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Atonic astatic form of cerebral palsy - methods of treatment and rehabilitation. Atonic-astatic form of cerebral palsy

The atonic-astatic form is manifested by muscular hypotension, dynamic and static ataxia, cerebellar dysarthria, and, as a rule, preserved or slightly impaired intelligence.

The atonic-astatic form occurs as a result of either gross violations of the fronto-bridge-cerebellar pathway, or an intrauterine brain disease with a predominant lesion of the cerebellum. In children with this form of cerebral palsy in the initial residual stage, against the background of general muscular hypotension, the pronatoric position of the forearms and hands gradually develops, the tension of the adductors of the thighs and arch supports of the feet increases. At the same time, there may be a delay in the reduction of the cervical tonic and labyrinth reflexes, only by the age of 1.5-3 years the adjusting reflexes begin to develop. Tendon and periosteal reflexes are always high. Cerebellar disorders are manifested from an early age - at first there is ataxia and tremor of the hands, then, when the child begins to stand, trunk ataxia develops, as well as dys- and hypermetry. This explains the atactic gait. Mental and speech development with lesions predominantly of the cerebellum can be delayed to one degree or another. Cerebellar dysarthria is revealed.

In case of damage to the entire fronto-bridge-cerebellar tract or predominantly to the frontal lobes of the brain, head control, the functions of sitting, standing and walking practically do not develop (astasia, abasia) or are formed very slowly. Locomotor ataxia, although present, is not the dominant syndrome. Another indispensable clinical sign is a deep mental and speech development delay, or oligophrenia, more often in the degree of imbecility. Convulsive and hypertensive syndrome are observed in 15-20% of children.



The prognosis of motor development and social adaptation in most patients with cerebellar cerebral palsy is favorable. Children study in special boarding schools or mass schools and later master professions that do not require fine differentiation of hand movements. The prognosis for motor abilities and social adaptation in case of damage to the fronto-bridge-cerebellar pathway is unfavorable.

HYPERKINETIC FORM

Hyperkinesis is often observed in various forms of cerebral palsy. However, in some cases they are clinically leading and then they speak of a hyperkinetic form of cerebral palsy. The hyperkinetic form is characterized by the presence of hyperkinesis (choreoathetosis, choreic, torsion dystonia, etc.), extrapyramidal (hyperkinetic or spastic-hyperkinetic) dysarthria, with usually preserved intelligence.

Pathological anatomical changes are found in the striopallidary system, the cause of which may be incompatibility of the blood of the mother and fetus for Rh or ABO factors, intracranial birth trauma, etc.

The clinical picture consists of hyperkinesis and impaired muscle tone, more often in the direction of its diffuse increase (extrapyramidal rigidity). In some cases, at rest, muscle tone is normal or even reduced, but it rises sharply during active movements. In children in the initial residual stage of the disease, hypotonia of the muscles of the trunk and limbs can be observed already in the first months of life, later dystonia. In the muscles of the tongue, hyperkinesis usually appears at the 4-5th month of life. After 6-12 months, involuntary movements also occur in other muscles of the face, trunk and limbs. The most common form of children's cerebral hyperkinesis is double athetosis, in which hyperkinesis of an athetotic (worm-like) nature is localized in the mimic muscles of the face, upper and lower extremities, mainly in the distal sections, often capturing the torso. Choreic or choreoathetoid, hyperkinesis manifests itself in the form of faster, more widespread, proximal, high-amplitude, non-stereotypical movements. Torsion dystonia - hyperkinesis in the form of a slow contraction of the muscles of the body, leading to its rotation, head turn and other changes in posture. Hyperkinesis is minimal at rest, disappears during sleep, increases with voluntary movements, is provoked by emotions, and is more pronounced in the supine and standing position. Hyperkinesis and muscular dystonia destabilize the posture. Voluntary movements are discoordinated, spasmodic, sweeping.

In 60-70% of cases, pseudobulbar symptoms are detected (salivation, difficulty chewing, swallowing), in 10-15% convulsions. The formation of the reactions of rectification and balance is sharply delayed and defective. On the part of the intellect, changes are detected much less frequently (5-8%) than in other forms of cerebral palsy. In most patients, speech is impaired by the type of extrapyramidal dysarthria.

The prognosis for the development of motor functions and social adaptation depends on the severity of the damage to the nervous system. In 60-70% of cases, children learn to walk independently, however, voluntary motor activity, especially fine motor skills, is largely impaired. With moderate motor impairment, children can learn to write and draw. Patients with security intelligence graduate from general education schools, specialized secondary schools, and sometimes higher educational institutions.

DIAGNOSTICS

Cerebral palsy in the chronic residual and late residual stages is diagnosed based on the detection of:

1) pathologies of intrauterine development and childbirth, or diseases of the central nervous system in the first days or weeks of life, before the main structures, paths and centers of the brain have yet been formed;

2) characteristic movement disorders;

3) violations of speech and intelligence.

A list of pathological signs indicating the threat of cerebral palsy in infants.

I. Anamnesis:

1. Parents' complaints about developmental delay.

2. A large number of risk factors in the prenatal and intranatal periods.

3. Neurological disorders in the neonatal period.

II. Neurological examination:

1. Violation of muscle tone: hypertension, hypotension, dystonia.

2. Congenital reflex reactions:

a) the presence of unconditioned reflexes after 3-4 months. (normally should be inhibited),

b) activation of tonic neck and labyrinth reflexes in all positions.

3. Violation of posture and voluntary movements:

a) head: tilting in the supine position, constant turning to one side, excessive tilting in the prone position, difficulty holding with traction, upright, prone, sitting,

b) pressed to the body, not brought to the midline, the child does not pull them into the mouth, does not take them to the sides, does not reach for the toy, the hands are clenched into a fist, there is no optical support of the hands,

c) legs: excessive extension and adduction in the position on the back, vertically on the support, walking on toes, poor support, bending in the knee joints,

d) delay in global motor reactions: the child does not turn on his side, does not turn on his stomach, turns sideways, does not sit on his own, does not lean on his hands in a position on his stomach, does not get on all fours, does not sit down and does not stand up on his own, does not stand on his own, stands on bent and adducted legs, does not walk, walks on toes, asymmetry of posture and voluntary movements.

4. Delay in speech and mental development.

5. Neurosonography data: ventriculomegaly, periventricular leukomalacia, intra- and periventricular hemorrhages, polycystic disease, porencephaly, etc.

TREATMENT

The allocation of cerebral palsy to a separate group is due to the immaturity of the brain of the newborn, both anatomically and functionally. During this period, various harmful causes can produce similar clinical changes in the nervous system. With cerebral palsy, the immature, developing brain is affected, which has great compensatory capabilities.

Cerebral palsy is in fact the residual effects of an already transferred pathological process, while motor and other disorders tend to reverse development. The goal of the doctor is to direct this spontaneous regression of symptoms along the right path, to control it, to prevent contractures, various vicious postures and movements from developing.

Due to the complexity of the pathogenesis and the variety of clinical forms of cerebral palsy, it is necessary to participate in the treatment process of such specialists as a neuropathologist, psychiatrist, orthopedist, physiotherapist, speech therapist, etc.

In order to properly plan the treatment of a patient with cerebral palsy, it is necessary to first determine: 1) what indicators of motor development (head control, turning, sitting, standing up, standing, walking, manipulating the arm and hand) are relatively normal, but lag behind chronological age; 2) what period do certain static and locomotor functions correspond to, are they mosaic; 3) why the child performs some movements and cannot perform others; 4) what elements of movement are absent in each skill and hinder its development; 5) whether tonic reflex activity has an effect on posture and movement; 6) the degree of spasticity at rest, when trying to move, in what positions it is more pronounced; 7) the presence of contractures and deformities or their early signs; 8) the level of mental and speech development, the nature of combined disorders.

Objectives of treatment: 1) develop in the child patterns of movements that contribute to the normalization of muscle tone, counteract gravity, maintain balance, and create the possibility of independent movement, acquire self-service skills; 2) to prevent the formation of pathological postures, abnormal muscle tone and movements, the development of contractures and deformities; 3) educate parents on methods of curative care and available curative and corrective measures.

The main directions of corrective work on the formation of motor functions involve a complex, systemic effect, including medication, physiotherapy, 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.

The construction of a rehabilitation program should proceed from the basic principles:

1. Rehabilitation measures begin from the first days of the disease and are carried out continuously, subject to the phased construction of the program.

2. Rehabilitation measures should be comprehensive, versatile, but unidirectional (meaning the unity of biological and psychosocial methods of influence).

3. The rehabilitation program should be individual for each child, depending on the nosological form, the nature of the course of the disease, age, etc.

4. The final stage of the rehabilitation program should be the most complete social adaptation possible.

The first stage of rehabilitation is rehabilitation treatment in a hospital. Depending on the nature of the pathological process, its duration is different.

The second stage is readaptation, i.e. adaptation of the patient to the conditions of existence at one level or another in accordance with the degree of restoration and compensation of functions. It is better to start this stage of baking in a local sanatorium. Especially effective is the treatment of children with the consequences of diseases of the nervous system at balneological and mud resorts. Natural factors - radon, sulfide waters, therapeutic mud - cause humoral and hemodynamic changes in the body, affect the state of the nervous and endocrine systems, metabolism, improve the trophic functions of the body. The use of spa treatment at the second stage of rehabilitation, which has a long aftereffect, significantly increases the volume of the child's recovery reactions.

The third stage is the actual rehabilitation, the return to normal activities, to their former duties. In children, this stage pursues the complete elimination of the defect, the return to the environment of peers. At this stage, a significant place in the rehabilitation program is given to social, psychological, educational and educational influences.

PHYSIOTHERAPY

Therapeutic physical culture is one of the leading components of the complex treatment of patients with disorders of the musculoskeletal system.

The main tasks of physical therapy in cerebral palsy are as follows: 1) normalization of the unconditional reflex basis for the formation of voluntary movements; 2) development of the patient's sensorimotor capabilities based on the restructuring of vicious compensations and stimulation of the coordinated functions of the analyzer systems; 3) teaching vital motor skills and elements of sports exercises based on the development of the general mobility of the patient; 4) special versatile training of coordination of movements.

Proper protective and stimulating motor regimen and physical exercises contribute to the overall strengthening of the body, restoration of the function of various systems, development of coordination links and favorable compensatory reactions. Therapeutic gymnastics is aimed at: 1. normalization of muscle tone; 2. normalization or formation of weakened or absent congenital motor reflexes (stepping, protective, crawling, reflex from head to body, from body to head, support reflex, Perez, Robinson, etc.); 3. suppression of primitive tonic reflexes that were not reduced to the term, but, on the contrary, growing (asymmetric and symmetrical cervical, labyrinthine, grasping, etc.); 4. stimulation from the 3rd-4th week of life of the development of a reflex from the head to the neck (the first adjusting reflex, indicating the development of adequate activity of antigravitational mechanisms), as well as mechanical, then optical reactions of the support of the upper limbs, the correct grip of objects, visual-motor coordination ; 5. correcting the position of the fingers; prevention of muscle atrophy, limited mobility in the joints; 6. restoration of active and passive movements and general statics and kinematics of the patient.

To solve these problems, domestic and foreign researchers have developed a number of methods, among which in the first place should be called the method of K.I. tonic and formation of congenital motor reflexes. I. Voit (1970), S. A. Bortfeld (1986). K.A. Semenova (1979) improved the system of K. and B. Bobat and offered their own methods.

The process of physiotherapy exercises should be theoretically substantiated, built in coordination with other methods of treatment. To select training methods, a preliminary thorough examination of the patient, a detailed clarification of the nature of the lesion, the state of the joints and the muscular system, the degree of loss of functionality and the prognosis of the disease are necessary.

Since the physiological meaning of physical therapy is the development of new conditioned reflex connections and mechanisms in the process of corrective work, both the demonstration and the verbal explanation of the complex of physical exercises are of equal importance. The main form of their organization is individual lessons. It is necessary to periodically determine changes in the state of functions with the help of special tests, and, if possible, physiological studies. Such examinations make it possible to timely identify the need to change the methodology and at the same time reflect the dynamics of the functional state of the patient, the effectiveness of his treatment at each stage.

The ultimate goal of exercise therapy is the development of new motor acts, teaching the child self-service and independent movement.

MASSAGE

Massage is widely used for disorders of the musculoskeletal system. Mechanically acting on tissues, it causes a reaction primarily from the vascular and nervous systems. Under the influence of massage, lymph and blood circulation, gas exchange between blood and tissues is enhanced. Afferent impulses arising in the skin and deeper tissues have a stimulating effect on the activity of the central nervous system. Regular massage helps to increase the contractility of muscles, their elasticity and accelerates their recovery after fatigue or prolonged immobilization. Since orthopedic patients require prolonged use of massage, it is advisable to teach the basic techniques of massage to parents and relatives of the ballroom.

A complex of physiotherapy exercises begins with a massage. Conventional physiological massage is in most cases not suitable, since work with each muscle group should be approached selectively, taking into account its tone, as well as its effect on a synergistic muscle group, so as not to cause a pathological increase in their tone. . K.A. Semenova (1974) developed a special systemic acupressure, which can be used to take into account the characteristics of physiological and pathological synergies.

MEDICAL THERAPY

Drug treatment depends on the stage of the course of the disease, the structure of the defect, the mental and somatic status of the child and is aimed at:

1. termination of intrauterine inflammatory primary and secondary autoimmune processes, if any;

2. prevention of cicatricial adhesions resulting from inflammation, mechanical birth trauma and hemorrhages; consequences of asphyxia, including chronic metabolic acidosis;

3. intensification of metabolic processes in the nervous tissue, primarily redox and protein metabolism;

4. providing energy processes in the brain;

5. elimination of primary or secondary hypertensive and convulsive syndromes;

6. normalization of muscle tone, reduction of violent movements, increased activity of compensatory processes in the nervous system;

7. stimulation of mental and speech development.

The use of drugs in children with cerebral palsy aims to create favorable conditions for a more successful exercise therapy. Drug therapy in the residual period includes the appointment of drugs that lower muscle tone, improve the conduction of nerve impulses in synapses, reduce hyperkinesis, normalize the course of metabolic processes in the nervous tissue, as well as anticonvulsants (in the presence of seizures), dehydrating (with hypertension-hydrocephalic syndrome) and fortifying agents.

Drugs that reduce muscle tone (inhibit cells of the reticular formation, block mono- and postsynaptic spinal reflexes, have a central and peripheral anticholinergic effect): mydocalm, baclofen, surdolit, amedin, norakin, cyclodol, tropacin, scutamil C, levodopa, nakom, sinimet, etc. These drugs are prescribed in a gradually increasing dosage. It has been established that 40-60 minutes after taking one of the listed drugs, a decrease in muscle tone occurs and at this time it is recommended to carry out exercise therapy.

Drugs that improve neuromuscular conduction: prozerin, galantamine, nivalin, kalimin, oksazil dibazol. They do not act on dead nerve cells, but only on those parts of the nervous tissue that have been in a state of oppression for a long time. It must be remembered that with regard to neuromuscular transmission of excitation, prozerin and its analogues are antagonists of tropacin and other drugs from the atropine group, so they cannot be administered simultaneously.

To reduce hyperkinesis, tranquilizers are most often used (elenium, amizil, phenibut, noofen, relanium, phenazepam, etc.), neuroleptics, less often - atropine-containing drugs (cyclodol, ortan, tropacin), as well as pyridoxine. In some cases, when conservative treatment is ineffective, so-called stereotoxic operations on the basal ganglia of the brain are resorted to. At the same time, a neurolytic mixture (usually alcohol with mayodil) is injected into the region of the pale ball or some nuclei of the thalamus. According to the literature data, hyperkinesis stops in 70% of cases and muscle tone decreases in 80% of cases. Chemopallidectomy is performed only by neurosurgeons in specialized departments.

In cerebellar forms of cerebral palsy, when muscle tone is reduced, duplex, securinin, echinopsin, mediator stimulants are prescribed.

Drugs that stimulate metabolic processes in the nervous system (activate protein and carbohydrate metabolism, while removing toxic decay products, increase respiratory activity, energy processes in brain tissue, improve blood circulation, promote differentiation of nerve cells, myelination of pathways, improve brain functionality): glutamic acid , aminalon, nootropil, piracetam, encephabol, cerebrolysin, diavitol, lipoic acid, cogitum, prefison, carnitine, pantogam, pyridoxine, cyanocobolamin, neuromedin, etc. In convulsions, stimulant drugs should be administered carefully, gradually increasing the dose, in combination with anticonvulsants and sedatives.

Drugs that improve microcirculation (increase cerebral and peripheral circulation, improve the rheological properties of blood, activate metabolic processes): teonikol, xanthinol, trental, cavinton, actovegin, emoxipin.

Preparations that have a resolving effect and stimulate regeneration (reduce productive and stimulate regenerative processes in the nervous system, increase tissue permeability and improve their trophism): aloe, lidase, pyrogenal, propermil.

Dehydrating drugs (increase diuresis, reduce CSF production): magnesium sulfate, diacarb, triampur, hypothiazitis, furosemide, lasix, glycerin, etc.

The presence of epileptic seizures without fail requires the appointment of anticonvulsants (phenobarbital, difenin, antelepsin, carbamazepine, valproic acid derivatives - depakine, convulsofin, etc.). Anticonvulsant therapy for patients with cerebral palsy is prescribed individually, taking into account the characteristics of the underlying disease, the nature of epileptic paroxysms, their frequency, and the time of occurrence during the day. Anticonvulsants must be taken continuously, for a long time (3-5 years of effective therapy), followed by gradual withdrawal.

In addition to such a differentiated drug treatment, it is recommended to periodically take pharmacological agents that regulate the metabolism in the nervous tissue and increase the body's resistance to adverse external influences. These are preparations of phosphorus and calcium, ATP, vitamins of groups B, E, C, thymalin, etc.

PHYSICAL THERAPIES

In the complex therapy of cerebral palsy, a significant place is occupied by physical methods of treatment (electrophototherapy, hydrotherapy, electrophoresis, ultrasound, magnetotherapy, electrical stimulation of muscles and nerves, mud therapy, paraffin-iozokerite therapy, IRT, etc.). ), aimed at reducing spasticity, improving blood circulation in the muscles .

Below is a brief description of some of the physiotherapy procedures.

So, for therapeutic purposes, you can use galvanic current. Various methods of its application have been proposed (galvanic collar according to A.E. Shcherbak, galvanization of cervical sympathetic nodes, transcerebral galvanization, etc.). During the procedure, the patient should not experience discomfort (the initial current strength is 4-5 mA, gradually increased to 10-12 mA), the treatment is carried out daily or every other day, in total 20-25 sessions. With the help of galvanic current, various medicinal substances (electrophoresis) can be administered, which create a long-acting depot in the deep layers of the skin. In children with cerebral palsy, a galvanic collar with calcium chloride, potassium iodide, magnesium sulfate, novocaine, bromine is most often used. At the same time, trophic and blood supply to the muscles improves, their tone decreases, the activity of higher vegetative centers normalizes, and hyperkinesis decreases. In order to resolve gliosis scars in the central nervous system, transcerebral Bourguignon electrophoresis with potassium iodide can be used. To reduce muscle tone in the same way, an extract from the belladonna root can be administered (1-2 ml of a 0.2% aqueous solution of the belladonna root is taken, dissolved in 100 ml of water and two pads are moistened, which are applied to closed eyelids), to improve metabolism - glutamic acid, to relieve arousal - GHB.

With increased muscle tone, it is recommended to prescribe paravertebral ultraviolet irradiation, the so-called "creeping" DUV and KuV erythema. You can also apply local electrothermal procedures (irradiation with a "Solux" lamp, diathermy, inductothermy). After such procedures, which contribute to the expansion of blood vessels and a decrease in muscle tone, rational electrical muscle stimulation can be applied using the ACM-2 or ACM-3 devices. According to I.M. Levin, in this way, you can start teaching the child active muscle contraction.

In 1957, K.A. Semenova proposed the treatment of cerebral palsy with low-frequency pulsed current, the source of which is the ASU-2, ASM-3 apparatus. The technique of this procedure is as follows: narrow electrodes are applied to the distal parts of the hands and feet. The strength of the current, the duration of the pulse should be individually selected depending on the age of the child, his tolerance to the current and the clinical manifestations of the disease. The time of current exposure is 5-8 minutes, followed by a change in the polarity of the current for the same time. The course of treatment is 20-25 sessions. You can conduct up to 10 courses with a break of 1.5-3 months. According to K.A. Semenova, these procedures improve the general condition of the child, reduce muscle tone, and increase the range of active movements. I.M. Levin suggests that with the distal location of the electrodes on the limbs, electrophoresis of novocaine with adrenaline is performed (8 drops of a 0.1% solution of adrenaline are added to 40 ml of a 2% solution of novocaine). Napkins moistened with such a solution are applied to the distal sections of the hands or feet and attached to the bifurcated anode. The cathode is superimposed on the middle third of the forearm or lower leg. In total, the course of treatment is 10-20 procedures.

In order to influence the general condition of the body, as well as to reduce muscle tone, water procedures are widely used: general warm baths, salt baths (1-2 kg of table salt per 200 liters of water), pine baths (50-60 grams of liquid extract per bath needles), as well as brine and sea baths. Water temperature 35-38 °, every other day for 10-15 minutes, for a course of treatment 10-15 baths. Water procedures must be combined with therapeutic exercises. With high muscle tone, selective underwater shower-massage can be carried out.

In the complex treatment of cerebral palsy, organic and inorganic mud and mud-like substances can be widely used: sapropels, clay, sand, peat, ozocerite and paraffin. Mud procedures are carried out mainly in the form of an application ("collar", "pants", "harem pants", etc.) at a temperature of 40-42 ° every other day for 15-20 minutes. In total, there are 15-20 procedures for the course of treatment. When treating with paraffin and ozocerite, the duration of the procedure increases to 30-40 minutes. At home, it is also possible to carry out treatment with sifted river sand, which, at a temperature of 45-50 °, is poured into wooden boxes or linen bags, and the affected limb is placed there. In summer, you can cover the upper and lower limbs of the patient with a layer of sand 5-6 cm thick and use natural solar heating. All these thermal procedures cause hyperemia and improve muscle nutrition, reduce muscle tone, and reduce contractures.

Climatotherapy - the impact on the body of natural factors - air, solar radiation, water. They are especially successfully used in specialized climatic resorts - in the Crimea, the Caucasus, Central Asia, and the Baltic states.

ORTHOPEDIC TREATMENT

Orthopedic baking is aimed at preventing and correcting deformities, restoring support and active mobility of the affected limbs and their appearance. In traumatology and orthopedics, both a variety of conservative and surgical methods of treatment are used. Orthopedic products that can be used to give parts of the body a physiological position include splints, shank-panties, splints, splints, collars, rollers. The orthopedic regimen should be developed for each patient individually and strictly observed.

Orthopedic methods for the treatment of cerebral palsy (both conservative and surgical) are subject to the competence of orthopedists, surgeons, and therefore are not considered in this brochure.

UPBRINGING

Along with the necessary treatment for patients with cerebral palsy, the correct organization of educational work is no less important. It should be borne in mind that 70-80% of these patients have mental disorders. Mental disability should not be regarded as something static, permanent, but as a situation that, in principle, can be changed in order to carry out appropriate educational and therapeutic measures. In the presence of severe mental retardation, patients must be placed in homes for the disabled. Children with moderate mental retardation should attend special kindergartens and schools. With the preservation of intelligence or a slight delay in mental development, patients can attend general schools or (better) specialized kindergartens and boarding schools, where the necessary conditions for educational work are created. These conditions determine the originality of the methodological approach to education:

1. creation of small groups, taking into account the level of development;

2. for each group, a plan is drawn up for one week, with the development of an individual activation plan for each child;

3. you should reduce the duration of classes so as not to overload the ability to concentrate;

4. more frequent exercises are needed to consolidate knowledge and special time for repetition;

5. rest time should be longer than in healthy children;

6. an important element of education is the development of hygiene skills and training in certain social duties;

7. special attention should be paid to the development of motor skills and speech with the participation of a physiotherapist and a speech therapist;

8. due to increased distractibility, it is necessary to more strictly manage the game, reveal the possibilities of organizing it, and activate games.

Tasks in the first year of life: 1) fostering the habit of contact and the need for it - addressing the child, drawing his attention to surrounding objects; 2) the development of visual perception and concentration with the use of light stimuli, as well as the display of objects with simple and clear forms (ball, rattle); 3) development of auditory perception and concentration with the use of voice, tambourine bell, etc. Use of sounds of different directions of tonality, sequence, Encouraging the child to extract sounds (“patties”, rattle, etc.); 4) development of lip movements - sucking, chewing (gradual transition to solid nutrition), prompting the child to blow, blow out air; 5) training of touch - contact with a variety of objects, at first by correcting the movement of the child's hand; 6) exercises for the hands - stimulation of grasping (“give me a pen”), “patties”, punches, rolling the ball, playing with cubes, with water, throwing, playing with fingers, etc .; 7) training of general motor skills - the transition from spontaneous movements to a given rhythm to singing, tambourine, etc., crawling, somersaulting, standing up, walking by the handle. Of particular importance is the performance of rhythmic gymnastic exercises; 8) teaching the simplest movements; 9) stimulation of participation in the reproduction of rhythm, sounds, melodies; 10) the motivation to name one's desires and objects with a certain word by repeated repetition; 11) development of emotional reactions - joy, trust, well-being, etc. By demonstrating emotions, stories, appropriate games and reinforcing the child's reaction; 12) in the process of education, intimidation and effeminacy should be avoided. Not all features of the child's behavior are associated with his mental retardation; 13) along with purposeful educational influences, it is necessary to provide the child with the opportunity for independent play and activities.

The process of social adaptation of such children should be facilitated by improving interpersonal relationships.

Involving parents in the process of raising children can become more effective if they are constantly informed about current pedagogical tasks and some of the learning tasks are transferred home.

LOGOPEDIC CORRECTION

The changing unstable nature of muscle tone disorders in the speech muscles, its great dependence on external influences, the emotional state of the child, the position of his body and head in space determine the peculiarities of sound pronunciation in these children. The lack of stability of articulatory disorders leads to the inconstancy of violations of the phonetic side of speech. If in a calm state dystonia of the speech muscles is observed, then when trying to speak, a sharp increase in muscle tone in the articulatory muscles is observed.

The appearance of hyperkinesis of the speech muscles sharply distorts speech, makes it obscure, and sometimes impossible. In addition, hyperkinesis of the diaphragm and intercostal muscles can also be noted, which, in turn, grossly disrupts breathing, fluency of speech, and in severe cases leads to the appearance of violent screams or groans.

The most common form of speech disorders is pseudobulbar dysarthria, which is characterized by impaired muscle tone. This speech disorder is characterized by limited mobility of the articulatory muscles; the most subtle isolated movements are especially affected, salivation is increased, breathing and voice formation are disturbed.

The main tasks of stimulation and correction of pre-speech development in the early stage of the disease are:

1. special breathing exercises aimed at developing voice reactions;

2. acupressure systemic massage, which stimulates the development of oral reflexes, eliminates oral synkinesis, corrects the position of the tongue and the tone of its muscles;

3. massage of the facial muscles (especially the muscles of the lips), the hyoid muscles, and the muscles of the neck, which provide the possibility of pronunciation;

4. development of a visual binocular fixation reflex, coordination of hand and eye movements, on the basis of which orienting, then orienting-cognitive reactions are formed, and, finally, inner speech, the first elements of its understanding.

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. The work should be aimed at the development of all aspects of the child's speech activity. The system of speech therapy measures includes not only the development of articulatory motor skills and the sound-producing side of speech, but also the formation of its lexical and grammatical side, the creation of the conditions necessary for the child to master written speech.

In complicated forms of dysarthria, the work of a speech therapist involves the enrichment of auditory experience, the development of auditory attention, the skills of sound localization in space, auditory memory, phonemic hearing, and the semantic side of the child's speech. The work is based mainly on visual perception. When conducting speech therapy classes, it is necessary to pay attention to the prevention and overcoming of various synkinesis in the skeletal muscles and, especially in the fingers, as well as in the mimic muscles.

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

FORECAST AND PREVENTION

The prognosis for children with cerebral palsy depends on the time of brain pathology and the degree of its severity. With antenatal injuries, the prognosis is the more serious, the earlier the pathological process developed. Widespread destructive brain lesions are worse prognostically than focal ones. Combined disorders significantly aggravate the prognosis - decreased vision, hearing, mental disorders, convulsions, hydrocephalic syndrome, somatic, infectious diseases.

The prognosis of motor, mental and speech disorders depends on the time of diagnosis, the start of treatment and its succession in different age periods.

The prognosis of social adaptation is more favorable with spastic hemi- and diplegia, and unfavorable with bilateral hemiplegia and atonic-astatic forms of cerebral palsy.

For the prevention of pre- and perinatal brain lesions, a comprehensive solution is needed for a wide range of issues related to the prevention of both the direct effects of harmful factors on the fetus and those mediated by the mother's body, the improvement of methods for diagnosing pathological conditions of the fetus and newborn, corrective and restorative therapy, health education.

BIBLIOGRAPHY

1. Badalyan L.O., Zhurba L.T., Timonina O.V. Cerebral palsy. - "Health", Kyiv, 1988.- 327 p.

2. Perinatal pathology /Under the total. ed. M.Ya.Studenikin (USSR), J.Kulz, G.Eggers (GDR). USSR-GDR.-M.: Medicine, 1984.- 267 p.

3. Semenova K.A. Makhmudova N.M. Medical rehabilitation and social adaptation of patients with cerebral palsy. - Tashkent: Medicine, 1979. - 487 p.

4. Shanko G.G., Bondarenko E.S., Freidkov V.I. Neurology of childhood: diseases of the nervous system of newborns and young children, epilepsy, traumatic and vascular lesions: Proc. allowance for in-comrade. - Mn .: Vysh. school., 1990.- 495 p.

5. Shukhova E.V. Rehabilitation of children with diseases of the nervous system. - M.: Medicine, 1979.- 255 p.


APPS

INDUSTRY STANDARDS FOR EXAMINATION AND TREATMENT OF CHILDREN WITH ICP IN HOSPITAL CONDITIONS

It is also called the "flaccid" form. It is characterized mainly by a decrease in muscle tone. The child cannot control the movements of the head, limbs, torso. There are also disorders of coordination of movements and balance, but these symptoms are not dominant. Another feature of this form is that motor disorders are invariably combined with a sharp delay in the development of speech and the psyche.

In the supine position, the child is lethargic, inactive. Muscle tone is reduced, and less in the arms than in the legs. Hand movements are more active.

The child begins to hold his head only after 6 months. If he is taken under the armpits, he cannot maintain a vertical posture, the head and torso are tilted forward. In the position on the stomach - unable to hold his head for a long time and lean on his hands.

The child begins to sit at one and a half to two years. In this position, the legs are widely separated, turned (rotated) outward. Expressed kyphosis of the thoracic spine. The posture is unstable, the body sways from side to side. Resilience appears at 4-6 years.


The child begins to stand from 4 to 8 years old, legs wide apart and holding on to an adult’s hand or a support. Without support, he falls under the influence of gravity, while the protective reaction of the hands and compensatory movements of the body, aimed at maintaining balance, are absent. The patient's torso is held with support on the heels during recurvation (overextension) of the knee joints. The head and torso are tilted forward, the hip joints are in a state of flexion, the shins are tilted back, and the feet are flat-valgus. The posture is largely due to severe weakness of the quadriceps femoris.

Such children can move independently after 7-9 years, and only for short distances. The gait is characterized by instability, irregularity. Children often fall. Legs when walking are widely spaced.

In 80-90% of children, there is a pronounced decrease in intelligence, speech impairment. Such children are often aggressive, negatively inclined, it is difficult to agree on anything with them.

The prognosis for the restoration of motor functions and social adaptation is unfavorable.

A.S. Levin, V.V. Nikolaev, N.A. Usakov

Atonic-astatic form of cerebral palsy is a pathological process that occurs against the background of congenital diseases. This is a severe form of the disease that is difficult to treat. In pathology, there are failures in coordination of movements and low muscle tone.

The occurrence of an atonic-astatic form of cerebral palsy is observed under the influence of various causes. Most often, pathology occurs during violations or during childbirth. The astatic type of the disease develops when:

  • Hypoxia. The disease is characterized by insufficient supply of oxygen to the child's brain. It occurs when the mother has bad habits during pregnancy - smoking, alcohol, drug addiction. With diabetes mellitus or a critical decrease in hemoglobin in the blood, the patient is diagnosed with hypoxia.

  • Birth trauma. If a woman has an excessively narrow pelvis and at the same time a large fetus, then this leads to injury during the birth process. Children of older women are at risk. The disease develops with premature birth or overbearing of the child. Weak attempts and damage to the pelvic area lead to pathology. Most often, trauma is considered as a factor that exacerbates the disease.
  • Hemolytic disease of the fetus. The disease develops when the blood of mother and child is incompatible. The immune system of a woman destroys the child's red blood cells, which excludes the possibility of its full development. This leads to severe brain toxicity. If the child survives, then he has impaired brain function.

  • Bacterial, viral and non-infectious diseases. During the course of the disease, intrauterine disorders in the development of the fetus are noted. At risk are the children of women who suffered from toxoplasmosis, rubella measles, herpes, cytomegalovirus infection. Pathology develops with heart disease, nervous strain, anemia, etc.
  • Taking medicines. If during pregnancy the patient is taking antibiotics, non-steroidal anti-inflammatory drugs, antidepressants, second-generation anxiolytics, aspirin, antiepileptic drugs, lithium preparations without consulting a doctor, this leads to the development of the disease.
  • Heredity. If the unborn child in the family has people with this form of the disease, then he is at risk.
  • Prematurity. If a premature baby has a small. Body weight, then pathology can be diagnosed in him.

There are various reasons for the development of the pathological process, which a woman should familiarize herself with during the planning period for a child.

Symptoms of the disease

The atonic type of the disease is characterized by pronounced symptoms, which makes it possible to determine it almost immediately after the birth of the crumbs. If you pull the hands when the child is sick, then muscle tension will not be observed. He will remain passive. The baby's head is tilted back.

If you put the child on his back, he will not seek to move, which is explained by a significant decrease in the tone of the muscular system. In the muscles of the upper extremities, the working capacity is higher than in the lower ones. During the course of the disease, the child observes stereotypical motor activity. The pathological process is accompanied by an intense expression of tendon reflexes.

With a disease, the child begins to hold his head only after 6 months after birth. In the prone position, the baby does not strive to reach for the toy. Even when reaching the required age, the child cannot roll over on his own. If you lay the baby on his stomach, then he can hold the head and rest on the handles.

The baby learns to sit without support after 7 months. Such children begin to walk only when they reach the age of 6-8 years. At preschool age, the onset of mental deviations and aggression is noted. The disease is accompanied by convulsions, strabismus, nystagmus, glaucoma.

Due to the pronounced symptoms of the disease, it is possible to detect it in a timely manner. When the first signs of illness appear, parents should show the child to a pediatrician who will correctly diagnose and prescribe effective therapy.

Features treatment

Treatment of the atonic form of the disease does not bring the desired results. During the course of the pathology, rehabilitation measures are recommended. Patients are prescribed:

  • physiotherapy;
  • acupuncture;

Patients must perform daily. He is shown regular classes with a speech therapist. All of the above methods are characterized by a small positive effect. They help to increase the activity of the baby.

Medicines do not bring the desired therapeutic effect, so they are used to eliminate unpleasant symptoms. In order to reduce intracranial pressure, the patient is recommended to take vasodilator drugs and diuretics. Improvement of metabolic processes in the brain is provided by nootropic drugs.

Reduce child aggression sedative medications. The selection of certain medications should be carried out only by a doctor in accordance with the characteristics of the course of the pathology and the age of the patient.

Sometimes children are prescribed surgery. A specific rehabilitation method is hippotherapy. Thanks to the interaction with the horse, the mood of the baby is improved and the mental and physical condition is stabilized. This provides an increase in the chances of social adaptation in the future.

Should be selected by a doctor after examining the child, which will ensure an improvement in his condition.

Complications

In the absence of rehabilitation measures during the course of the pathological process, the patient may be diagnosed with the appearance of complications. Most often they appear as:

  • Seizures. The development of epilepsy is observed in 50 percent of patients. This complication negatively affects the development of the baby. In epilepsy, there is an increase in the severity of other symptoms, which reduces the effectiveness of rehabilitation methods.
  • Orthopedic disorders. With the disease, excessive muscle weakness is noted, which leads to the development of various curvature of the spine - scoliosis, lordosis, kyphosis. In pathology, there is an inconsistency in the work of the muscles and disturbances in the blood supply. With age, the progression of complications is diagnosed.
  • mental retardation. Complications are observed in almost all children, which negatively affects rehabilitation. Adult children have difficulty communicating with others, so they close in on themselves.
  • Digestive disorders. Against the background of low physical activity, disorders in the digestive system are diagnosed. The most common is chronic constipation. In pathology, obesity of patients is observed.

Complications are manifested in the form of salivation and enuresis. In patients with pathology, visual and auditory function is impaired.

The atonic form of cerebral palsy is a complex pathological process that leads to a variety of undesirable effects. The symptomatology of the pathology is pronounced, which makes it possible to detect it in a timely manner. Since there is no scheme for effective treatment of pathology, it is recommended to carry out its prevention, which consists in careful planning of pregnancy.

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:

  1. How long has the child been experiencing behavioral changes?
  2. Did the parents notice deviations in the physical activity of the baby before?
  3. Was oxygen starvation diagnosed during childbearing?
  4. Was the baby born prematurely or according to the DA?
  5. Was the birth normal or was the baby traumatized?
  6. Did the baby's mother during pregnancy suffer from rubella, syphilis, influenza, various chronic ailments, including pneumonia and tuberculosis?
  7. Were stimulants used during childbirth?
  8. 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.

Demonstration. 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. I tried to bend my legs at the hip joints and crawl, but I didn’t have enough strength. Pacifier feeding. The child, according to the mother, never cried in all 5 years of her 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 gr., "calcine" x 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 continue 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 continued 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 the 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. He 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, and 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.

Hyperkinetic forms of cerebral palsy are very diverse, so it is difficult to give accurate recommendations for the treatment of each specific form.
In the context of the pathogenesis of cerebral palsy described in this book, hyperkinesis can be considered not only as a result of local damage to the nuclei of the brain, but also as a dynamic generalized form of specific responses to nonspecific stimuli in the form of intermittent spastic contractions of the striated muscles.
Increased randomness of movements is due to damage to the nuclei of the brain and additional compression or overstretching of the membranes of the roots at the exit from the intervertebral foramina. Irritation of the nerve fibers in the roots leads to an additional distortion of the signals coming from the gamma receptors of the tendon-ligamentous apparatus of the joints of the extremities, which forms the child's inadequate motor reactions.

Features of the rehabilitation of children with generalized forms of hyperkinesis

Based on the concept of a specific response to a nonspecific stimulus, it is possible to recommend techniques that facilitate the rehabilitation of such children.
1. Traction rotational manipulation technology is performed for all children with hyperkinesis, although its implementation in the first days causes certain difficulties.
Hyperkinesis of the head and individual limbs responds well to correction, which sometimes stops even after a week of procedures. With generalized forms of hyperkinesis, only 10% of children manage to eliminate the chaotic movements immediately after the first course of traction rotational manipulation technology. After the procedures, the rest of the children have improved sleep, facilitated movements, and the appearance of high-amplitude simulated movements. All children with hyperkinesis after the first course of intensive rehabilitation have accelerated growth and development. But, some time after the first course of procedures, the growth of the vertebrae in length leads to an increase in compression of the roots or overstretching of the dura mater around the nerve roots, which can manifest itself in the form of a resumption of hyperkinesis. Unlike recurrence, renewed hyperkinesis will never reach the same phenomena that were observed before the first course of procedures. Purposeful movements that the child has learned after the first course of rehabilitation are preserved. The fact of increased hyperkinesis indicates the need to repeat a short course of traction rotational manipulation technology. After repeated 5-7 procedures, the phenomena of hyperkinesis decrease even more than after the first course of procedures. During the treatment period, it is very important not to miss the moment of facilitating movements in order to develop the skills of coordinated movements until the growth and development of the vertebrae leads to a new manifestation of the hyperkinesis clinic.