4 l’esame neurologico -...
TRANSCRIPT
FIRENZE
21 e 22 aprile 2006
Scuola Marescialli e Brigadieri dei Carabinieri
L’esame neurologico
IV SESSIONE
VALUTAZIONI NEUROEVOLUTIVE
DEL NEONATO E DEL LATTANTE
La Semeiotica neurologica nel neonato, nel lattante e nel
bambino
La Semeiotica neurologica nel neonato, nel lattante e nel
bambino
4
«esami neurologici» in uso tra i partecipanti al corso
(Treviso 1-2 dicembre 2014)
0
5
10
15
20
25
30
35
40
Non
strutturato
Strutturato Brazelton Amiel-Tison
e scuola
francese
GMs Bayley
38
7
23
9
15
8
%
Giulia 400 g, 27 s
come sarà?
normalità
funzione
autonomiaforma clinica
patologia
domande sulla prognosi
Interrogativi sulle anomalie
� E’ un’anomalia o un esito della prolungata ospedalizzazione
� E’ neurologica oppure è un abitudine posturale?
� E’ periferica o centrale?
� E’ transitoria o definitiva?
� Le anomalie riscontrate sono maggiori o minori
Patterns Of Motor Disability In Very Preterm ChildrenM. Bracewell and N. Marlow
Mental Retardation and Developmental Disabilities R esearch Reviews 8: 241–248, 2002
1. focal brain injuries patterns of brain injury, secondary to ischaemic or haemorrhagic lesions, but modified by activation of inflammatory cytokines
PVL IVH
Patterns Of Motor Disability In Very Preterm ChildrenM. Bracewell and N. Marlow
MRDDRR, 2002
2. interruption of normal brain maturation ex-utero
during the period between birth and term, the development of fiber organization or myelination of preterm
children does not keep up with the intrauterine development of infants born at term
Nagy Z Pediatr Res 2003
3. Neuromotor problems, wider than simply CP, abnormal patterns of early motor development:
minor impairment or “hidden disability”
Patterns Of Motor Disability In Very Preterm ChildrenM. Bracewell and N. Marlow
MRDDRR, 2002
4. the results of nursing postures
Patterns Of Motor Disability In Very Preterm ChildrenM. Bracewell and N. Marlow
MRDDRR, 2002
5. the results of chronic lung disease
Patterns Of Motor Disability In Very Preterm ChildrenM. Bracewell and N. Marlow
MRDDRR, 2002
Why Is the Neurological Examination So Badly Neglected in Early Childhood?
Claudine Amiel-Tison, Julie Gosselin and Sheila Gahagan
2005;116;1047
� survival
� respiratory, nutritional, neurodevelopmental vulnerabilities and disabilities
� resiliency
M. E. MsallEarly Human Development (2006) 82:157-166
PN 580 g, EG 26,6 w
modificabilità
resilienza
adattabilità
variabilità
Tono
Tono
� Ipertonia o paratonia
• Ajuriaguerra J, 1993
Tono
� Ipertonia o paratonia
� Ipotonia vs ipostenia
• Grenier A, 1985
Tono
� Ipertonia o paratonia
� Ipotonia o ipostenia
� midollare (riflesso miotatico) o ad integrazione corticale/sottocorticale (il controllo posturale)
• Thomas A, 1952
Tono
� Ipertonia o paratonia
� Ipotonia o ipostenia
� midollare (riflesso miotatico) o ad integrazione corticale/sottocorticale (il controllo posturale)
� problema neurologico (spasticità) o una componente reologica del muscolo (estensibilità)
• Tardieu A, 1988
19
� Paralisideficit di reclutamento di unità motorie: ipostenia, ipomobilità, deficit del comando volontario
� Iperattività muscolareriorganizzazione reattività spinale (sprouting): abnorme reazione allo stiramento, abnorme irradiazione, cocontrazione
� Contrattura cambiamenti nelle proprietà reologiche del muscolo (viscosità, elasticità, perdita di sarcomeri, accumulo di tessuto connettivo): riduzione lunghezze muscolari ( ►accorciamenti muscolari e tendinei, retrazione)
Spasticità
Fenomeni di origine centrale o periferica
13,48
Tono � Condizioni ambientali
Esami neurologiciad orientamento classico
André-Thomas, 1952Precthl e Beintema, 1964Saint-Anne Dargassies, 1955,1977Brazelton, 1977
Esami neurologici recenti
Amiel-Tison e A. Stewart 1994Precthl, Ferrari, Cioni 1990Dubowitz, Dubowitz, Mercuri 1999Lester, Tronick 2004
Strumenti a nostra disposizione
André-Thomas , Saint-Anne-Dargassies S . Etudes neurologiques sur le nouveau-né et le jeune nourisson, Masson 1952 .
Andre-Thomas A, Chesni Y, Saint Anne Dargassies S. The neurological examination of the infant. Clinics in Developmental Medicine 1. London: Heinemann; 1960
Amiel-Tison C, Grenier A, 1985
Amiel-Tison, 1985
Tono passivo (tono a riposo)
Si valuta l’estensibilità del muscolo attraverso la ampiezza del movimento passivo effettuata lentamente e delicatamente dall'esaminatore
MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES R ESEARCH REVIEWS 11: 34–51 (2005)
The Amiel-Tison Neurological Assessment at Term: Conceptual and Methodological Continuity in the course of Follow-up
test - the active engagement of agonist and antagonist muscles in the axis, the antigravity forces (lower system) and the control exerted on these forces by the upper system
Tono attivo
si riferisce a movimenti attivi del bambino in reazione a determinate situazioni proposte dall'esaminatore
Amiel-Tison, 1985
A. Sistema Inferiore Sottocorticale
• funzione antigravitaria• automatismi innati
B. Sistema Superiore Corticospinale
• Influenze inibitrici ed eccitatrici sul mn,
• controllo posturale dell’asse,
• motricità volontaria e fine delle dita
Amiel-Tison, 2002
Update of the Amiel-Tison Neurologic Assessment for the Term Neonate or at 40 Weeks Corrected Age
Claudine Amiel-Tison, Pediatric Neurology, 2002
Cohort profile.
Leroux B G et al. BMJ Open 2013;3:e002431
©2013 by British Medical Journal Publishing Group
Five of the 13 items from the Amiel-Tison neurologi cal assessment tool at term were significantly associated with suboptimal neuromotor developmental status at 2 years.
Leroux B G et al. BMJ Open 2013;3:e002431
©2013 by British Medical Journal Publishing Group
Evaluation neurologique de la naissance à 6 ansC. Amiel-Tison, J Gosselin, 2007Evaluation neurologique de la naissance à 6 ansC. Amiel-Tison, J Gosselin, 2007
1-9 Month 12
3 4
A. Grenier (1990)
Quali competenze per il neonato
Concetto di motricità liberata
Criteri di normalità (A. Grenier)
Concetto di concatenamenti
rapporti reciproci tra asse arti componenti prossimali e distali che valutano l’integrazione dei sistemi preposti al movimento
to compare � Early Assessment of Motor Abilities in Infancy (EPAM), by M. Le Metayer,
� the Standard Amiel-Tison examination (EDS),
Neonatology Departments
• Saint-Étienne, France
• Roanne, France
• Rouen, France
• Liège, Belgique
• Mangiagalli, Milan, Italie
M. Le Métayer. Bilan cérébromoteur du jeune enfant. EMC, Médecine physique et Réadaptation 2009:1-31 (26-028-B-20).
Prospective Multicenter International Study «Etude EPAM», 2011-2013
Exam des Attitudes Motrices Précoces (EPAM)
• 227 children from five Belgian, Italian or French department of neonatology over a period of 2 years
• the predictive power is statistically equivalent
• EPAM method finds its interest in the clinical examination to apprehend neuromotor damage of infants with a neurological established risk.
Neonatal Intensive Care Unit Network (NNNS)
Training Presentation
Neonatal Intensive Care Unit Network (NNNS)
Training Presentation
NNNSNNNS
NICUNICU
Network Network
Neurobehavioral Neurobehavioral
Scale Scale
What is it & how
can we use it in
NICU Research and Practice?
SCALA NNNS Lester Tronick, 2004
NNNS Neonatal Intensive Care Unit Network
NNNS Packages & Procedures:
Preexamination Observation
Habituation
Unwrap & Supine
Lower extremity reflexes
Upper extremities and facial reflexes
Upright Responses
Infant prone
Pick up infant
Infant supine on examiner’s lap
Infant spin
Infant supine in crib
Post examination Observation
Consolability
Habituation
� Light
� Rattle
� Bell
4 min (2,15-3,30), 1° filmato
Pick Up Infant
• Cuddle in arms
• Cuddle on shoulder
(12,30 min)
17-18 1° filmato
Infant Supine on examiner’s lap
Orientation
� Animate visual
� Animate visual & auditory
� Inanimate visual
� Inanimate auditory
� Inanimate visual & auditory
� Animate auditory
The order of the orientation items is not predetermined. The rattle and face/ voice are more arousing and should be used if the infant is not maintaining a state 4 or 5.
Consolability
11,45-12,45 1° filmato NNNS
Administer consolability procedure after the infant has been in a sustained state 6 for at least 15 seconds. Wait 15 seconds to give infant opportunity to calm on own. If the infant does not get to state 4 or lower, begin with face alone and then proceed through items 10 to 2.
10. Face alone9. Voice and face8. Hand steadily on belly7. Hand on belly and restraining one or
both arms6. Picking up and holding in arms5. Picking up and holding on shoulder4. Holding and rocking3. Wrapping, holding in arms or on
shoulder, and rocking2. Pacifier or finger to suck in addition to
wrapping , holding , and rocking.
L. Dubowitz, V. Dubowitz, E. MercuriHammersmith Hospital,Clinics in Developmental Medicine, No.148 Mac Keith Press, 2000
Dubowitz L, Dubowitz V. The neurologicalassessment of the preterm andfull term infant. Clinics in Developmental Medicine vol 79. London: Heinemann; 1981.
HammersmithInfantNeurologicalExamination
Early Human Development (2005) 81, 947—956
DM Romeo, D Ricci et al , Neurologic Assessment Tool for Screening Preterm Infants at Term Age, J. OF PEDIATRICS, 2012
I GMs, sono pattern motori complessi, di origine endogena, coinvolgono tutte le partì del corpo, durano da alcuni secondi a un minuto
la sequenza, la velocità, la forza, l’ampiezza delle parti che si muovono, ladirezione dei movimenti, sono variabili anche nel corso dello stesso GM.
l'inizio e la fine del GM sono graduali
l’intensità del movimento varia continuamente con «crescendo» e «decrescendo» durante il corso di un GM
General Movements (Prechtl, 1990)
I GENERAL MOVEMENTS
WRITHING PERIOD
FIDGETY
PERIOD
VOLUNTARY
AND
ANTIGRAVITAR
Y MOVEMENTS
I GENERAL MOVEMENTS
NEL WRITHING PERIOD
NORMALITA’
NORMAL
ANORMALITA’
POOR
REPERTOIRE
CRAMPED
SYNCRONIZED CHAOTIC
I GENERAL MOVEMENTS
NEL FIDGETY PERIOD
NORMALITA’
FIDGETY
ANORMALITA’
ABNORMAL FIDGETY ABSENT FIDGETY
I AMPIEZZA 1 prevalentemente piccola
1 prevalentemente grande
1 piccola e grande, senza vie di mezzo
2 variabile
II VELOCITA’ 1 costantemente bassa
1 costantemente alta
1 bassa e alta, senza vie di mezzo
2 variabile
III SEQUENZE 1 disorganizzate
1 monotona nell’ambito di un solo GM
1 ripetizione della stessa sequenza da un GM all’altro
2 sequenza variabile
IV SETTORI DELLO SPAZIO 1 non variabili, su un solo piano
2 variabili
Ferrari F et al, Detailed scoring on GMs during preterm, term and early postterm age,, Ealy Hum Dev 1990, 23:151-156
V FLUIDITA’ ED ELEGANZA 1 Non fluente, poche rotazioni
1 Non fluente, rotazioni assenti
2 fluente ed elegante, con molte rotazioni
VI INIZIO E FINE 1 brusco
1 piccole variazioni di intensità
2 smooth, graduale crescendo e decrescendo
VII MOVIMENTI FINI DISTALI 1 pugno
1 movimenti delle dita rari o assenti
1 solo apertura e chiusura sincronizzata delle dita
1 pochi movimenti variabili delle dita
2varietà di movimenti delle dita e delle mani, rotazioni
incluse
Ferrari F et al, Detailed scoring on GMs during preterm, term and early postterm age,, Ealy Hum Dev 1990, 23:151-156
VIII CARATTERI DEL MOVIMENTO 1 cramped
1 floppy
1 flapping
1 tremolous
1 poor
2 complex and variable
Global Judgement
Normal
Poor repertoire
Cramped syncronised
Chaotic
Hypokinesia
Normal
Poor repertoire
Cramped syncronised
Chaotic
Hypokinesia
Ferrari F et al, Detailed scoring on GMs during preterm, term and early
postterm age,, Ealy Hum Dev 1990, 23:151-156
GMs – Dati peri-neonatali
Normal
Degenza in TIN
< 60 gg
(p=0,04)
Fidgety
RM normale
(p=0,05)
No WMD
(p=0,05)
Cramped
Syncronized
RM patologica
(p=0,02)
WMD
(p=0,02)
Absent
Fidgety
RM patologica
(p=0,02)
WMD
(p=0,03)
Poor
Repertoire
N.S.
Abnormal
Fidgety
Sesso maschile
(p=0,07)
Tesi di laurea STUDIO OSSERVAZIONALE SUL VALORE PROGNOSTICO DEI GENERAL MOVEMENTS, 2014
Prognosi
N e F PR e AFCS e F-
Outcome
neuroevolutivo
NORMALE
Outcome
neuroevolutivo
PATOLOGICO
AIM Review the properties of neurobehavioural and neuromotor assessments for preterm infants.
METHOD77 assessment measures were identified. 8 met the study inclusion criteria:
1. Assessment of Preterm Infants' Behaviour (APIB),
2. Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS),
3. Brazelton Neonatal Behavioural Assessment Scale (NBAS).
4. Test of Infant Motor Performance (TIMP),
5. Prechtl's Assessment of General Movements (GMs),
6. Neurobehavioural Assessment of the Preterm Infant (NAPI),
7. Dubowitz Neurological Assessment of the Preterm and Full-term Infant (Dubowitz),
8. Neuromotor Behavioural Assessment (NMBA),
Measures of assessment were included if
(1) they were primarily neurobehavioural or neuromotor assessments suitable for preterm infants up to 4 months c. a. and were discriminative, predictive, or evaluative
(2) standardized procedures designed for serial/longitudinal use
(3) criterion or norm referenced
DEV MED & CHILD NEUROLOGY, 2012, 54:129-139
� the NNNS and APIB have strong psychometric qualities with better utility for research.
� the GMs, TIMP, and NAPI have strong psychometric qualities but better utility for clinical settings.
� the GMs has best prediction of future outcome and the TIMPhas best evaluative validity
DEV MED & CHILD NEUROLOGY, 2012, 54:129-139
Strumenti a nostra disposizione
* Amiel-Tison tono e integrazione sottosistemi
* Dubowitz, Dubowitz, Mercuri studi normativi preterm vs at term
* Lester, Tronick (NNNS) orientamento, comportamento
* Precthl, Cioni, Ferrari qualità della motricità spontanea