• Drug hx• Immunization

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Examination:

• General observation• Physical examination:• Vital signs, growth parameter,

developmental stage of child in gross motor, fine motor, language and social, delay may include cerebral palsy, chronic ongoing eg: tumor, or secondary to another diseases

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• Neurological examination:• Cranial nerve examination• Motor and reflexes• Coordination and gait• Signs of meningitis (neck stiffness,

kerning sign, brudzinski sign)

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Investigation

1- RBS2-S.electrolyate 3-CSF examinations: indication for

LP:1.infant<12months with 1st time febrile convulsion to determine meningitis

2.12 to 18 months with a simple febrile seizure 3.any child with meningial signs4-EEG: if normal not exclude diagnosis5-Ctscan:if head trauma present, & MRI: focal

neurological deficit, recurrent seizure

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Management • The objectives:• Maintenance of adequate airway, breathing and

circulation (ABCs).• Termination of the seizure and prevention of

recurrence.• Diagnosis and initial therapy of life-threatening

causes of CSE (eg, hypoglycemia, meningitis and cerebral space-occupying lesions).

• Management of refractory status epilepticus (RSE).

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