2. Long term effects of chronic neurological conditions Flashcards
Epidemiology of chronic neuro condiitions
- 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
What is spina bifida?
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
Potential cause of spina bifida?
Folic acidic deficiency
What is cerebral palsy?
Spectrum of motor disorders affecting posture, movement and co-ordination
Cause of cerebral palsy>?
Brain lesion resulting in abnormal development of CNS
Incidence and prevalence of CP?
2-3 per 1000 live births in the UK
Prevalence in scotland is 15,000 cases
Spinal cord closure in…
first 30 days
Anterior neuropore at closure at….
26 days
Posterior neuropore closure at…..
29 days
Difference between mild and severe disability in spina bifida?
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
Neurological consequences of severe spina bifida
Lower motor neurone lesion
Paralysis, loss of sensation and reflexes distal to the abnormality
Neonatal consequences of severe spina bifida
High risk of meningitis in open lesions in the neonate
Hydrocephalus in 70-90% because of the interruption of the circulation of CSF
Shunting of hydrocephalus, problems?
Shunts can become infected or blocked.
Shunts used to relieve high ICP
Hydrocephalus, associated conditions?
Renal anomalies
Sphincter function
Intellectual impairments Musculoskeletal
Neural abnormalities, antenatal diagnosis techniques?
• Ultrasound
spinal anomalies identifiable at 16-18 weeks
• α fetoprotein raised in neural tube defects maternal serum at 16-20 weeks amniocentesis
Potential problems associated with antenatal diagnosis?
- Not everyone attends for antenatal care
- Some mothers may first attend after the legal gestational age for termination
- Culture/religion may prevent abortion
What are the neurological consequences of a L4 lesion?
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)
Musculoskeletal problems associated with neuro conditions?
LMN, muscle weakness/ paralysis Difficulties with walking
Spinal deformity possible
Disuse osteoporosis - risk of fracture
Skin ulceration
Paralytic deformities of the feet associated with neuro conditions?
Difficulties with shoe wear
Plantar ulceration
(Hard to treat as with surgical aesthetic repair, muscle function deteriorates)
Cause of scoliosis?
Surfical correction?
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
What factors influence walking in neuro patients?
Neurological level
Intellectual impairment
Psychological
Age
Prognosis for independent walking as a adult???
Assumes no significant intellectual or psychological impairment to walking
Thoracic and upper lumbar lesions – none
Lower lumbar and sacral– can walk but will need
splints to compensate for paralysed muscles
Mobility is not the same as ______
Mobility is not the same as walking
Result of knee gait in a L4 lesion?
- Patient relies on intact quadriceps
- Paralysed calf muscles result in excess ankle dorsiflexion
- Muscle fatigue
- Energy inefficient gait
- Knee pain
Challenges to mobility as an adult with a L4 lesion
- Increasing height and weight as child grows but muscle strength does not change
- Muscle fatigue and knee pain may worsen and adult becomes more reliant on a wheelchair
- An L4 lesion does not preclude driving, through use of adapted vehicle
- Likely to use a self propelling or electric wheelchair for shorter distances
- Will require adapted housing if living independently
Possible MSK problem in joint?
Charcot joints: Loss of protective sensation and proprioception in a joint can result in joint destruction
Problems associated with chronic neuro patients?
- Musculoskeletal problems
- Urinary tract consequences
- Faecal incontinence
- Sexual potential
- Education
Normal expectations of Lower Urinary Tracts
- That bladder should fill to good capacity.
- Should empty to completion.
- Emptying should be under voluntary control.
- That filling and emptying should not be
detrimental to renal function.
Features urinary incontinence in a neurogenic bladder?
Under S2-4 control
Incomplete bladder emptying
leads to back pressure on ureters and eventual renal
parenchymal damage and failure, if left untreated
Techniques to achieve social continence in childhood?
- Nappies (diapers) acceptable before primary school
- 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 - Urinary diversion used for physical or social reasons (Urine drains continuously into a stoma bag)
What are the faecal incontinence issues associates with chronic neuro conditions?
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
Sexual impact of chronic neuro condition?
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
Education impacts of chronic neuro conditions?
Mainstream school
Special needs school: learning and physical disability
College to acquire life skills for those with learning difficulties
Impact on employment of chronic neuro conditions?
‘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
Aims of independent living as an adult for optimal outcome?
Normal intellect
Social continence stable
Independently mobile, can drive an adapted vehicle and use walking aids
Independent living using household adaptations Employed
Challenges to independent living as a adult
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
Who is more socially integrated…
adults or children with CP?
Older people feel LESS socially integrated than younger people
