Forms of children's cerebral palsy. Atonic-astatic form (at an early age, hypotonic form). Atonic-astatic form of cerebral palsy

10.07.2019

double hemiplegia

This is the most severe form of cerebral palsy occurs with significant brain damage in the period of intrauterine life.

Movement disorders are detected already in the neonatal period, as a rule, there is no protective reflex, all tonic reflexes are sharply expressed.

The functions of the arms and legs are practically absent. The mental development of children is usually at the level of mental retardation in a moderate or severe degree.

Spastic diplegia

This is the most common form of cerebral palsy, known as Little's disease or syndrome. In terms of the prevalence of motor disorders, spastic diplegia is tetraparesis (i.e., the arms and legs are affected), but the lower limbs are affected to a much greater extent.

In children with spastic diplegia, secondary mental retardation is often observed, 30-35% of children suffer from mild mental retardation. 70% have speech disorders in the form of dysarthria, much less often in the form of motor alalia.

Depending on the severity of motor disorders, there are severe, moderate and mild degrees of spastic diplegia.

Hemiparetic form

With this form, one side of the body is affected, the left side with a right-sided brain lesion and the right side with a left-sided one. With this form of cerebral palsy, the upper limb is usually more severely affected. Right-sided hemiparesis is more common than left-sided.

Hyperkinetic form

Atonic-astatic form

mixed form

With it, there are combinations of all the above forms: spastic-hyperkinetic, hyperkinetic-cerebellar, etc. Speech and intellect disorders occur with the same frequency.

5. Etiology and pathogenesis of cerebral palsy

The term "cerebral palsy" combines syndromes of movement disorders resulting from brain damage in the early stages of ontogenesis.

Pathogenesis of cerebral palsy

Structural changes in the brain in children with cerebral palsy are divided into two groups:

Nonspecific changes in the cells themselves;

Changes associated with impaired brain development, i.e., with dysontogenesis.

The most vulnerable are those processes that are more active at the moment. This can explain the variety of observed morphological changes in the brain of deceased children with cerebral palsy.

There is a relationship between the severity of cerebral cortex impairment and clinical manifestations of movement disorders.

Cerebral palsy is a residual condition, i.e. does not have a progressive course. However, as the child develops, various manifestations of insufficiency of motor, speech and other mental functions may change, which is associated with the age-related dynamics of the morphological and functional relationships of the pathologically developing brain. In addition, more pronounced manifestations of decompensation may be determined by the growing discrepancy between the capabilities of the damaged central nervous system and the requirements of the environment as the child grows. The phenomena of decompensation can also increase with the complication of motor disorders by various pathological neurological and psychopathological syndromes. Among them, the most important are: hypertensive-hydrocephalic syndrome, convulsive syndrome, syndrome of vegetative-visceral dysfunctions, persistent cerebrasthenic syndrome.

The basis of cerebral palsy is intrauterine or perinatal damage to the child's brain under the influence of various adverse factors that acted during the intrauterine period of development and (or) at the time of birth. In more rare cases (about 2-3%), a genetic factor may play a role in the occurrence of cerebral palsy.

Prenatal factors

There are usually 3 groups of these factors:

1. the state of health of the mother;

2. deviations during pregnancy;

3. factors that disrupt the development of the fetus.

Postnatal factors

At the postnatal stage, the following causes of deviations are distinguished:

Injuries: skull and bones, subdural hematomas, etc.;

Infections: meningitis, encephalitis, brain abscess;

Intoxication: drugs, antibiotics (streptomycin), lead, arsenic, etc.;

Oxygen deficiency: suffocation, drowning
and etc.;

With neoplasms and other acquired abnormalities in the brain: brain tumors, cysts, hydrocephalus, etc.

A significant number of cases of cerebral palsy are classified as a group with unknown etiology (according to some authors, up to 30% of cases).

6. Spastic diplegia. Clinical characteristics

In children with spastic diplegia, secondary mental retardation is often observed, which can be eliminated by the age of 6-8 if treatment is started early and properly carried out; 30-35% of children with spastic diplegia suffer from mild mental retardation. 70% have speech disorders in the form of dysarthria, much less often in the form of motor alalia.

The severity of speech, mental and motor disorders varies widely. This is due to the time and strength of the action of harmful factors. Depending on the severity of the brain damage, already in the neonatal period, congenital motor reflexes are weakly expressed or do not appear at all: protective, crawling, supports, stepping movements of the newborn, etc., i.e., the basis is violated, on the basis of which the installation reflexes are formed. The grasping reflex, on the contrary, is most often strengthened, as well as tonic reflexes: cervical, labyrinth; and the degree of their severity can increase by 2-4 months. life.

The tone of the muscles of the tongue is sharply increased, so that it is brought to the root, and its mobility is sharply limited. The child's eyes go up. Thus, the functions of vision and speech are drawn into a vicious circle.

With the severity of the symmetrical neck-tonic reflex, when the head is bent, a flexion posture occurs in the arms and an extensor posture in the legs, and when the head is extended, on the contrary, the arms are extended and the legs are bent. This rigid connection of tonic reflexes with muscles by 2-3 years leads to the formation of persistent pathological synergies and, as a result, to persistent vicious postures and attitudes.

By the age of 2-3, vicious postures and attitudes become persistent, and from that time on, depending on the severity of motor disorders, severe, moderate and mild degrees of spastic diplegia are distinguished.

Children with severe unable to move independently or using crutches. The manipulative activity of their hands is significantly reduced. These children do not serve themselves or serve partially. They relatively quickly develop contractures and deformities in all joints of the lower extremities. 70-80% of children have speech disorders, 50-60% - mental retardation, 25-35% - mental retardation. In these children, for 3-7 years or more, tonic reflexes are not reduced and adjusting rectifying reflexes are hardly formed.

Children from medium degree the severity of the motor lesion moves independently, although with a defective posture. They have a well-developed manipulative activity of the hands. Tonic reflexes are expressed slightly. Contractures and deformities develop to a lesser extent. Speech disorders are observed in 65-75% of children, mental retardation - in 45-55%, in 15-25% - mental retardation.

Children with mild degree The severity of motor damage is noted by awkwardness and slowness of the pace of movements in the hands, a relatively slight limitation of the volume of active movements in the legs, mainly in the ankle joints, a slight increase in muscle tone. Children move independently, but their gait remains somewhat defective. Speech disorders are observed in 40-50% of children, mental retardation - in 20-30%, mental retardation - in 5%.

Prognostically, spastic diplegia is a favorable form of the disease in relation to overcoming mental and speech disorders and less favorable in relation to the formation of locomotion.

7. Double hemiplegia. Clinical characteristics

This is the most severe form of cerebral palsy occurs with significant brain damage in the period of intrauterine life. All clinical manifestations are associated with pronounced destructive-atrophic changes, expansion of the subarachnoid spaces and the ventricular system of the brain. There is a pseudobulbar symptom, salivation, etc. All the most important human functions are severely impaired: motor, mental, speech.

Motor disorders are detected already in the neonatal period, as a rule, there is no protective reflex, all tonic reflexes are sharply expressed: labyrinthine, cervical, reflex from the head to the body and from the pelvis to the body. Chain setting reflexes do not develop; the child cannot learn to sit, stand and walk independently.

The functions of the arms and legs are practically absent. Rigidity of the muscles always predominates, aggravated under the influence of 1 remaining intense tonic reflexes (cervical and labyrinthine). Due to the increased activity of tonic reflexes, the child in the position on the stomach or back has a pronounced flexion or extension posture (see Fig. 1). When supported in an upright position, as a rule, there is an extensor posture with the head hanging down. All tendon reflexes are very high, muscle tone in the arms and legs is sharply impaired. Voluntary motor skills are completely or almost not developed [T.G. Shamarin, G.I. Belova, 1999].

The mental development of children is usually at the level of mental retardation in a moderate or severe degree.

No speech: anartria or severe dysarthria.

The prognosis for the further development of motor, speech and mental functions is extremely unfavorable. The diagnosis of "double hemiplegia" indicates the complete disability of the child.

8. Hemiparetic form of cerebral palsy. Clinical characteristics

This form of the disease is characterized by lesions of one-sided arms and legs. In 80% of cases, it develops in a child in the early postnatal period, when, due to injuries, infections, etc., the emerging pyramidal pathways of the brain are affected. With this form, one side of the body is affected, the left side with a right-sided brain lesion and the right side with a left-sided one. With this form of cerebral palsy, the upper limb is usually more severely affected. Right-sided hemiparesis is more common than left-sided. Apparently, the left hemisphere, when exposed to harmful factors, suffers primarily as a younger phylogenetically, the functions of which are the most complex and diverse. 25-35% of children have a mild degree of mental retardation, 45-50% have secondary mental retardation, which can be overcome with timely rehabilitation therapy. Speech disorders are observed in 20-35% of children, more often by the type of pseudobulbar dysarthria, less often by motor alalia.

After the birth of a child with this form of cerebral palsy, all innate motor reflexes are formed. However, already in the first weeks of life, limitation of spontaneous movements and high tendon reflexes in the affected limbs can be detected; the support reflex, stepping movements, crawling are worse expressed in the paretic leg. The grasp reflex is less pronounced in the affected hand. The child begins to sit on time or with a slight delay, while the posture is asymmetrical, which can lead to scoliosis.

Manifestations of hemiparesis are formed, as a rule, by 6-10 months of a child's life, which gradually increase (Fig. 3). Starting from 2-3 years of age, the main symptoms of the disease do not progress, they are in many ways similar to those observed in adults. Movement disorders are persistent, despite ongoing therapy.

There are 3 degrees of severity of the hemiparetic form of cerebral palsy: severe, moderate, mild.

At severe lesions of the upper and lower limbs, pronounced violations of muscle tone are observed according to the type of spasticity and rigidity. The volume of active movements, especially in the forearm, hand, fingers and foot, is minimal. Manipulative activity of the upper limb is practically absent. The hand, the length of all phalanges of the fingers, the shoulder blade, and the foot are reduced. In the paretic arm and leg, muscle hypotrophy and bone growth retardation are noted. Children begin to walk on their own only from 3-3.5 years, while there is a gross violation of posture, scoliosis of the spinal column and pelvic tilt are formed. In 25-35% of children, mental retardation is detected, in 55-60% - speech disorders, in 40-50% - convulsive syndrome.

At moderate lesions of the motor function, violations of muscle tone, trophic disorders, limitation of the volume of active movements are less pronounced. The function of the upper limb is significantly impaired, but the patient can take objects with his hand. Children begin to walk independently from 1.5-2.5 years old, limping on a sore leg, relying on the forefoot. 20-30% of children have mental retardation, 15-20% have mental retardation, 40-50% have speech disorders, and 20-30% have convulsive syndrome.

At mild degree lesions of violation of muscle tone and trophism are insignificant, the volume of active movements in the hand is preserved, but awkwardness of movements is noted. Children begin to walk independently from 1 year 1 month. - 1 year 3 months without rolling the foot in the affected leg. In 25-30% of children, mental retardation is noted, in 5% - mental retardation, in 25-30% - speech disorders.

9. Hyperkinetic form of cerebral palsy. Clinical characteristics

The cause of this form of cerebral palsy is most often bilirubin encephalopathy as a result of hemolytic disease of the newborn. Less commonly, the cause may be prematurity followed by traumatic brain injury during childbirth, in which there is a rupture of the arteries that supply blood to the subcortical nuclei.

In the neurological status of these patients, hyperkinesias (violent movements), muscle rigidity of the neck, trunk, and legs are observed. Despite the severe motor defect, the limited possibility of self-service, the level of intellectual development in this form of cerebral palsy is higher than in the previous ones.

After the birth of such a child, congenital motor reflexes are disturbed: congenital movements are sluggish and limited. The sucking reflex is weakened, coordination of sucking, swallowing, breathing is disturbed. In some cases, muscle tone is reduced. At 2-3 months, sudden muscle spasms may occur. Reduced tone is replaced by dystonia. Adjusting chain reflexes are significantly delayed in their formation. The delay in the formation of adjusting reflexes, muscular dystonia, and subsequently hyperkinesis disrupt the formation of normal postures and lead to the fact that the child cannot learn to sit, stand and walk independently for a long time. Very rarely, a child begins to walk independently from 2-3 years old, most often independent movement becomes possible at 4-7 years old, sometimes only at 9-12 years old.

In the hyperkinetic form of cerebral palsy, hyperkinesis of a different nature can be observed, they are most often polymorphic.

There are types of hyperkinesis: choreiform, athetoid, choreatetosis, parkinsonian tremor. Choreiform hyperkinesis is characterized by fast and jerky movements, most often it is more pronounced in the proximal limbs (see Fig. 4). Athetosis is characterized by slow, worm-like movements that occur simultaneously in the flexors and extensors, and occurs predominantly in the distal extremities.

Hyperkinesis occurs from 3-4 months of a child's life in the muscles of the tongue and only by 10-18 months appears in other parts of the body, reaching its maximum development by 2-3 years of age. The intensity of hyperkinesis increases under the influence of exteroceptive, proprioceptive and especially emotional stimuli. At rest, hyperkinesis is significantly reduced and almost completely disappears during sleep.

Violation of muscle tone is manifested by dystonia. Often, many children have ataxia, which is masked by hyperkinesis and is detected during its reduction. Many children have a decrease in facial expressions, paralysis of the abducens and facial nerves. Almost all children have expressed vegetative disorders, significantly reduced body weight.

Speech dysfunction occurs in 90% of patients, more often in the form of hyperkinetic dysarthria, mental retardation - in 50%, hearing loss - in 25-30%.

Intelligence in most cases develops quite satisfactorily, and learning difficulties can be associated with severe disorders of speech and voluntary motor skills due to hyperkinesis.

Prognostically, this is a completely favorable form in terms of learning and social adaptation. The prognosis of the disease depends on the nature and intensity of hyperkinesis: with choreic - children, as a rule, master independent movement by 2-3 years; with double athetosis, the prognosis is extremely unfavorable.

10. Atonic-astatic form of cerebral palsy. Clinical characteristics

This form of cerebral palsy is much less common than other forms, characterized by paresis, low muscle tone in the presence of pathological tonic reflexes, impaired coordination of movements, balance.

From the moment of birth, the failure of congenital motor reflexes is revealed: there are no support reflexes, automatic gait, crawling, weakly expressed or absent, protective and grasping reflexes (see Fig. 6). Reduced muscle tone (hypotension). Chain adjusting reflexes are significantly delayed in development. Such patients begin to sit independently by 1-2 years, walk -6 years.

By the age of 3-5, with systematic, directed treatment, children, as a rule, master the possibility of voluntary movements. Speech disorders in the form of cerebellar or pseudobulbar dysarthria are observed in 60-75% of children, there is a mental retardation.

As a rule, with this form of cerebral palsy, the fronto-iosto-cerebellar pathway, frontal lobes and cerebellum are affected. Characteristic symptoms are ataxia, hypermetria, intentional tremor. In those cases where there is a pronounced immaturity of the brain as a whole, and the pathological process extends mainly to its anterior sections, mental retardation is found more often in mild, less often moderate severity, euphoria, fussiness, and disinhibition are observed.

This form is prognostically severe.

11. Early diagnosis and prognosis of the development of children with cerebral palsy

Establishing an early diagnosis of cerebral palsy is very important for the effectiveness of its subsequent treatment. Such a diagnosis is rather complicated, which, unfortunately, is facilitated by the fact that such a diagnosis is not given sufficient importance.

Usually, the assumption of the presence of cerebral palsy is confirmed in the second half of the first year of life, when movement disorders become noticeable. At the same time, it showed that when examining children aged 1, 6, 8, 12 months. in high-risk groups using sensorimotor indicators on the appropriate scale by 6 months, highly informative data on the possible course of further development of cerebral palsy can be obtained. An analysis of individual indicators of deviations showed that if by 8 months there are three or more altered indicators of development, then the possibility of developing cerebral palsy is high.

At the same time, compared with healthy children, already at the age of 4 months, children with cerebral palsy have significantly reduced indicators of the development of intellectual abilities. As a symptom suspicious of the presence of cerebral palsy, a change in muscle tone, the state of "childish" reflexes, a delay in the development of movement, and atypical movements are usually considered.

Even in children with relatively mild manifestations of motor disorders, there is a delay in mental and speech development in the first years of life. In some patients, this condition is further smoothed out, but in some children certain disorders of mental development and speech remain of varying degrees of severity. Most patients with cerebral palsy have disorders of vision, kinesthesia, vestibular system, body scheme, which entails a pathology of spatial representations, and hence reading and writing disorders, a restriction in the choice of profession.

Some children with cerebral palsy have a strong decrease in activity, a lack of motivation to act and communicate with others, impaired development of cognitive activity, emotional and volitional disorders, and there are certain attention disorders: low activity, inertia, difficulty in engaging in purposeful activities, high distractibility, etc. d.

In the syndrome of cerebral palsy, intellectual disorders are of great importance, which are characterized by a dissociated development of mental functions. Such violations are different in nature and degree in various forms of cerebral palsy.

Damage to still immature brain structures significantly affects the further development of cognitive processes and the personality of children with cerebral palsy. It is known that dead nerve cells are not capable of recovery, but the extraordinary functional plasticity of the child's nervous tissue contributes to the development of compensatory capabilities. Therefore, corrective work started in a timely manner with sick children is important in overcoming speech disorders, visual-spatial functions, and personal development.

Long-term experience of domestic and foreign specialists working with children with cerebral palsy has shown that the earlier the medical, psychological and pedagogical rehabilitation of these children is started, the more effective it is and the better its results.

Of particular difficulty is the prognostic assessment of the psychomotor development of children with cerebral palsy. A favorable prognosis is most likely in spastic diplegia and hemiparetic forms of cerebral palsy.

12. Clinical symptoms of damage to the motor sphere in cerebral palsy

It is possible to identify the broken links common to all forms of cerebral palsy, which constitute the structure of the motor defect in cerebral palsy.

1. The presence of paralysis and paresis.

Central paralysis - complete inability to make voluntary movements Paresis - a weak form of paralysis, which is expressed in limiting the ability to make voluntary movements (limitation of range of motion, decreased muscle strength, etc.). Central paralysis and paresis are caused by damage to the motor areas and motor pathways of the brain.

2. Violation of muscle tone.

Spasticity, muscle hypertension - increased muscle tone.

Muscular dystonia - variability in muscle tone.

Muscular hypotension - muscles are characterized by weakness, flabbiness, lethargy.

3. Increased tendon and periosteal (periosteal) reflexes (hyperreflexia) .

Tendon and periosteal reflexes are increased, the zone of their induction (reflexogenic zone) is expanded. The extreme degree is manifested by clonus - rhythmic, long-lasting contractions of a muscle that occur after its sharp stretching.

4. Synkinesis (friendly movements) .

Synkinesias are involuntary movements accompanying voluntary ones. There are physiological and pathological synkinesis.

5. Insufficient development of chain rectifying reflexes .

With underdevelopment of these reflexes, it is difficult for a child to keep the head and torso in the desired position.

6. Unformed reactions of balance and coordination of movements.

The balance of the body is the state of a stable position of the body in space. There is a static balance of the body (when standing) and a dynamic balance (when moving).

Disturbances in body balance and coordination of movements are manifested in an abnormal gait, which is observed in various forms of cerebral palsy.

7. Violation of the sensation of movements (kinesthesia).

In all forms of cerebral palsy, kinesthetic sensitivity is disturbed, which leads to difficulties in determining the position of one's own body in space, to difficulties in maintaining balance and maintaining a posture, to impaired coordination of movements, etc. Many children have a distorted perception of the direction of movement. For example, the movement of the hand forward in a straight line is felt by them as a movement to the side.

8. Violent movements.

Violent movements are expressed in hyperkinesis. Violent movements significantly complicate the implementation of arbitrary motor acts.

9. Protective reflexes.

Symptoms of damage to the pyramidal system, manifested in central paralysis. Protective reflexes are involuntary movements, expressed in flexion or extension of a paralyzed limb when it is stimulated.

10. Pathological reflexes (flexion and extension).

Pathological reflexes are called, which in an adult healthy person are not caused, but appear only with lesions of the nervous system.

Pathological reflexes are divided into flexion and extensor (for limbs). 11.Pozotonic reflexes.

Pozotonic reflexes are congenital unconditionally reflex motor automatisms. With normal development by 3 months. In life, these reflexes already fade away and do not appear, which creates optimal conditions for the development of voluntary movements. Preservation of postural reflexes is a symptom of CNS damage, a symptom of cerebral palsy.

13. Characteristics of motor functions in children with cerebral palsy

In children with cerebral palsy, the formation of all motor functions is delayed or impaired: holding the head, skills of sitting, standing, walking, and manipulative activity. Large variations in the timing of the development of motor functions are associated with the form and severity of the disease, the state of intelligence, with the time of the beginning of systematic treatment and correction work.

For children with cerebral palsy in the first five months of life, a strong lag in the development of their motor functions is characteristic.

Only a small part of children can hold their head by 5 months. They have a pathological condition of the hands, characterized by bringing the first finger to the palm and tightly clenching the fists. In some cases, the brush is paretic, hanging down. The vast majority of children lack hand-eye coordination. The position of the child's body in some cases is forced with the head thrown back, which limits the child's field of vision and is one of the reasons for the delay in his mental development from the first months of life. The general muscle tone is pathologically changed, in most cases with a tendency to increase it. Already at this age, a delay in motor development is combined with a lag in the development of voice activity and orienting-cognitive activity of the child.

By 12 months, only a small number of children hold their heads, mostly children cannot sit on their own, which negatively affects the development of their cognitive activity. Most children have a pathological condition of the hands, insufficiency or lack of visual-motor coordination and manipulative activity.

Only some children can stand at the support, and many have a forced position of the body, the impossibility of turning from side to side, pathological support when trying to put them on their feet.

By the age of two, some children still do not hold their heads well, do not know how to freely turn it and look at their surroundings. They are not able to turn and change the position of their body, sit independently, grab and hold toys. In most cases, the children's hands are clenched into fists, the first finger is tightly brought to the palm, and its participation is impossible when grasping toys. Only very few children have access to objective activities with the help of an adult. In all cases, there is a pathological change in muscle tone.

Only some children can stand at the support, step over with support by the hands. As a rule, disorders of voluntary motor skills are combined with a pronounced pathology of the articulatory apparatus, voice, and breathing. At the same time, a number of children have a rather high level of emotional reactions and cognitive activity in general. In children with a pronounced pathology of the motor sphere and articulatory apparatus, pre-speech vocal activity is practically absent in this age period.

14. Sensory disorders in children with cerebral palsy.

Perception in children with cerebral palsy differs significantly from the perception of normally developing children, and here we can talk about a quantitative lag behind age standards, and about a qualitative originality in the formation of this mental function.

In a child with cerebral palsy, to an optical and sound stimulus, general movements are inhibited. At the same time, there is no motor component of the orienting reaction, i.e. turning the head towards the source of sound or light. In some children, instead of orienting reactions, protective-defensive reactions occur: startle, crying, fright.

In children with cerebral palsy, impaired visual perception (gnosis) makes it difficult to recognize complicated variants of subject images (crossed out, superimposed on each other, “noisy”, etc.). Significant difficulties are observed in the perception of conflicting composite figures (for example, a duck and a hare). Some children often retain a visual trace from the previous image for a long time, which interferes with further perception. There is a fuzzy perception of pictures: children can “recognize” the same picture with a familiar object in different ways.

Violation of visual perception may be associated with visual impairment, which is often observed in children with cerebral palsy.

Some children with cerebral palsy have hearing loss, which negatively affects the formation and development of auditory perception, including phonemic (indistinguishability of words similar in title: "goat" - "spit", "house" - "tom"). Any violation of the hearing of perception leads to a delay in speech development. Errors caused by a violation of phonemic perception are most clearly manifested in writing.

A weak sense of one's movements and difficulties in carrying out actions with objects are the reasons for the lack of active tactile perception in children with cerebral palsy, including recognition of objects by touch (stereognosis). It is known that in a healthy child, the first acquaintance with objects of the surrounding world takes place by feeling objects with his hands. Stereognosis is an innate property, and is acquired in the process of subject-practical activity of the child. In most children with cerebral palsy, there is a limitation in object-practical activity, groping movements of the hands are weak, tactile recognition of objects by touch is difficult.

15. Violation of visual-motor coordination in children with cerebral palsy.

For the formation of subject-practical and cognitive activity, the coordination of hand and eye movements is important. At first, a healthy child, moving his hand within the field of vision, does not pay attention to it. Further, the gaze begins to follow the hand, and then direct the movements of the hand.

In children with cerebral palsy, as a result of damage to the motor sphere, as well as the muscular apparatus of the eyes, the coordinated movements of the hand and eye are underdeveloped. In this case, children are unable to follow their movements with their eyes, which prevents the development of manipulative activity, design and drawing, and further inhibits the formation of learning skills (reading, writing) and cognitive activity.

Visual-motor coordination is especially important at the initial stage of learning to read, when the child traces the movement of the finger with the eye, indicates and determines the sequence of letters, syllables, words. The technique and fluency of reading are formed on this basis. Such students do not keep the working line in a notebook or while reading, because they slip from one line to another, as a result of which they cannot understand the meaning of what they read and check their letter.

The lack of formation of visual-motor coordination is manifested not only in reading and writing, but also in mastering self-service skills and other labor and educational skills.

For the same reason, the process of forming self-service skills slows down. The inability to follow the actions of their hands with their eyes, to coordinate the movements of the hand and eye leads to insufficient organization of a voluntary motor act in physical education classes: children cannot keep a target, they find it difficult to throw and catch the ball, to master skills in other sports games.

16. Violation of spatial analysis and synthesis in children with cerebral palsy.

In children with impaired fixation of the gaze, with insufficient tracking of the object and limitation of the field of view, pronounced spatial disturbances can be observed. Children especially find it difficult to determine the right and left sides of their body and the body of a friend, in showing its parts. The necessary knowledge for the formation of spatial concepts of “left” and “right” is developed on the basis of a preserved perception of the body scheme. In children with cerebral palsy, violations of the body scheme are often noted, they are especially pronounced when the left limbs are affected. The child hardly perceives, remembers parts of his body, gets confused for a long time in determining the direction.

At the initial stages of schooling, it turns out, as a rule, that other spatial representations, such as “above”, “below”, “left”, “right”, “behind”, are not assimilated by children.

Spatial analysis is carried out by a whole complex of analyzers, although the main role belongs to the motor analyzer, which is the main broken link in cerebral palsy. Due to motor insufficiency, limited field of vision, impaired gaze fixation, speech defect, the development of orientation in space may be delayed, and by school age, children

From the moment of birth, the failure of congenital motor reflexes is revealed: there are no support reflexes, automatic gait, crawling, protective and grasping reflexes are weakly expressed or absent. Reduced muscle tone (hypotension). The adjusting reflex to the head and the chain adjusting reflexes are significantly delayed in their development. Such patients begin to sit independently by 1-2 years, walk - 6 years. As a rule, with this form, the fronto-bridge-cerebellar path, the frontal lobes and the cerebellum are affected. Characteristic symptoms are ataxia, hypermetry, intentional tremor. 60-70% of children have speech disorders and mental retardation. When the frontal lobes are affected, euphoria, fussiness, and disinhibition are observed.

Autonomic nervous system disorders

Brain damage in cerebral palsy also causes a violation of the autonomic nervous system. In young children, disorders of the autonomic nervous system can be manifested by a decrease or lack of appetite, sleep disturbance, general anxiety, periodic fever, regurgitation, vomiting, thirst, constipation, diarrhea. Older children may experience increased sweating, especially of the palmar surfaces of the hands and soles of the feet (hyperhidrosis), coldness and cyanosis of the hands and feet (acrocyanosis), gastrointestinal disorders, dysregulation of the cardiovascular and respiratory systems, trophic disorders. If the autonomic nervous system is disturbed, a perversion of immunological reactivity can also be observed, which is accompanied by frequent colds and the occurrence of chronic inflammatory processes.

Speech disorders

After the first breath, the newborn screams, as if announcing the world about his first victory over the forces of gravity. Subsequently, during the first month of life, the cry will be the only signal to the outside world about the discomfort experienced by the body of the newborn.

On the basis of the cry and reflexes of oral automatism (sucking, swallowing, proboscis, search), provided that the hearing is preserved, the child's speech will be formed.

The following forms of speech disorders are distinguished:

Dysarthria

Dysarthria is characterized by a violation of sound pronunciation and voice. Depending on the causes of impaired sound pronunciation and voice, the following dysarthria are distinguished:

a) pseudobulbar.

With pseudobulbar dysarthria, an increase in the tone of the muscles of the tongue, the circular muscles of the mouth, face, and neck leads to the restriction of voluntary movements in the articulatory apparatus. The nature of the increase in tone largely depends on the influence of tonic reflexes. Lesions of the cortico-nuclear tracts and cranial nerves lead to the failure of the function of the glossopharyngeal nerves, while there is a violation of voice formation, breathing, difficulty chewing, choking during meals, increased salivation, etc. (pseudobulbar and bulbar syndromes).

The presence of various synkinesis in the articulatory and skeletal muscles further complicates sound and word pronunciation.

Pseudobulbar dysarthria is observed in spastic forms of cerebral palsy (double hemiplegia, spastic diplegia and hemiparesis).

b) cerebellar.

With cerebellar dysarthria, as a result of hypotension of the articulatory muscles, the lips are flaccid, the tongue is thin, flattened in the oral cavity. Hypotonia of the articulation muscles and dyschronization of respiration, phonation, articulation (due to cerebellar disorders) lead to the fact that speech is slow, jerky, fading towards the end of the phrase (scanned speech).

Cerebellar dysarthria is observed in the atonic-astatic form of cerebral palsy.

c) extrapyramidal.

Extrapyramidal dysarthria is observed in the hyperkinetic form of cerebral palsy. Hyperkinesia in this form of the disease extends to the muscles of the tongue, lips, face, diaphragm, intercostal muscles, which leads to a significant difficulty in the smoothness and proportionality of successive speech articulations.

The tone of the articulatory muscles is disturbed by the type of dystonia, which can change dramatically under the influence of tonic reflexes, the emotional states of the child, and various external factors.

Anartria.

In connection with a sharp violation of the tone in the articulatory muscles, a pronounced lesion of the cortical - nuclear pathways, there is a complete or almost complete absence of sound pronunciation. Anarthria may occur more often - with double hemiplegia.

Alalia.

This is a systemic underdevelopment of speech as a result of damage to the cortical speech zones. In contrast to dysarthria, the speech motor apparatus with alalia is intact.

Depending on the defeat of one or another cortical zone of speech, the following alalia are distinguished:

a) Motor (expressive).

With this form of alalia, there is difficulty in switching from one word to another or underdevelopment of correct articulation skills.

c) touch.

With this form of alalia, the understanding of addressed speech is impaired.

Hearing loss

Even before birth, the fetus responds with movement to a sound stimulus. After birth, a newborn reacts to a sharp sound by closing the eyelids, restlessness, a change in the respiratory rhythm, and turning the head. At two months, the child begins to turn his head or eyes to the sound, to respond to the mother's voice, at 3-4 months this reaction becomes permanent.

In 6-25% of children with cerebral palsy, hearing damage is observed from a slight degree of decrease to complete deafness. Hearing is most often affected in patients with hyperkinetic form of cerebral palsy (in 30% of children).

With a slight degree of hearing damage, as a rule, hearing for high tones suffers, while the sound pronunciation of high frequencies is disturbed. The child simply does not use such sounds as - in, k, s, f, sh in his speech. In some patients, phonemic hearing is underdeveloped with a violation of the differentiation of close phonemes (ba - pa, wa - fa, etc.). This category of patients has difficulties in learning to read and write. In a dictation letter, such patients make many mistakes. In some cases, there is a fluctuation in auditory perception: patients in some periods of life begin to hear better, in some - worse. Fluctuations in the degree of hearing loss most often depend on fluctuations in intracranial pressure.

In some cases, there is an increased sensitivity to sound stimuli, which is accompanied by an increase in muscle tone, increased hyperkinesis and speech disorders.

Any violation of auditory perception leads to a delay in speech development, and with a sharp decrease in hearing, speech is not formed at all.

Clinical data on hearing impairment can be confirmed already in the first months of a child's life by examining slow cortical auditory evoked potentials, and from 5-6 years old - using audiometry.

visual impairment

A newborn reacts to a light source by reflex closing of the eyelids and a slight throwing of the head back. By two months of life, a blinking reflex appears, which occurs when an object approaches the eyes, by three months - fixes the gaze on the object, follows objects, by 4 months - reaches for the toy and grabs it, by 6 months - looks from object to object , examines the toy.

Children with cerebral palsy may experience a decrease in visual acuity, visual field disturbances, refractive errors, strabismus (convergent, divergent, unilateral, bilateral), gaze paresis, changes in the fundus, optical-gnostic disorders.

Mental disorders

The sequence of formation of human motor, speech and mental functions is programmed by the genetic code. The formation of motor, mental and speech functions is the result of the development of the brain. Evidence of this is that in the 1st year of a child's life, the mass of the brain increases by 3.5 - 4 times.

In the sequence of development of human functions, a program of a self-developing system is laid down: the development of speech, psyche, movements stimulates the development of the brain. In turn, the development of the brain is the basis for the further development of mental, speech and motor functions. This is the reason for the enormous potential of mental functions, speech, human movements.

In their development, all the most important human functions are interconnected with each other: the development or delay in the formation of one of them stimulates or inhibits the functional activity of others. Thus, oligophrenic children without seemingly impaired motor analyzers master statics and locomotion much later, i.e., they begin to sit, stand, and walk later. All their movements turn out to be awkward, devoid of opportunities for further improvement. While it would seem that the speech-motor apparatus is preserved, speech is also formed with a delay and remains elementary and inexpressive.

A child is born with absolute ignorance about himself, his body and the world around him. In order for knowledge to appear, appropriate experience is needed, which will be processed by the brain and manifested in the form of certain mental functions. The child can acquire this experience with the help of information that the brain receives from the outside world through the system of analyzers: hearing, vision, touch, smell, proprioceptive afferentation.

Already in the first months of life, the child, touching his chest, face, mouth, and then other parts of the body, thanks to tactile, kinesthetic, visual analyzers, develops the perception of his body. With the help of kinesthetic, visual, vestibular analyzers - forms knowledge about body parts. Subsequently, the child takes the toys in his hands, pulls them into his mouth, manipulates them, and knowledge about the surrounding objects, their shape, consistency, etc. is formed.

Mastering independent walking has a qualitative impact on mental development, as it greatly expands the boundaries of acquaintance with space and the outside world and allows you to communicate with peers and adults at a different level. It is known that if a child first acquires the ability to walk independently at an older age (even at the age of 8-15 years), his mental characteristics also improve significantly.

Damage to the brain during the period of intrauterine development of the fetus and during childbirth can cause one or another mental disorder. Moreover, the nature of a mental defect depends on the degree of brain damage and on the duration of the action of harmful factors. When the brain is damaged in the first half of pregnancy, as a rule, there is a gross underdevelopment of the intellect. With brain damage in the second half of the mother's pregnancy or during childbirth, mental disorders are of a mosaic nature. It is known that after birth, the child's brain develops intensively, and in connection with this, a number of brain dysfunctions could be compensated. However, in children with cerebral palsy, already from the first months of life, brain development can be significantly impaired due to motor disorders, impaired visual, sound, kinesthetic perception, delays in the formation of visual-auditory, visual-motor-kinesthetic and other connections, i.e. a child suffering from cerebral palsy already in the first year of life is deprived of many important stimuli and needs programmed by the genetic code (i.e. exposed to various deprivations):

1. Violations of proprioceptive afferentation, vision, hearing lead to sensory deprivation, which has a significant negative impact on the development of the child's brain and, consequently, on the development of his mental functions.

2. Speech, motor, sensory disorders lead to a decrease in the child's contact with peers, with parents and adults, in connection with which the child is subjected to emotional and social deprivation.

Thus, the lack of stimuli in a child suffering from cerebral palsy leads to underdevelopment of the cortical and subcortical structures of the brain, which is reflected in a number of mental disorders: violation of spatial perception, body schema, emotional-volitional sphere, constructive praxis, personality development, perception, decrease in the stock of information and representations (mental retardation).

Correctional and pedagogical work in teaching children with cerebral palsy .

The main directions of corrective work on the formation of motor functions involve a complex, systemic effect, including medication, physiotherapy and orthopedic treatment, various massages, physiotherapy exercises, directly related to the conduct of physical education lessons, labor, with the development and correction of movements at all regime moments,

Speech therapy work for all forms of speech disorders is based on taking into account data from a pathogenetic analysis of the structure of a speech defect. In this case, it is necessary to identify the leading defect, secondary disorders and compensatory-adaptive reactions of the child. The work is always aimed at the development of all aspects of the child's speech activity.

Work on articulatory motor skills is carried out in close unity with physiotherapy exercises against the background of strictly individualized drug therapy.

Education of children with disorders of the musculoskeletal system is carried out in a special type of school - boarding schools (schools) for children with the consequences of poliomyelitis and cerebral palsy. These schools accept school-age children who move independently and do not require individual care. Schools have a preparatory class, where children of the age of seven are accepted. Children with cerebral palsy are allocated to special classes within the school,

As health is restored, on the basis of the conclusion of a psychological, medical and pedagogical consultation, students can be transferred to a general education school or a general boarding school.

At the end of the nine-year and eleven-year schools, the pedagogical council gives graduates appropriate recommendations for employment. Employment of school graduates, who by the end are disabled of groups 1-2, is carried out by social security authorities.

An example of the rehabilitation of a 5-year-old child with an atonic-astatic form of cerebral palsy (from the author's video archive).

Boy Yura, 5 years old, was admitted for rehabilitation due to atonic-astatic form of cerebral palsy.

The boy from the first pregnancy, which proceeded without complications in the mother of 27 years.

Delivery is urgent. Long dry period. Stimulation of labor activity. The child was born in blue asphyxia. Apgar score - 5 points. Resuscitation within 5 minutes. Then for a month he was in the department for nursing newborns. After being discharged home, there was a decrease in the tone of all muscle groups. The child did not hold his head. When the body was verticalized, the eyes rolled under the forehead. From the moment he was discharged home, he received nootropics, cerebrolysin, vitamins, massage, and acupuncture. Repeatedly annually he was treated in various rehabilitation centers in Ukraine and Russia. There were no positive dynamics. The child was recognized as unpromising in terms of rehabilitation. Parents were repeatedly offered to take their child to a nursing home.

Upon admission to us for rehabilitation in November 1994, there was a sharp lag in weight, height, and other age-related parametric data. Teeth: 2 upper and 2 lower incisors. At the age of 5, the child looked like one and a half year old children in terms of height and weight. Active movements in the extremities are sluggish, low-amplitude. During the verticalization of the body, a short-term fixation of the eyes in the middle position for 2-3 seconds was noted, then the eyes rolled under the upper edge of the orbits. The head was held by the child for 1-2 minutes in a vertical position. In a horizontal position, lying on his stomach, the child tried to raise his head, but could not turn it. Tried to

bend the legs in the hip joints and crawl, but the strength was not enough. Pacifier feeding. The child, according to the mother, never cried in all 5 years of his life. All reflexes are sharply reduced. According to the parents, the last year the child began to periodically make weak sounds. During the inspection period, he did not make a sound. CT scan of the brain showed no gross pathology.

Rehabilitation. Nootropics and cerebrolysin were canceled for the child from the first day. Eleutherococcus was prescribed 10 drops once in the morning for a month. Vitamin "C" 0.25 g, "calcine" 3 times a day. It is recommended to give the child more water, juices. At the same time, procedures were started according to the author's technology (see description of procedures) 2 times a day, in the morning and in the evening. General intensive massage of the whole body and limbs. Interestingly, by the evening of the second day, after three procedures, the child was able to raise his head and roll over in bed on his own. On the third day, he was already crying and actively resisting the procedures, although he was still very weak. The mother noted a sharp increase in the child's appetite. By the end of the week, the child was able to sit up on his own without support in bed, actively cooed and made various sounds. He began to reach for bright toys.

The tone in the legs and arms sharply increased, by the end of the second week the child actively tried to crawl, rolled from back to stomach, from stomach to back, tried to rise in the crib. By the end of the second week, the mother noted the eruption of new teeth. Discharged after 2 weeks for admission to the continuation of rehabilitation after 3 months.

Three months after the first course of intensive rehabilitation, the parametric characteristics of the child (height, weight) corresponded to the age of 3 years. The number of teeth increased to 15. The movements in the arms were in full, some hypertonicity of the flexors of the upper and lower extremities was determined. Eats on its own. Can walk, the trunk holds straight, but there is a predominance of flexor tone and rotation of the feet inward. He speaks tongue-tied, but the vocabulary is large. Reads poetry. The child has a good memory. It is amazing that the child is trying to tell with emotions and details about the first days of rehabilitation.

The 2nd course of rehabilitation lasted for 2 weeks with the use of a medical suit DK (see description in the following chapters). The child began to speak more clearly, count up to 20. He learned to ride a 3-wheeled bicycle, which he did all day long. During the rehabilitation period, the legs stretched out, straightened, but a slight rotation of the feet inward remained.

During the year, the child's parents used the DK medical suit. Follow-up after a year showed that the child is developing rapidly. At the time of examination, the child was one year behind his peers in terms of height and weight. The intelligence of the child was even higher than that of peers. Knows a lot of poetry, can read, write in block letters, count up to a thousand. Walks and runs freely, but remains a slight rotation of the feet inward.

This example convincingly indicates that atonic-astatic forms of cerebral palsy can be corrected even faster than spastic forms. During the first course of rehabilitation measures for children with atonic-astatic form of cerebral palsy, it is necessary to prescribe a hard general massage of the whole body and limbs. At a certain stage of recovery, such a child will have a clinic that resembles a spastic form of cerebral palsy with predominant lower paraparesis. But this clinic will differ from the true form of spastic paraplegia by the absence of spastic, uncontrolled movements, the absence of hyperreflexia and hyperesthesia. This clinic can be explained by the “shortened muscle syndrome”, which develops due to the rapid growth of bones and the lag in the growth and development of the abductor and extensor muscles. Physiotherapy, massage, exercise therapy lead to accelerated development of muscles, normalize the balance of muscles, align posture, eliminate growth deformities of long tubular bones. Accelerated growth and teething in the first month of rehabilitation are an objective criterion for the positive dynamics of the rehabilitation process and the development of the body.

In our country, for many years there has been a classification adopted by the world-famous neurologist Ksenia Alexandrovna Semenova. A clear gradation of symptoms and manifestations of the disease helps speech therapists, psychologists and doctors to select the best treatment options. For example, the atonic-astatic form of cerebral palsy is distinguished by certain motor, speech and mental abnormalities. It occurs with pathologies of the cerebellum and frontal lobes of the brain. This form of malaise is considered very severe, it is extremely difficult to treat.

Symptoms

Even in the first year of a baby's life, parents can see a decrease in the pace of psychomotor development. Today, self-diagnosis sites on the Internet help to convince or disbelieve your fears. Parents answer a series of questions by completing the fields electronically and then receive a probable diagnosis. This is only an approximate result, a specialist in a medical institution should confirm or refute it.

The specialist makes a diagnosis based on the following symptoms of the atonic-astatic form of cerebral palsy:

Lit .: Big Medical Encyclopedia, 1956

Parents may notice deviations from the norm in the behavior of the child in the first year of life. As a rule, the baby cannot keep balance, his coordination of movements is disturbed, tremor is clearly visible, movements are excessive. The following causes of the atonic-astatic form of cerebral palsy lead to such consequences:

Damage to the cerebellum only. In this case, children do not show initiative, they read and write poorly.
Damage to the cerebellum and frontal lobes. Then the child may show aggressiveness, underdevelopment of cognitive activity.

According to the studies of Ekaterina Semenova, children with this form of cerebral palsy also have mental retardation, and in a severe stage. The doctor recommended sending patients to institutions of the Ministry of Social Protection. This is due to the fact that in most cases, with this form of cerebral palsy, the child cannot take care of himself, as well as attend preschool and school institutions.

Parents usually go to a therapist when they want to figure out how to help their child. To the question of which doctor treats cerebral palsy in the atonic-astatic form, one can give the following answer:

During the first visit to a specialist, the child will be examined, and the parents will have to answer the following questions:

How long has the child been experiencing behavioral changes?
Did the parents notice deviations in the physical activity of the baby before?
Was oxygen starvation diagnosed during childbearing?
Was the baby born prematurely or according to the DA?
Was the birth normal or was the baby traumatized?
Did the baby's mother during pregnancy suffer from rubella, syphilis, influenza, various chronic ailments, including pneumonia and tuberculosis?
Were stimulants used during childbirth?
With what body weight was the baby born?

Treatment of atonic form of cerebral palsy

More than 80% of children with this type of cerebral palsy have reduced intelligence. Usually they are aggressive, reacting negatively even to standard situations. In addition, in many patients, the treatment of the atonic form of cerebral palsy is also difficult because the child is not proactive, depressed, and refuses any manipulations. Also, 50% of children have convulsions, optic nerves atrophy. In general, the atonic-astatic form of cerebral palsy has an extremely unfavorable prognosis. However, to improve the patient's condition, however, are prescribed.

In our country, the classification of cerebral palsy has been in force for many years, adopted by the world-famous neurologist Ksenia Alexandrovna Semenova. A clear gradation of symptoms and manifestations of the disease helps speech therapists, psychologists and doctors to select the best treatment options. For example, the atonic-astatic form of cerebral palsy is distinguished by certain motor, speech and mental abnormalities. It occurs with pathologies of the cerebellum and frontal lobes of the brain. This form of malaise is considered very severe, it is extremely difficult to treat.

Symptoms

The specialist makes a diagnosis based on the following symptoms of the atonic-astatic form of cerebral palsy:

Lit .: Big Medical Encyclopedia, 1956

Damage to the cerebellum only. In this case, children do not show initiative, they read and write poorly.
Damage to the cerebellum and frontal lobes. Then the child may show aggressiveness, underdevelopment of cognitive activity.

During the first visit to a specialist, the child will be examined, and the parents will have to answer the following questions:

How long has the child been experiencing behavioral changes?
Did the parents notice deviations in the physical activity of the baby before?
Was oxygen starvation diagnosed during childbearing?
Was the baby born prematurely or according to the DA?
Was the birth normal or was the baby traumatized?
Did the baby's mother during pregnancy suffer from rubella, syphilis, influenza, various chronic ailments, including pneumonia and tuberculosis?
Were stimulants used during childbirth?
With what body weight was the baby born?