UNDERSTANDING THE CHILD WITH ATHETOSIS Robyn Smith Department of Physiotherapy University of Free State 2012

Athetoid group NB!!! Characterised by: Fluctuating postural/ muscle tone Involuntary movements Do not confuse with ATAXIA = in co-ordinated movements

Athetoid group Classified according to type of involuntary movement into 4 groups Pure athetosis Choreoathetosis Athetosis with dystonic spasms Athetosis with spasticity

A look at muscle tone in the athetoid group Low toneNormal toneHigh tone Pure athetosis choreoathetosis Athetoid with dystonic spasms Athetoid with spasticity

Etiology Kericterus hyperbilirubinaemia (severe jaundice) Rh- incompatability Prematurity Asphyxia Metabolic disorders Encephalitis/ meningitis Heavy metal poisoning Rheumatic fever Degenerative disorders brain

Management of jaundice

Etiology NB!!!!! = damage to the basal ganglia Basal ganglia are NB for: Control of movement Scale and amplitude determination of movement Important in the control of eye movements

Characteristics High IQ –cortex not involved  However usually severely disabled  Emotionally volatile  Often frustrated –temper tantrums Lack of proximal stability  Poor grading movement  Poor balance Muscle contractures usually not a concern  Due to constantly changing muscle tone and movement  Repetitive asymmetrical movement patterns may lead to deformities

Characteristics Muscle tone fluctuates constantly – Inconsistent motor responses, child unsure of outcome of an action General underlying hypotonia  Ligament laxity  Hypermobile

Athetoid Most are wheelchair bound Need lap and/or cross straps in the case of dystonic spasms to prevent the spasm from throwing them out of chair Adequate trunk and foot support is critical to their stability

Seating : Shona Madiba buggy Custom made to fit patient and meet specific support needs Cost extremely expensive R 8000

Associated problems Speech & hearing Vocalisation & speech problem –speech poor and indistinct Often hearing loss Can hear but does not listen due constant movement head Feeding Difficulty in swallowing due to muscle incoordination Battle especially with liquids and runny consistencies Extreme difficulty in feeding safely

Associated problems Vision Battle to focus May have nystagmus = rapid, rhythmic, involuntary eye movements caused by damage brain Eyes unable move independently head Lack of stability of head affects vision

Development Fluctuating tone present sometimes birth Initially seem hypotonic Develop extension pattern head, neck, retraction shoulders Persistent ATNR Due to involuntary movements fail to develop adequate head and trunk control Athetoid very intelligent and quickly learn to use pathological reflexes for function !!!! Habitual patterns

Development Prone ATNR get up on one arm TLR and STNR to get into M-sitting Sitting Like to M-sit as is stable position Uses ATNR for hand function Chair –stabilises using arm around backrest or hooks foot around leg chair Promotes further asymmetry resulting postural deformity

Development Gait Struggle to learn to walk due to fluctuating tone, poor central control and involuntary movement Asymmetry may be noted Lumbar lordosis and anterior tilt due to poor central control Knees locked together for stability Arm held together or against leg for stability Often appears in-coordinated

Treatment Principles Fluctuating tone Stabilise postural tone NB underlying tone is on low side Address spasticity if necessary Strategies inhibit dystonic spasms Promote symmetry & good biomechanic al alignment

References Brown, E NDT basic course material (unpublished) Smith, R Paediatric dictate, UFS (unpublished) Smith, R role of physiotherapy in vestibular rehabilitation, PowerPoint presentation Images courtesy of Google images (2009)