2. Long term effects of chronic neurological conditions

Question 1

Epidemiology of chronic neuro condiitions

Answer 1

• 10 million in UK living with neurological condition impacting on their lives
• 1 million (2%) in UK disabled by their neurological condition
• 600,000 (1%) newly diagnosed each year with neurological condition

Question 2

What is spina bifida?

Answer 2

a group of congenital conditions where there is an incomplete development or covering of the brain and/or spinal cord, caused by a failure of the foetal spine to close normally in the first month of pregnancy

Question 3

Potential cause of spina bifida?

Answer 3

Folic acidic deficiency

Question 4

What is cerebral palsy?

Answer 4

Spectrum of motor disorders affecting posture, movement and co-ordination

Question 5

Cause of cerebral palsy>?

Answer 5

Brain lesion resulting in abnormal development of CNS

Question 6

Incidence and prevalence of CP?

Answer 6

2-3 per 1000 live births in the UK

Prevalence in scotland is 15,000 cases

Question 7

Spinal cord closure in…

Answer 7

first 30 days

Question 8

Anterior neuropore at closure at….

Answer 8

26 days

Question 9

Posterior neuropore closure at…..

Answer 9

29 days

Question 10

Difference between mild and severe disability in spina bifida?

Answer 10

Mild: When cord remains in neural canal

• Sac contains the meninges and CSF but not the spinal cord
• Mild disability
• Least common

Serious: Cord is displaced from the neural canal or has not been developed

Question 11

Neurological consequences of severe spina bifida

Answer 11

Lower motor neurone lesion

Paralysis, loss of sensation and reflexes distal to the abnormality

Question 12

Neonatal consequences of severe spina bifida

Answer 12

High risk of meningitis in open lesions in the neonate

Hydrocephalus in 70-90% because of the interruption of the circulation of CSF

Question 13

Shunting of hydrocephalus, problems?

Answer 13

Shunts can become infected or blocked.

Shunts used to relieve high ICP

Question 14

Hydrocephalus, associated conditions?

Answer 14

Renal anomalies
Sphincter function
Intellectual impairments Musculoskeletal

Question 15

Neural abnormalities, antenatal diagnosis techniques?

Answer 15

• Ultrasound
spinal anomalies identifiable at 16-18 weeks

• α fetoprotein raised in neural tube defects maternal serum at 16-20 weeks amniocentesis

Question 16

Potential problems associated with antenatal diagnosis?

Answer 16

• Not everyone attends for antenatal care
• Some mothers may first attend after the legal gestational age for termination
• Culture/religion may prevent abortion

Question 17

What are the neurological consequences of a L4 lesion?

Answer 17

Motor loss
• no motor function below the knee
• apart from tibialis anterior
• weak glutei

Sensory
• no sensation distal to L4

Sphincters non-functioning (S2,3,4)

Question 18

Musculoskeletal problems associated with neuro conditions?

Answer 18

LMN, muscle weakness/ paralysis Difficulties with walking
Spinal deformity possible
Disuse osteoporosis - risk of fracture
Skin ulceration

Question 19

Paralytic deformities of the feet associated with neuro conditions?

Answer 19

Difficulties with shoe wear

Plantar ulceration

(Hard to treat as with surgical aesthetic repair, muscle function deteriorates)

Question 20

Cause of scoliosis?

Surfical correction?

Answer 20

Scoliosis is due to a combination of congenital abnormalities of the spine and spinal muscle weakness

If surgical correction is required,
this is usually done after the age of 10 years to allow sufficient spinal
growth beforehand

Question 21

What factors influence walking in neuro patients?

Answer 21

Neurological level
Intellectual impairment
Psychological
Age

Question 22

Prognosis for independent walking as a adult???

Assumes no significant intellectual or psychological impairment to walking

Answer 22

 Thoracic and upper lumbar lesions – none

 Lower lumbar and sacral– can walk but will need
splints to compensate for paralysed muscles

Question 23

Mobility is not the same as ______

Answer 23

Mobility is not the same as walking

Question 24

Result of knee gait in a L4 lesion?

Answer 24

1. Patient relies on intact quadriceps
2. Paralysed calf muscles result in excess ankle dorsiflexion
3. Muscle fatigue
4. Energy inefficient gait
5. Knee pain

Question 25

Challenges to mobility as an adult with a L4 lesion

Answer 25

1. Increasing height and weight as child grows but muscle strength does not change
2. Muscle fatigue and knee pain may worsen and adult becomes more reliant on a wheelchair
3. An L4 lesion does not preclude driving, through use of adapted vehicle
4. Likely to use a self propelling or electric wheelchair for shorter distances
5. Will require adapted housing if living independently

Question 26

Possible MSK problem in joint?

Answer 26

Charcot joints: Loss of protective sensation and proprioception in a joint can result in joint destruction

Question 27

Problems associated with chronic neuro patients?

Answer 27

1. Musculoskeletal problems
2. Urinary tract consequences
3. Faecal incontinence
4. Sexual potential
5. Education

Question 28

Normal expectations of Lower Urinary Tracts

Answer 28

1. That bladder should fill to good capacity.
2. Should empty to completion.
3. Emptying should be under voluntary control.
4. That filling and emptying should not be
   detrimental to renal function.

Question 29

Features urinary incontinence in a neurogenic bladder?

Answer 29

Under S2-4 control

Incomplete bladder emptying
leads to back pressure on ureters and eventual renal
parenchymal damage and failure, if left untreated

Question 30

Techniques to achieve social continence in childhood?

Answer 30

1. Nappies (diapers) acceptable before primary school
2. Clean intermittent catheterisation often the best option - carer or patient self catherisation
   - Permanent bladder catheterisation is not a satisfactory long term solution because of a high risk of UTIs
3. Urinary diversion used for physical or social reasons (Urine drains continuously into a stoma bag)

Question 31

What are the faecal incontinence issues associates with chronic neuro conditions?

Answer 31

Faecal incontinence is often a barrier to social acceptance at any age
Paralysis of external anal sphincter and mechanism to indicate a full rectum
Some patients will have weak abdominal and perineal muscles

Treatment:
1. Daily rectal enema
2. Constipation may require laxatives or manual evacuation
3. Surgical diversion may be
necessary for physical or social reasons

Question 32

Sexual impact of chronic neuro condition?

Answer 32

Libidomay be normal

Sensation absent (S2-4)

Erections may be possible due to spinal reflex

Fertility females normal,
males usually sterile

Menstruation may cause further social difficulty

Question 33

Education impacts of chronic neuro conditions?

Answer 33

Mainstream school
Special needs school: learning and physical disability
College to acquire life skills for those with learning difficulties

Question 34

Impact on employment of chronic neuro conditions?

Answer 34

‘Ability’ rather than ‘disability’ i.e. what the young person or adult can do and not what they cannot do
Extensive UK disability legislation
Patients whose disabilities preclude employment may attend a day centre

Question 35

Aims of independent living as an adult for optimal outcome?

Answer 35

Normal intellect
Social continence stable
Independently mobile, can drive an adapted vehicle and use walking aids
Independent living using household adaptations Employed

Question 36

Challenges to independent living as a adult

Answer 36

Learning difficulties Behavioural difficulties
Social continence not achieved
Cannot transfer independently
Ageing parents
Some patients will live in a sheltered facility and be looked after by a team of carers

Question 37

Who is more socially integrated…

adults or children with CP?

Answer 37

Older people feel LESS socially integrated than younger people