Postural Tone Research Articles

Trends in Neuropediatric Physical Therapy

Among the various diseases that cause neuromotor deficits in children, the chronic non-progressive encephalopathy [cerebral palsy (CP)] is one of the most frequent. Children affected by PC may present: sensory disorders, cognitive disorders, abnormal patterns of posture, and postural tone change (1). The literature has signaled some protocols which seem to enhance the neuromotor rehabilitation of these children.

Atypical presentation of cardiac syncope in the elderly: a case report

ABSTRACT: Syncope is defined as a transient, self-limited, loss of consciousness with an1. inability to maintain postural tone, which is followed by spontaneous recoverySyncope can be cardiac or non cardiac in origin. In elderly, cardiac syncope hasworse prognosis and can present atypically. We report the case of a 75 year oldpatient who presented with history of syncope at home after developing anallergic reaction to diclofenac and colchicine. He had non-ST elevationmyocardial infarction (NSTEMI) and angiogram revealed severe atheromatouscoronary disease with culprit right coronary artery (RCA) lesion. Transient sinusnode dysfunction secondary to ischemia was thought to cause his syncope. Hehad coronary artery bypass grafting and was discharged home a few days later.CONCLUSION: Significant coronary artery disease was unmasked in our patientby an initial allergic reaction. In elderly patients, a thorough work- up to rule outcardiac syncope is indicated.INTRODUCTIONCASE REPORTSyncope is defined as a transient, self-limited, loss of consciousness with an1 inability to maintain postural tone, which is followed by spontaneous recovery.Syncope is a common clinical problem accounting for 1-3% of all emergency2 department (ED) visits and 6% acute admissions. Assessment of syncope inpatients presenting to the emergency department is challenging because of theheterogeneity of underlying pathophysiologic processes and diseases. Althoughmany underlying causes of syncope are benign, others are associated withsubstantial morbidity or mortality, including cardiac arrhythmia, myocardial3,4 infarction, pulmonary embolism and occult hemorrhage.A 75

Influence of Asymmetrical Tonic Neck Reflex on motor development of infants with hypotony of posture

Abstract Introduction: One of the commonly used terms in the assessment of CNS functioning is muscle tone. In literature we can find many different and not standardized definitions. Postural tone depends on topographic distribution in proximal and distal parts of body and antigravital activity. For diagnostic and therapeutic purpose the term postural tone is used. The aim of this study was to assess (monitoring) the psychomotor development of infants between 2 months and 2 years of life with abnormal posture tone (hypotonia of posture) and asymmetry of postural and motor patterns. Infants participated in NDT-Bobath therapeutic intervention. Material and methods: 65 infants fulfilling specified criteria were examined during 2 years of prospective study. According to hypotonic type, infants were divided into two groups. The presence of asymmetrical tonic neck activity in spontaneous movements was coded in two-points scale (1 or 2). Results: All infants were examined at first visit with INSITE developmental scale which displayed psychomotor retardation. At the age of 2 years, only 21,87% from first group and 100% from second group still were assessed as retarded. Conclusions: Disintegrated activity ATOS decreased the level of motor development of 24-month-old infants even to 4 months of developmental age. In the second group, the number of infants with more disorders in quality of movement and decreased final developmental age is much bigger.

Minor neurological dysfunction and cognition in 9-year-olds born at term

BackgroundIn children with developmental disorders, motor problems often co-occur with cognitive difficulties. Associations between specific cognitive deficits underlying learning problems and minor neurological dysfunction (MND) are still unknown. AimsTo assess associations between specific types of MND as clinical markers of non-optimal brain function and performance in specific cognitive domains. Study designPart of a randomized controlled trial. SubjectsThree hundred and forty one 9-year-old children born at term (177 boys, 164 girls). Outcome measuresChildren were neurologically assessed to detect eight types of MND: mild dysfunction in posture and muscle tone, reflexes, coordination, fine manipulative ability, sensory function, cranial nerve function, choreiform dyskinesia and excessive associated movements. Cognitive function in the domains of attention, memory and language was evaluated using the Test of Everyday Attention for Children (TEA-Ch), a developmental neuropsychological assessment (NEPSY) and the Children's Memory Scale. ResultsFine manipulative disability and coordination problems were associated with lower scores on attention, memory and learning and language, other types of MND were not. Girls with coordination problems performed significantly worse on attention/executive function than those without this dysfunction; however, in boys, such association was absent. ConclusionParticularly, fine manipulative disability and coordination problems were associated with worse cognitive function in the domains of attention, learning and memory and language. Previous and present data suggest a minor sex difference in neurocognitive associations: in girls dysfunction of the cerebello-thalamo-cortical pathways may be associated with cognitive deficits, while in boys cognitive impairment may be associated with dysfunction of cortico-striato-thalamo-cortical pathways.

Index of Suspicion

* ALT: : alanine aminotransferase AST: : aspartate aminotransferase BUN: : blood urea nitrogen CBC: : complete blood count CNS: : central nervous system CSF: : cerebrospinal fluid CT: : computed tomography ECG: : electrocardiography ED: : emergency department EEG: : electroencephalography ESR: : erythrocyte sedimentation rate GI: : gastrointestinal GU: : genitourinary Hct: : hematocrit Hgb: : hemoglobin MRI: : magnetic resonance imaging WBC: : white blood cell A 2-year-old white girl presents with a 2-month history of a rash around her mouth and nose. On examination, she has perioral and perinasal pink papules and papulopustules, which coalesce to form thin plaques, as well as occasional periorbital papules and a small area of crusting in the perinasal region (Fig 1). The rash is nonpruritic but accompanied by a burning sensation. Notably, the patient’s vermilion border is spared. Figure 1. Perioral and perinasal pink papules and papulopustules that have coalesced to form thin plaques, occasional periorbital papules, and a small area of crusting in the perinasal region. Her past medical history is significant for a congenital cystic adenomatoid malformation (surgically resected at 6 weeks of age), atopic dermatitis, seasonal rhinitis, and asthma, requiring fluticasone propionate (44 mcg/puff twice daily) via a metered dose inhaler with spacer and face mask for the past 6 months (Fig 2). The dermatitis has been treated with over-the-counter cream and ointment without relief, but no topical products containing hydrocortisone have been used. The patient is seen by a dermatologist for the cause of the persistent facial rash, and her history and findings on physical examination lead to a presumptive diagnosis. Figure 2. Patient using metered dose inhaler with spacer and face mask. A 2-year-old boy presents with a history of seizures since the age of 9 months. The first episode started as a febrile seizure and led to status epilepticus. He was diagnosed as having generalized epilepsy of unknown origin after evaluation by a neurologist and EEG. The seizure activity initially was generalized and tonic-clonic in nature. He would drop and exhibit jerking movements of the arms and legs, followed by generalized tonic posturing, accompanied also by rolling back of the eyes, drooling, and oral cyanosis. Recently, however, his seizures have consisted of myoclonic jerks, mainly of the …

Clinical and Electroencephalographic Assessment of the State of Premature Children Treated with Cytoflavin during the First Year of Life

The aim of the present work was to perform clinical and neurophysiological assessment of the rates of neuromental development during the first year of life in preterm neonates with cerebral ischemia grade II–III, allowing for the effects of treatment with Cytoflavin and resuscitation measures. A total of 120 children with gestational ages of 28–36 weeks and body weights of 1060–3150 g were studied. The study group included 61 children whose complex treatment included Cytoflavin at a dose of 2 ml/kg/day i.v. for five days. The control group consisted of 59 patients who received basal treatment without Cytoflavin. Follow-up to a corrected age (CA) of one year included assessment of overall condition and neurological status (using a quantitative assessment of postural muscle tone on the INFANIB scale, psychomotor development on the BSID-II scale, and the functional state of the CNS by computerized electroencephalography by monitoring of physiological sleep). The results demonstrated faster normalization of all study measures of development in children receiving Cytoflavin in their complex treatment as compared with the control group.

체간근력 강화 운동이 뇌성마비 아동의 앉은 자세 균형 수행력과 근 긴장도 변화에 미치는 영향

본 연구는 경직성 양하지 뇌성마비 아동을 대상으로 하여 체간 근력 강화 운동이 앉은 자세 균형 수행력과 근 긴장도 변화에 어떠한 영향을 미치는지 알아보고자 하였다. 대상자는 대운동 분류 시스템 제 IV단계의 경직성 양하지 뇌성마비 아동 16명을 무작위로 배분하여 주 3회 6주 동안 실시하였고, 실험군은 체간 근력 강화 운동을 대조군은 기본 물리치료만 실시하였다. 체간 근력 강화 운동은 복부근과 배부근 강화를 위한 2가지 운동으로 구성하였다. 대상자들의 균형 수행력 측정은 BPM(Balance Performance Monitor)를 사용하였고 근 긴장도 측정은 MMAS(Modified Modified Ashworth Scale)를 사용하였다. 연구 결과, 앉은 자세 균형수행력 변화에서 실험군과 대조군의 동요거리, 동요속도에서 유의한 차이가 있었고(p<.05), 앉은 자세 균형 수행력 변화 비교에서 실험군과 대조군 사이에 동요속도, 동요거리에서 유의한 차이가 있었다(p<.05). 또한 근긴장도 측정 결과 실험군과 대조군의 무릎관절 굽힘근, 엉덩관절 모음근에서 유의한 차이가 나타나지 않았다(p>.05). 따라서 실험군과 대조군 모두에서 균형 수행력 향상이 나타났지만 실험군에서 조금 더 유의하게 향상되었고, 근 긴장도의 변화는 두 군에서 나타나지 않았다. 경직성 양하지 뇌성마비 아동에게 체간 근력 강화 운동은 근 긴장도의 변화 없이 앉은 자세 균형 수행력을 향상시키는데 효과적임을 알 수 있었다. This study aims to investigate the effect of trunk muscle strengthening exercises on balance performance of sitting posture and muscle tone, targeting the children with spastic diplegic cerebral palsy. 16 children with spastic diplegic cerebral palsy in IV phase of GMFCS were sampled at random and the tests were conducted for 6 weeks, 3 times per week. For experimental groups, only trunk muscle strengthening exercises were conducted and for control groups, only basic physical therapy was conducted. The trunk muscle strengthening exercise consisted of 2 exercises to strengthen abdominal muscles and back muscles. BPM(Balance Performance Monitor) was used to measure balance performance and MMAS(Modified Modified Ashworth Scale) was used to measure muscle tone. As a result, the changes of sitting balance performance in experimental groups and control groups show significant difference in the changes of sway path and sway velocity(p<.05), the comparison of changes in sitting balance performance in between experimental groups and control groups show significant difference in the changes of sway path and sway velocity(p<.05). Knee flexor muscles and hip adductor muscles in both groups show no significant difference in changes of the muscle tone(p>.05). Therefore, the balance performance in both experimental groups and control groups was improved. However, the experimental group had more significant improvement in balance performance and no change in muscle tone was detected in both groups. Thus, these findings show trunk muscle strengthening exercises are effective in improving the balance performance of sitting posture for the children with spastic diplegic cerebral palsy without changing muscle tone.

Widespread intracerebral metastases from prostate adenocarcinoma

A 62-year-old man with prostate cancer and pulmonary metastases presented with a partial-onset seizure, involving a forced leftward head deviation and tonic limb posturing. He complained of no other symptoms...

Syncope-like epileptic seizures in Panayiotopoulos syndrome

To describe the clinical features of syncope-like epileptic seizures (SLES) and their frequency in Panayiotopoulos syndrome (PS). This was a 6-year prospective study of all children aged 1-15 years referred for an EEG. PS was defined by the occurrence of at least one autonomic seizure (AS) in a neurodevelopmentally normal child and at least one EEG with focal spikes. SLES were defined as self-terminating events of sudden loss of postural tone and unresponsiveness, occurring either concurrently with other ictal autonomic symptoms and signs that characterize PS (AS + SLES) or on their own (pure SLES). PS was diagnosed in 33 of 394 consecutive children with at least one afebrile seizure (8.4%). SLES occurred at least once in 17 of 33 children (51.5%); 12 presented SLES in all their AS, and 5 had also AS without SLES. Overall, 53 of 74 AS manifested with SLES (71.6%); 25 were AS + SLES and 28 were pure SLES. The latter occurred in 7 children suddenly and without premonition or obvious triggers while standing, sitting, lying down, or asleep, did not resolve in the horizontal position, and were not associated with stiffening or any involuntary movements, even when longer than a few minutes. Concurrent autonomic symptoms during AS + SLES included emesis, incontinence, mydriasis, miosis, and cardiorespiratory abnormalities. SLES is a common ictal manifestation of PS and should be considered in the differential diagnosis of suspected syncope, particularly when clinical signs are atypical for neurocardiogenic syncope and the EEG shows focal spikes.

Neck atonia with a focal stimulation‐induced seizure arising from the SMA: Pathophysiological considerations

A 28-year-old patient with pharmacoresistant non-lesional right frontal epilepsy underwent extra‐operative intracranial EEG recordings and electrical cortical stimulation (ECS) to map eloquent cortex. Right supplementary motor area (SMA) ECS induced a brief seizure with habitual symptoms involving neck tingling followed by asymmetric tonic posturing. An additional feature was neck atonia. During atonia and sensory aura, discharges were seen in the mesial frontal electrodes and precentral gyrus. Besides motor signs, atonia, although rare and not described in the neck muscles, and sensations have been reported with SMA stimulation. The mechanisms underlying neck atonia in seizures arising from the SMA can be explained by supplementary negative motor area (SNMA) – though this was not mapped in electrodes overlying the ictal onset zone in our patient – or primary sensorimotor cortex activation through rapid propagation. Given the broad spectrum of signs elicited by SMA stimulation and rapid spread of seizures arising from the SMA, caution should be taken to not diagnose these as non-epileptic, as had previously occurred in this patient.

Review Study on Effect of Stimulation of Vestibular Apparatus on Postural Muscle Tone in Cerebral Palsy

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Rapidly Expanding Head Circumference

A baby girl is born at term to a 34-year-old multigravid mother by cesarean delivery for decreased fetal movement. Prenatal laboratory studies are unremarkable, and prenatal ultrasounds done at 10, 12, 20, 28, and 30 weeks are all normal. Delivery is complicated by meconium-stained amniotic fluid, for which the infant requires oral suctioning and some blow by oxygen. Apgars are 8 and 9 at 1 and 5 minutes. The infant is sent to the general care nursery. On examination, the birth weight is 2.9 kg (25%), length is 49 cm (50%), and head circumference is 36 cm (95%). Otherwise, her examination is unremarkable. On the second day after birth, the infant is reported by the mother to be sleepier and not feeding as well. Her exam is notable for a tense anterior fontanelle, widely spaced posterior sutures, and head circumference increased to 37 cm (>95%). A head ultrasound is performed and shows a large echogenic mass measuring 9 cm in the left cerebral hemisphere, with resultant obstructive hydrocephalus of the right lateral ventricle and midline shift to the right (Fig 1). Head computed tomography scan shows a large left hemisphere hemorrhagic mass lesion, concerning for mass versus hemorrhage. The infant is transferred to the NICU for further care. Figure 1. Head ultrasound image demonstrating a large echogenic mass in the left cerebral hemisphere measuring up to 9 cm. Mass/hemorrhage causing obstructive hydrocephalus of the right lateral ventricle and midline shift to the right. In the NICU, the infant is noted to have apnea and bradycardia, severe enough to require intubation. Sluggish pupils and intermittent tonic posturing of the upper extremities are also …

Paroxysmal nonepileptic events in pediatric patients confirmed by long-term video-EEG monitoring — Single tertiary center review of 143 patients

The purpose of the study was to evaluate the clinical characteristics of paroxysmal nonepileptic events (PNEs) in pediatric patients. Reports of 1108 patients who underwent long-term video-EEG monitoring at Seoul National University Children's Hospital were reviewed retrospectively. One hundred forty-three (12.9%) patients were diagnosed as having PNEs. The most common type of PNE was staring. Staring, tonic posturing, sleep myoclonus, and sleep-related disorders were more common in patients younger than 6years old. Psychogenic nonepileptic seizure was the most common PNE in patients older than 6years. Patients who were younger than 6years old showed shorter disease duration and more varied types of PNEs when compared to older patients (6years old or older). Presence of epilepsy was not significantly related to clinical difference in PNEs. In patients with developmental delay, staring and tonic posture were significantly more frequent than patients without developmental delay. Thirty-two patients without concurrent epilepsy were misdiagnosed with epilepsy, and AEDs were discontinued after the correct diagnosis of PNEs. Whenever the diagnosis of paroxysmal abnormal behavior is uncertain, correct diagnosis should be made using long-term video-EEG monitoring, especially in younger pediatric patients and patients with developmental delay.

Case example: Pulmonic stenosis in a Miniature Schnauzer

A nine-month-old female neutered Miniature Schnauzer was referred for the investigation of intermittent collapse episodes of two months' duration. The episodes occurred on excitement and exertion and lasted only seconds,...

Ventricular tachycardia manifested as tonic seizure

Nonepileptic seizures are sudden changes in behavior that resemble epileptic seizures but are not associated with the typical neurophysiological changes that characterize epileptic seizures. Cardiovascular disorders may cause loss of consciousness complicated by abnormal movements due to generalized cerebral hypoxia, leading to the initial impression of seizure. We report a case where a patient suffered from frequent loss of consciousness together with generalized tonic postures manifesting as leg extension, arm flexion or extension and upward gazing. These episodes were confirmed to be nonepileptic and caused by ventricular tachycardia.

The role of the electroencephalogram as a tool for the investigation of syncope

Sir, Syncope, defined as sudden loss of consciousness associated with the inability to maintain postural tone, followed by spontaneous recovery is a common cause for referral to emergency departments. Incidence of a first syncopal episode has been estimated at 6.2 per 1,000 person years or a 10-year cumulative rate of 6 % [1]. Associated risk factors are increasing age and a history of cardiovascular disease. History taking and obtaining a detailed eye-witness account of the event is of paramount importance in correctly assessing people with paroxysmal episodes of loss of consciousness. Electroencephalograms (EEGs) are frequently requested as part of the work up for patients presenting with syncope despite the fact that the potential yield from this is very low [2, 3]. We carried out a retrospective audit over 6 months of all EEG requests for the investigation of syncope. Cases with referral letters containing one or more of the following key terms were included: ‘syncope’, ‘faint’, ‘loss of consciousness’, and ‘micturition associated syncope’. The subsequent EEG results and any comments made upon the simultaneous ECG tracings were recorded. The following data were obtained from the referrals: • Referring team and specialty • Age and sex of the patient • Whether loss of consciousness was documented in the referral • Presence of cardiac symptoms at time of event • Family history of epilepsy • EEG result • Presence of ECG abnormalities, as reported by the attending neurophysiologist

An unusual case of loss of consciousness: when an epileptic brain let the heart slow down

The differential diagnosis of an episode of transient loss of consciousness can be sometimes very tricking, in particular when symptoms peculiar of syncope are mixed with focal neurological symptoms. We report the case of a 54-year-old woman who suddenly claimed, during a polygraphic recording (electroencephalography/electrocardiogram), a feeling of fear and tachycardia followed by loss of consciousness and then a tonic posturing of the left limbs. Polygraphic recording showed a critical electroencephalographic pattern starting from left temporo-zygomatic channels followed after few seconds by a sudden slowing of cortical background activity associated with an episode of asystole, as witnessed simultaneously by electrocardiogram. Muscular activity covered electroencephalographic activity of following minutes. This case provides an opportunity to highlight the existence of rare conditions such as ictal arrhythmias which should be considered in the differential diagnosis of episodes of transient loss of consciousness in particular when dysautonomic and neurological symptoms are intermingled. Autonomic symptoms (vomiting, tachycardia, cyanosis, bradycardia and asystole) may be also more frequent in idiopathic (more rarely symptomatic) epilepsies of childhood (Panayiotopoulos syndrome).

Light and Heavy Touch Reduces Postural Sway and Modifies Axial Tone in Parkinson’s Disease

Background. Light touch with a stable object reduces postural sway by increasing axial postural tone in healthy subjects. However, it is unknown whether subjects with Parkinson’s disease (PD), who have more postural sway and higher axial postural tone than healthy subjects, can benefit from haptic touch. Objective. To investigate the effect of light and heavy touch on postural stability and hip tone in subjects with PD. Methods. Fourteen subjects with mid-stage PD and 14 healthy control subjects were evaluated during quiet standing with eyes closed with their arms (a) crossed, (b) lightly touching a fixed rigid bar in front of them, and (c) firmly gripping the bar. Postural sway was measured with a forceplate, and axial hip tone was quantified using a unique device that measures the resistance of the hips to yaw rotation while maintaining active stance. Results. Subjects with PD significantly decreased their postural sway with light or heavy touch (P < .001 vs arms crossed), similarly as control subjects. Without touch, hip tone was larger in PD subjects. With touch, however, tone values were similar in both groups. This change in hip tone with touch was highly correlated with the initial amount of tone (PD, r = −.72 to −.95; controls, r = −.74 to −.85). Conclusions. The authors showed, for the first time, that subjects with PD benefit from touch similarly to control subjects and that despite higher axial postural tone, PD subjects are able to modulate their tone with touch. Future studies should investigate the complex relationship between touch and postural tone.

Combination of Hippotherapy with Technical Bobath Method in Body Extensor Control of a Patient with Tetraplegia due to Cerebral Palsy

The hippotherapy is a therapeutic method based on the practice of horsemanship activities that uses the horse as main kinesiotherapic agent. Already the Neuroevolutive concept of Bobath consecrated there are years, it is used of specific techniques of inhibition, facilitation and neuromuscular stimulation, objectifying to modify standard postural tonus and abnormal movements, facilitating standard motors of more appropriate movements. Therefore, this study has as objective to verify the evolution of an experimental protocol through exercises, associating the hippotherapy treatment to Bobath’s techniques. It was used as study object an individual of the seven year-old masculine sex, with spastic tetraplegic diagnosis due to cerebral paralysis. The apprentice presented thoracic hyperkyfosis, hypertonic flexor reaction associated to the extending hypotonic thoracic reaction of the musculature, time delay in the recovery and rectification side, deficit of lateral balance, without capacity of executing March. The procedures were accomplished in the section of hippotherapy of Unisep, in two neighbors, PR, Brazil. The apprentice accomplished fifteen sessions with maximum duration of 30 minutes on the horse. The activities were structured seeking to stimulate motive coordination, proprioception, vestibular and motor-sensory system, they provided alterations of 20% in the thoracic cifosis, it improves in the time of the lateral reactions of protection in up to 700%, it improves of the muscular force of upper extremities passing of the degree 3 for 4 according to the scale of Oxford and it improves of the muscular tonus of upper extremities of the degree 3 for 1, according to the modified scale of Ashworth

Long‐term follow‐up of febrile infection–related epilepsy syndrome

Febrile infection-related epilepsy syndrome (FIRES) is an increasingly recognized epileptic syndrome that presents with multifocal refractory status epilepticus in previously normal children and evolves into a chronic, refractory, focal epilepsy with associated cognitive and behavioral difficulties. Herein we describe the features of the chronic epilepsy and critically review evidence for the etiology of this syndrome. Seven patients with FIRES were studied. The duration of follow-up in six survivors was 5-17 years. Clinical, electroencephalography (EEG), neuroimaging, and other investigative findings during the acute and chronic phases were reviewed. These previously normal children presented with a febrile illness and status epilepticus that was refractory to antiepileptic medications in all children, to immunotherapies (including immunoglobulin, corticosteroids, plasma exchange, and rituximab) in four, and to acute vagus nerve stimulation in one. Markers of cerebral inflammation were few and response to antiepileptic and immunomodulatory therapies was poor. Evolution to chronic epilepsy occurred without a silent period. Seizure characteristics in the chronic phase were strikingly stereotyped and similar to the acute phase, with head and eye version, unilateral facial jerking, asymmetric tonic posturing, and unilateral limb jerking in all patients. Electrographic ictal onset was lateralized in all recorded seizures, unilateral in one patient, and independent bilateral in three. Seizures were refractory to multiple antiepileptic medications in all patients and partly responsive to chronic vagus nerve stimulation in two patients. Moderate to severe intellectual impairment was noted in four patients, and borderline intellectual abilities were noted in two. Magnetic resonance imaging (MRI) in the chronic phase was normal in three patients and showed mild diffuse cortical atrophy and/or mild hippocampal atrophy or sclerosis in three. The similar perirolandic and perisylvian features of acute and chronic seizures, the lack of a silent period, the absence of evidence of cerebral inflammation, and the poor response to immunotherapies suggest FIRES is best conceptualized as a chronic epilepsy with explosive onset, not a remote-symptomatic epilepsy with an acute inflammatory antecedent.