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Cerebral palsy (G80)

Pediatric neurology, Pediatrics

general information

Short description

Union of Pediatricians of Russia

ICD 10: G80

Year of approval (frequency of revision): 2016 (revised every 3 years)

Cerebral palsy (cerebral palsy) - a group of stable disorders of the development of motor skills and maintaining posture, leading to movement defects caused by non-progressive damage and / or anomaly of the developing brain in a fetus or newborn child.

Classification

ICD-10 coding

G80.0 - Spastic cerebral palsy

G80.1 - Spastic diplegia

G80.2 - Pediatric hemiplegia

G80.3 - Dyskinetic cerebral palsy

G80.4 - Ataxic cerebral palsy

G80.8 - Another type of infantile cerebral palsy

Examples of diagnoses

Cerebral palsy: spastic diplegia.

Cerebral palsy: spastic right-sided hemiparesis.

Cerebral palsy: dyskinetic form, choreo-athetosis.

Cerebral palsy: ataxic form.

Classification

In addition to the above-described international classification of cerebral palsy (ICD-10), there are a large number of copyright clinical and functional classifications. The most widespread in Russia were the classification of K.A. Semyonova (1978):

Double hemiplegia;

Hyperkinetic form;

Atonic-astatic form;

Hemiplegic form;

and L.O. Badalyan et al. (1988):

Table 1 - Classification of cerebral palsy

Early age	Older age
Spastic forms: Hemiplegia Diplegia Bilateral hemiplegia Dystonic form Hypotonic form	Spastic forms: Hemiplegia Diplegia Bilateral hemiplegia Hyperkinetic form Ataxic form Atonic-astatic form Mixed forms: Spastic-ataxic Spastic-hyperkinetic Atactico-hyperkinetic

In the domestic literature, the following stages of cerebral palsy development are distinguished (K.A.

Semyonova 1976):

Early: up to 4-5 months;

Initial residual stage: from 6 months to 3 years;

Late residual: over 3 years old.

Bilateral (double) hemiplegia in international clinical practice is also called quadriplegia, or tetraparesis. Given the persisting disagreements in expert assessments using the topographic classifications of cerebral palsy, international differences in classifications, today, more and more terms such as "bilateral", "unilateral", "dystonic", "choreoathetoid" and "ataxic" cerebral palsy ( Appendix D2).

Greater unanimity was achieved with the introduction of the functional classification of cerebral palsy - GMFCS (Gross Motor Function Classification System), proposed by R. Palisano et al. (1997). This is a descriptive system that takes into account the degree of development of motor skills and limitation of movements in everyday life for 5 age groups of patients with cerebral palsy: up to 2 years, from 2 to 4 years, from 4 to 6 years, from 6 to 12 years, from 12 to 18 years. According to GMFCS, there are 5 levels of development of large motor functions:

Level I - walking without restrictions;

Level II - walking with restrictions;

Level III - walking using hand-held mobility devices;

Level IV - independent movement is limited, motorized vehicles can be used;

Level V - complete dependence of the child on others - transportation in a wheelchair / wheelchair.

In addition to the classification of general motor functions, specialized scales for assessing spasticity and individual functions, and, first of all, the functions of the upper limbs, are widely used in patients with cerebral palsy.

Etiology and pathogenesis

Cerebral palsy is a polyetiologic disease. The leading cause of the development of cerebral palsy is damage or abnormalities in the development of the brain of the fetus and newborn. The pathophysiological basis of the formation of cerebral palsy is the lesion of the brain at a certain period of its development, followed by the formation of pathological muscle tone (mainly spasticity) while maintaining posotonic reflexes and a concomitant violation of the formation of chain adjusting rectifying reflexes. The main difference between cerebral palsy and other central paralysis is the time of exposure to a pathological factor.

The ratio of prenatal and perinatal factors of brain damage in cerebral palsy is different. Up to 80% of observations of brain lesions causing cerebral palsy occur during the period of intrauterine development of the fetus; subsequently intrauterine pathology is often aggravated by intrapartum.

More than 400 biological and environmental factors have been described that affect the course of normal fetal development, but their role in the formation of cerebral palsy has not been fully studied. A combination of several adverse factors, both during pregnancy and during childbirth, is often noted. The intrauterine causes of the development of cerebral palsy, first of all, include acute or chronic extragenital diseases of the mother ( hypertension, heart defects, anemia, obesity, diabetes and diseases of the thyroid gland, etc.), taking medications during pregnancy, occupational hazards, parental alcoholism, stress, psychological discomfort, physical trauma during pregnancy. A significant role belongs to the influence on the fetus of various infectious agents, especially of viral origin. Among the risk factors, there are also uterine bleeding, abnormalities of placental circulation, placenta previa or its detachment, immunological incompatibility of the blood of the mother and the fetus (according to the ABO systems, Rh factor and others).

Most of these unfavorable factors of the prenatal period lead to intrauterine fetal hypoxia and impaired uteroplacental blood circulation. Oxygen deficiency inhibits the synthesis of nucleic acids and proteins, which leads to structural disorders of embryonic development.

Various complications in childbirth: weakness contractile activity uterus, rapid or prolonged labor, cesarean section, a long anhydrous period, breech and pelvic presentation of the fetus, a long period of standing of the head in the birth canal, instrumental obstetrics, as well as premature birth and multiple pregnancies are also considered high risk factors for the development of cerebral palsy.

Until recently, birth asphyxia was considered the leading cause of brain damage in children. The study of the anamnesis of children who underwent birth asphyxia showed that 75% of them had an extremely unfavorable background of intrauterine development, burdened by additional risk factors for chronic hypoxia. Therefore, even in the presence of severe birth asphyxia, the causal relationship with the subsequently developed psychomotor deficit is not absolute.

An important place in the etiology of cerebral palsy is occupied by intracranial birth trauma due to mechanical effects on the fetus (compression of the brain, crushing and necrosis of the medulla, tissue rupture, hemorrhages in the membranes and brain matter, impaired dynamic blood circulation in the brain). However, one cannot fail to take into account that birth trauma most often occurs against the background of a previous defect in the development of the fetus, with pathological, and sometimes even with physiological childbirth.

The role of hereditary predisposition and genetic pathology in the structure of cerebral palsy remains a completely unresolved issue. Often, undifferentiated genetic syndromes are behind the diagnosis of cerebral palsy, which is especially characteristic of ataxic and dyskinetic forms of cerebral palsy. So the presence of athetosis and hyperkinesis, which are usually strictly associated with nuclear jaundice, in the absence of reliable anamnestic data, may have a genetic basis. Even the "classic" spastic forms of cerebral palsy with clear progression (and, moreover, the emergence of new ones) clinical symptoms should alert the doctor from the point of view of the possible presence of spastic paraplegia and other neurodegenerative diseases in the child.

Epidemiology

Cerebral palsy develops, according to various sources, in 2-3.6 cases per 1000 live newborns and is the main cause of childhood neurological disability in the world. Among premature infants, the incidence of cerebral palsy is 1%. In newborns with a body weight of less than 1500 g, the prevalence of cerebral palsy increases to 5-15%, and with extremely low body weight - up to 25-30%. Multiple pregnancies increase the risk of developing cerebral palsy: the frequency of cerebral palsy in singleton pregnancies is 0.2%, with twins - 1.5%, with triplets - 8.0%, with four-fetal pregnancies - 43%. Nevertheless, over the past 20 years, in parallel with the increase in the number of children born from multiple pregnancies with low and extremely low body weight, there has been a trend towards a decrease in the incidence of cerebral palsy in this population. In the Russian Federation, the prevalence of registered cases of cerebral palsy is 2.2-3.3 cases per 1000 newborns.

Clinical picture

Symptoms, course

Clinical picture

Spastic bilateral cerebral palsy

Spastic diplegia G80.1

The most common type of cerebral palsy (3/4 of all spastic forms), also known as Little's disease. Spastic diplegia is characterized by bilateral damage to the limbs, legs, to a greater extent than to the arms, early formation of deformities and contractures. Common concomitant symptoms are delayed mental and speech development, the presence of pseudobulbar syndrome, cranial nerve pathology leading to atrophy of the optic discs, dysarthria, hearing impairment, as well as a moderate decrease in intelligence. The prognosis of motor abilities is less favorable than with hemiparesis. Spastic diplegia develops mainly in infants born prematurely and is accompanied by characteristic changes in magnetic resonance imaging (MRI) of the brain.

Spastic tetraparesis (double hemiplegia) G80.0

One of the most severe forms of cerebral palsy, which is a consequence of abnormalities in the development of the brain, intrauterine infections and perinatal hypoxia with diffuse damage to the brain substance, often accompanied by the formation of secondary microcephaly. Clinically manifested by bilateral spasticity, equally expressed in the upper and lower extremities, or predominant in the hands. With this form of cerebral palsy, a wide range of comorbidities is observed: consequences of cranial nerve damage (strabismus, optic nerve atrophy, hearing impairment, pseudobulbar syndrome), pronounced cognitive and speech defects, epilepsy, early formation of severe secondary orthopedic complications (joint contractures and bone deformities). Severe motor hand defect and lack of motivation for treatment and learning severely limit self-care and simple labor activity.

Spastic unilateral cerebral palsy G80.2

It is characterized by unilateral spastic hemiparesis, in some patients - delayed mental and speech development. The arm usually suffers more than the leg. Less common is spastic monoparesis. Focal epileptic seizures... The cause is hemorrhagic stroke (usually one-sided), and congenital anomalies of brain development. Children with hemiparesis acquire age-related motor skills somewhat later than healthy children. Therefore, the level of social adaptation, as a rule, is determined not by the degree of the motor defect, but by the child's intellectual capabilities.

Dyskinetic cerebral palsy G80.3

It is characterized by involuntary movements, traditionally called hyperkinesis (athetosis, choreoathetosis, dystonia), changes in muscle tone (both increase and decrease in tone can be noted), speech disorders, more often in the form of hyperkinetic dysarthria. There is no correct installation of the trunk and limbs. The majority of children show the preservation of intellectual functions, which is prognostically favorable in relation to social adaptation and learning, more often violations in the emotional-volitional sphere prevail. One of the most common causes of this form is the transferred hemolytic disease of newborns with the development of "nuclear" jaundice, as well as acute intrapartum asphyxia in term infants with selective damage to the basal ganglia (status marmoratus). In this case, as a rule, the structures of the extrapyramidal system are damaged and auditory analyzer... The athetoid and dystonic variants are distinguished.

Ataxic cerebral palsy G80.4

It is characterized by low muscle tone, ataxia and high tendon and periosteal reflexes. Frequent speech disorders in the form of cerebellar or pseudobulbar dysarthria. Disorders of coordination are represented by the presence of intentional tremor and dysmetry when performing purposeful movements. It is observed with predominant damage to the cerebellum, frontal-ponto-cerebellar tract and, probably, frontal lobes due to birth trauma, hypoxic-ischemic factor, or congenital developmental anomalies. Intellectual deficit in this form varies from moderate to profound. In more than half of the cases, a thorough differential diagnosis with hereditary diseases is required.

Diagnostics

Complaints and anamnesis

In cerebral palsy, the clinical symptoms and the degree of functional impairment vary significantly in different patients and depend on the size and topography of the brain damage, as well as on the intensity and duration of previously conducted therapeutic and rehabilitation measures (Appendix D3)

Physical examination

In general, the leading clinical symptom in cerebral palsy is spasticity, which occurs in more than 80% of cases. Spasticity is "a movement disorder that is part of the upper motor neuron lesion syndrome, characterized by a speed-dependent increase in muscle tone and accompanied by an increase in tendon reflexes as a result of hyperexcitability of stretch receptors." In other cases, both a decrease in muscle tone and impaired coordination (ataxic cerebral palsy) and an unstable nature of its changes (dyskinetic cerebral palsy) are possible. For all forms of cerebral palsy, there may be:

Pathological tonic reflexes, which are especially pronounced when changing body position, especially when the patient is vertical;

Pathological synkinetic activity when performing voluntary movements;

Violation of the coordinating interactions of the muscles of synergists and antagonists;

An increase in general reflex excitability is a pronounced startle reflex.

The presence of these disorders from the early stages of a child's development leads to the formation of a pathological motor stereotype, and in spastic forms of cerebral palsy, to the consolidation of habitual limb attitudes, the development of articular contractures, and a progressive limitation of the child's functional capabilities. Brain damage in cerebral palsy may also initially be accompanied by cognitive and sensory impairment, convulsions.

Complications are formed mainly in the late residual stage and include, first of all, orthopedic pathology - the formation of articular-muscular contractures, deformities and shortening of the limbs, subluxations and dislocations of joints, scoliosis. As a result, movement disorders lead to an additional limitation of the child's ability to self-service, difficulties in obtaining education and full-fledged socialization.

Instrumental diagnostics

Comments: magnetic resonance imaging (MRI) is a more sensitive method than CT of the brain, and allows you to diagnose brain damage in the early stages, detect post-hypoxic brain damage, liquorodynamic disorders, congenital anomalies of the brain development).

Comments: video EEG monitoring allows you to determine the functional activity of the brain, the method is based on fixing electrical impulses that come from individual areas and zones of the brain.

Comments: x-ray of the bones of the skeleton is necessary to identify and assess deformities of the structures of the osteoarticular system, which occur secondarily with muscle spasticity.

Other diagnostics

Comments: indicated for all patients with an established diagnosis of cerebral palsy withthe frequency determined by the severity of the motor defect and the speedprogression of musculoskeletal pathology

Comments: indicated in the presence of stigma of dysembryogenesis, in clinicalthe picture of "sluggish child syndrome."

Differential diagnosis

Differential diagnostics.

Cerebral palsy is, first of all, a descriptive term, in this regard, for the diagnosis of cerebral palsy, as a rule, there are enough manifestations of specific non-progressive motor disorders, which usually become noticeable in the initial residual stage and the presence of one or more risk factors and complications in the perinatal period. However, a wide range of differential diagnoses of cerebral palsy and a high risk of missing hereditary diseases (including those with pathogenetic treatment), especially in young children, requires a thorough diagnostic search for any differences in clinical symptoms and anamnesis from the "classic" picture of cerebral palsy. The "alarming" factors include: the patient's absence of perinatal risk factors, disease progression, loss of previously acquired skills, repeated cases of cerebral palsy or early death of children in the family without an established cause, multiple developmental anomalies in the child. In this case, a mandatory neuroimaging examination (MRI of the brain), consultation with a geneticist, followed by additional laboratory tests are required. In the presence of hemiparesis, signs of stroke, a study of factors of the blood coagulation system, including polymorphism of coagulation genes, is shown. All patients with cerebral palsy require examination for the presence of visual and hearing impairments, mental and speech development delays, and nutritional status assessment. The exclusion of hereditary metabolic diseases, in addition to specialized biochemical tests, implies visualization of internal organs ( ultrasound procedure, MRI of internal organs, according to indications). If the symptom complex of a "flaccid child" predominates in the clinical picture ("flattened" posture, a decrease in resistance in the joints during passive movements, an increase in the range of motion in the joints, a delay in motor development), careful differential diagnosis Cerebral palsy with hereditary neuromuscular diseases.

Treatment

Conservative treatment

According to the European Consensus on the Treatment of Cerebral Palsy with Botulinum Therapy, published in 2009, there are several main groups of therapeutic effects for spastic forms of cerebral palsy. (Appendix D1).

The appointment of an oral drug with a muscle relaxant effect is recommended: Tolperisone (N-anticholinergic, centrally acting muscle relaxant) (ATX code: M03BX04) tablets of 50 and 150 mg. Prescribed in a dose: from 3 to 6 years - 5 mg / kg / day; 7-14 years old - 2-4 mg / kg / day (in 3 divided doses per day).

It is recommended to prescribe an oral drug with a muscle relaxant effect: Tizanidine Zh, VK (ATX Code: M03BX02) (drugs affecting neuromuscular transmission, centrally acting muscle relaxant, in the Russian Federation is not recommended for use under 18 years of age). By stimulating presynaptic α2 receptors, inhibits the release of excitatory amino acids that stimulate NMDA receptors. Suppresses polysynaptic impulse transmission at the level of intermediate neurons of the spinal cord). Tablets 2 and 4 mg. Starting dose (<10 лет) - 1 мг 2 р/д, (>10 years) - 2 mg 1 r / d; the maximum dose is 0.05 mg / kg / d, 2 mg 3 r / d.

With more pronounced spasticity, the use of baclofen preparations is recommended, vk (ATX code: M03BX01) (a derivative of γ-aminobutyric acid, stimulating GABAb-receptors, a muscle relaxant of central action): tablets of 10 and 25 mg.

Comments: The initial dose is 5 mg (1/2 table. 10 mg) 3 times a day. Whenif necessary, the dose can be increased every 3 days. Usually recommendeddoses for children: 1-2 years old - 10-20 mg / day; 2-6 years - 20-30 mg / day; 6-10 years old - 30-60mg / day For children over 10 years of age, the maximum dose is 1.5-2 mg / kg.

To reduce local spasticity, therapy with botulinum toxin type A (BTA) preparations is recommended: Botulinum toxin type A-

hemagglutinin complex g, bk (ATC code: M03AX01).

Comments: Intramuscular administration of BTA allows locally, reversibly,dose-dependently reduce muscle tone for up to 3-6 months or more. In Russia intreatment standards for cerebral palsy botulinum therapy has been introduced since 2004, for use intwo BTA drugs are registered for children: Dysport (Ipsen Biopharm Ltd.,Great Britain) - according to the indication, the dynamic deformity of the foot caused byspasticity in cerebral palsy, in children over 2 years old and Botox (ATC code: M03AX01)(Allergan Pharmaceutical Ireland, Ireland) - by indication: focalspasticity associated with dynamic foot deformity by typeEquine foot due to spasticity in patients 2 years of age and older with childrencerebral palsy on outpatient treatment.

The calculation of the BTA dose is based on determining 1) the total dose for administration; 2) generaldoses per kilogram of body weight; 3) the number of units of the drug permuscle; 4) the number of units of the drug per point of administration; 5) the number of unitsdrug per kilogram of body weight per muscle.

According to Russian recommendations, the dose of Botox is 4-6 U / kgthe body of the child; the total total dose of the drug for one procedure should notexceed 200 units. When using the drug Dysport, the total amountthe drug during the first injection should not exceed 30 U / kg per child's body weight (no more than 1000 U in total). The maximum dose for a large muscle is 10-15 U / kg of body weight, for a small muscle - 2-5 U / kgbody weight. BTA preparations are not equivalent, in terms of dosages,coefficient for direct conversion of various commercial forms of BTA is notexist.

Reduced spasticity, by itself, has minimal effect onthe acquisition of new functionality by a child with cerebral palsy, and forupper extremities "high level of evidence of effectivenessbTA injections identified only as an adjunct to physical rehabilitation in childrenwith spastic forms of cerebral palsy. When compared to placebo or notreatment with BTA injections alone did not show sufficient effectiveness. " In connection withthis mandatory element of the treatment of patients with cerebral palsy isfunctional therapy.

In addition to antispastic drugs, concomitant drugs used for cerebral palsy can be antiepileptic drugs, M- and H-anticholinergics, dopaminomimetics used for dystonia and hyperkinesis. Nootropics, angioprotectors and microcirculation correctors, drugs with metabolic effects, vitamins and vitamin-like agents are widely used in Russia in the treatment of cerebral palsy. The use of these drugs is aimed at correcting concomitant pathology in cerebral palsy. The main problem with the use of these drugs is the lack of studies of their effectiveness in cerebral palsy.

Surgery

Orthopedic and neurosurgical methods, playing an equally important role in restoring and maintaining the functional abilities of patients with cerebral palsy, require detailed consideration in separate recommendations due to their specificity and diversity.

With the ineffectiveness of oral antispastic drugs and BTA injections, it is recommended to use neurosurgical methods for treating spasticity:

Selective dorsal rhizotomy

Chronic epidural spinal cord stimulation

Installing an intrathecal baclofen pump
(Strength of Recommendation - 1; Strength of Evidence - B)

Medical rehabilitation

Physical rehabilitation methods are traditionally represented by massage, remedial gymnastics, instrumental kinesiotherapy, in a number of centers - robotic mechanotherapy using specialized simulators, including those based on the principle of biofeedback (for example, Lokomat is a robotic orthopedic device for restoring walking skills, Armeo is a complex for functional therapy of the upper limbs, etc.). Physiotherapy with cerebral palsy, especially for children in the first years of life, it is effectively supplemented with techniques based on inhibition of pathological reflexes and activation of physiological movements (methods of Voight, Bobat, etc.). A domestic development, which has found wide application in the complex rehabilitation of patients with cerebral palsy, is the use of the method of dynamic proprioceptive correction carried out using specialized suits (for example, Adele, Gravistat, Atlant) - systems consisting of elastic adjustable supporting elements, with the help of which targeted correction is created postures and dosed load on the musculoskeletal system of patients in order to normalize proprioceptive afferentation.

Traditionally in Russia, physiotherapeutic methods are widely used in the rehabilitation of patients with cerebral palsy, including those based on natural factors of influence: the application of mud, paraffin, ozokerite for antispastic purposes, electrophysiological methods - electrical stimulation, electrophoresis with medicinal substances, water procedures, etc.

Thus, reducing spasticity in cerebral palsy is only the first step towards increasing the functional activity of patients, requiring further targeted functional rehabilitation methods. Functional therapy is also a priority method of rehabilitation for forms of cerebral palsy that are not accompanied by changes in muscle tone in a spastic manner.

Alternative methods of treatment and rehabilitation of patients with cerebral palsy include acupuncture and acupuncture, manual therapy and osteopathy, hippotherapy and dolphin therapy, yoga, methods of Chinese traditional medicine, however, according to the criteria of evidence-based medicine, the effectiveness and safety of these techniques has not been evaluated at present.

Forecast

Outcomes and prognosis

The prognosis of the possibility of independent movement and self-care in patients with cerebral palsy largely depends on the type and volume of the motor defect, the level of intelligence and motivation, the quality of speech function and hand function. According to foreign studies, adult patients with cerebral palsy, IQ\u003e 80, intelligible speech and the ability to move independently, in 90% of cases, were employed in places provided to people without health limitations.

The mortality rate among patients with cerebral palsy is also directly related to the degree of motor deficit and concomitant diseases. Another predictor of premature death is decreased intelligence and inability to self-care. So it was shown that in European countries, patients with cerebral palsy and an IQ of less than 20 in half of the cases did not reach the age of 18, while those with an IQ of more than 35 - 92% of patients with cerebral palsy lived for more than 20 years.

In general, life expectancy and prognosis of social adaptation of patients with cerebral palsy largely depend on the timely provision of medical, pedagogical and social assistance to the child and his family. Social deprivation and the inaccessibility of comprehensive care can have a negative impact on the development of a child with cerebral palsy, perhaps even more significant than the original structural brain damage.

Prevention

Prevention and dispensary observation

Prevention of cerebral palsy includes both antenatal and postnatal activities. Antenatal includes improving the somatic health of mothers, preventing obstetric and gynecological pathology, premature birth and complicated pregnancy, timely detection and treatment of infectious diseases of the mother, promotion of a healthy lifestyle for both parents. Timely detection and prevention of a complicated course of childbirth, competent obstetric assistance can significantly reduce the risk of intrapartum damage to the central nervous system of a newborn. Recently, increasing importance has been attached to the study of the role of hereditary coagulopathies in the formation of focal brain damage in children with unilateral forms of cerebral palsy and the prevention of these complications.

Postnatal measures for the prevention of cerebral palsy include the use of corporal controlled hypothermia in nursing premature infants, controlled use of steroids in premature infants (reducing the risk of developing bronchopulmonary dysplasia, corticosteroids increase the risk of cerebral palsy), intensive measures to reduce hyperbilirubinemia and prevent dyskinetic forms of cerebral palsy.

Optimal care for a patient with cerebral palsy implies a multidisciplinary approach of a team of medical, pedagogical and social specialists, focusing on the needs of both the patient himself and his family members involved in the daily rehabilitation and social adaptation of a child with cerebral palsy (16). Cerebral palsy, being primarily a dysfunctional condition, requires continuous daily rehabilitation from the first days of the patient's life, taking into account the following medical and social aspects:

Movement, posture maintenance and physical activity of the child;

Communication;

Accompanying illnesses;

Everyday activity;

Baby care;

The quality of life of the patient and family members.

On the early stage the development of cerebral palsy (up to 4 months, according to the classification of K.A. Semyonova), the diagnosis is not always obvious, however, the presence of a burdened perinatal history, delayed psychomotor development of the child are indications for targeted observation of the child by a pediatrician and neurologist. Assistance to newborns threatened with the development of cerebral palsy begins at the maternity hospital and continues at stage 2 - in specialized departments at children's hospitals, and at stage 3 - on an outpatient basis at children's polyclinics under the supervision of a pediatrician, neurologist and specialist doctors (orthopedist, ophthalmologist, etc.). ). Primary examination a patient with cerebral palsy (Appendix B) and further treatment can be carried out in a hospital, day hospital and outpatient clinic in a children's clinic, which is determined by the severity of the patient's general condition. An additional stage of rehabilitation treatment for cerebral palsy is the referral of patients to sanatorium institutions. The length of continuous stay of a child with cerebral palsy in a medical institution depends on the severity of movement disorders and concomitant pathology. It is important not only to conduct courses of complex rehabilitation treatment in a medical institution, but also to implement recommendations regarding the level and nature of physical activity, the use of technical means of rehabilitation at home. The key principles of providing care for cerebral palsy are its early onset, continuity and continuity of all stages of rehabilitation, a multidisciplinary approach. There is a constant increase in the number and improvement of existing traditional and alternative methods of treating patients with cerebral palsy, but the fundamental goal remains the same - timely compensation of functional disorders that have developed as a result of damage to the child's brain, and minimization of secondary biomechanical deformities and social consequences of the disease. If the pathogenetic effect on the cause of cerebral palsy is impossible, the task is to optimally adapt the child to the existing defect, based on the principles of the plasticity of the nervous system.

Information

Sources and Literature

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Kurenkov A.L., Klochkova O.A., Zmanovskaya V.A., Falkovsky I.V., Kenis V.M., Vladykina L.N., Krasavina D.A., Nosko A.S., Rychkova L.V., Karimova Kh.M., Bursagova B.I., Namazova-Baranova L.S., Mamedyarov A.M., Kuzenkova L.M., Dontsov O.G., Ryzhenkov M.A., Butorina M.N., Pavlova O.L., Kharlamova N.N., Dankov D.M., Levitina E.V., Popkov D.A., Ryabykh S.O., Medvedeva S.N., Gubina E B., Agranovich O.V., Kiseleva T.I., Vasilyeva O.N., Zykov V.P., Mikhnovich V.I., Belogorova T.A. The first Russian consensus on the use of multilevel injections of Abobotulinumtoxin A in the treatment of spastic forms of infantile cerebral palsy. Journal of Neurology and Psychiatry. S. S. Korsakova. 2016; 11 (116): S. 98-107. 7. Semenova K.A., Mastyukova E.M., Smuglin M.Ya. Clinic and rehabilitation therapy for infantile cerebral palsy. M .: Medicine. 1972.328 s. 8. Boyd R.N., Graham H.K. 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S., Berweck S., Borggraefe I., van Campenhout A., Andersen G. L., Aydin R., Becher J. G., Bernert G. et al. The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol. 2010; 14: 45-66. 12. Koman L.A., Mooney J.F. 3rd, Smith B.P., Goodman A., Mulvaney T. Management of spasticity in cerebral palsy with botulinum-A toxin: report of a preliminary, randomized, double-blind trial. J Pediatr Orthop. 1994; 14 (3): 299-303. 13. Lance J.W. The control of muscle tone, reflexes, and movement: Robert Wartenberg Lecture. Neurology. 1980; 30 (12): 1303-13. 14. Little W.J. Course of lectures on the deformities of the human frame. Lancet. 1843; 44: 350- 354 15. Miller F. Cerebral palsy. New York: Springer Science. 2005.1055 p. 16. Palisano R., Rosenbaum P.L., Walter S., Russell D., Wood E., Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997; 39 (4): 214-223. 17. Surveillance of cerebral palsy in Europe (SCPE). Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol. 2000; 42: 816-824. 18. Tardieu G., Shentoub S., Delarue R. Research on a technique for measurement of spasticity. Rev Neurol (Paris). 1954; 91 (2): 143-4.

Information

Keywords

Impaired motor development

Spasticity

Delay in psycho-speech development,

Poor posture maintenance

Pathological reflexes

Impaired coordination

Epilepsy.

List of abbreviations

Cerebral Palsy - Cerebral Palsy

MRI - Magnetic Resonance Imaging

Criteria for assessing the quality of medical care

№	Quality criteria	Power	Level credibility evidence
1	Performed therapy with antispastic drugs of local spasticity (botulinum toxin type "A")	1	AND
2	Therapy with antispastic drugs of generalized spasticity (oral muscle relaxants)	1	IN
3	Physical rehabilitation methods (physiotherapy exercises / massage / applied kinesitherapy / robotic mechanotherapy / physiotherapy, etc.), focused on solving specific therapeutic tasks (reducing tone, suppressing pathological reflexes, preventing secondary deformities, improving function, etc.)	1	FROM

Appendix A1. The composition of the working group:

Baranov A.A., Acad. RAS, Professor, Doctor of Medical Sciences, Chairman of the Executive Committee of the Union of Pediatricians of Russia.

Namazova-Baranova L.S., Corresponding Member RAS, Professor, Doctor of Medical Sciences, Deputy Chairman of the Executive Committee of the Union of Pediatricians of Russia.

Kuzenkova L.M., Professor, Doctor of Medical Sciences, Member of the Union of Pediatricians of Russia

Kurenkov A.L., Professor, Doctor of Medical Sciences, Member of the Union of Pediatricians of Russia

Klochkova O.A., candidate of medical sciences, member of the Union of Pediatricians of Russia

Mamedyarov A.M., Ph.D., member of the Union of Pediatricians of Russia

Karimova H.M., Ph.D.

Bursagova B.I., Ph.D.

Vishneva E.A., Ph.D., member of the Union of Pediatricians of Russia

Appendix A2. Guidelines development methodology

Target audience of these clinical guidelines:

1. Pediatricians;

2. Physicians-neurologists;

3. General practitioners (family doctors);

4. Doctors-rehabilitologists, doctors-exercise therapy, doctors-physiotherapists;

5. Students of medical universities;

6. Trainees in residency and internship.

Methods used to collect / select evidence: search in electronic databases.

Description of the methods used to assess the quality and strength of evidence: The evidence base for the recommendations is the publications included in the Cochrane Library, EMBASE, MEDLINE and PubMed. Search depth - 5 years.

Methods used to assess the quality and strength of evidence:

Expert consensus;

Assessment of significance in accordance with the rating scheme.

Methods used to analyze evidence:

Systematic reviews with tables of evidence.

Description of the methods used to analyze the evidence

In selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure that it is valid. The outcome of the study affects the level of evidence attributed to the publication, which in turn affects the strength of the recommendation.

To minimize potential errors, each study was evaluated independently. Any differences in ratings were discussed by the entire writing team. If it was impossible to reach a consensus, an independent expert was involved.

Evidence tables: filled in by the authors of clinical guidelines.

Comments were received from primary care physicians regarding the clarity of the presentation of these recommendations, as well as their assessment of the importance of the proposed recommendations as a tool for daily practice.

All comments received from experts were carefully systematized and discussed by the members of the working group (the authors of the recommendations). Each item was discussed separately.

Consultation and expert assessment

The draft guidelines were peer-reviewed by independent experts who were primarily asked to comment on the clarity and accuracy of the interpretation of the evidence underlying the recommendations.

Working group

For the final revision and quality control, the recommendations were re-analyzed by the members of the working group, who came to the conclusion that all the comments and comments of the experts were taken into account, the risk of systematic errors in the development of recommendations was minimized.

The strength of the recommendations (1-2) based on the respective levels of evidence (A-C) and good practice points (GPPs) are given in the text of the recommendations.

Table A1 - Scheme for assessing the level of recommendations

FROMthe level of reliability of the recommendations	Risk-benefit ratio	Methodological quality of available evidence	Explanations on the application of recommendations
1A		Strong, consistent evidence based on well-performed RCTs or conclusive evidence presented in some other form.	Strong recommendation that can be used in most cases in the majority of patients without any changes or exceptions
1B	Benefits clearly prevail over risks and costs, or vice versa	Evidence based on the results of RCTs performed with some limitations (conflicting results, methodological errors, indirect or accidental, etc.), or other compelling reasons. Further research, if conducted, is likely to influence and change our confidence in the benefit-risk ratio.	Strong recommendation that can be applied in most cases
1C	Benefits are likely to outweigh potential risks and costs, or vice versa	Evidence based on observational studies, ad hoc clinical experience, RCTs with significant flaws. Any estimate of the effect is regarded as uncertain.	Relatively strong recommendation, subject to change if better quality evidence is obtained
2A	Benefits are comparable to potential risks and costs	Strong evidence based on well-performed RCTs or supported by other compelling evidence. Further research is unlikely to change our confidence in the benefit-risk balance.	The best tactics will depend on the clinical situation (circumstances), patient, or social preference.
2B	The benefits are comparable to the risks and complications, but there is uncertainty in this estimate.	Evidence based on RCTs performed with significant limitations (conflicting results, methodological flaws, indirect or incidental), or strong evidence presented in some other form. Further research, if conducted, is likely to influence and change our confidence in the benefit-risk ratio.	Alternative tactics in certain situations may be the best choice for some patients.
2C	Ambiguity in assessing the balance of benefits, risks and complications; the benefits may be commensurate with the potential risks and complications.	Evidence based on observational studies, ad hoc clinical experience, or RCTs with significant flaws. Any estimate of the effect is regarded as uncertain.	Very weak recommendation; alternative approaches can be used equally.

* In the table, the numerical value corresponds to the strength of the recommendations, the alphabetic value corresponds to the level of evidence

These clinical guidelines will be updated at least once every three years. The decision to update will be made on the basis of proposals submitted by medical professional non-profit organizations, taking into account the results of a comprehensive assessment of medicinal products, medical devices, as well as the results of clinical testing.

Appendix A3. Related documents

Procedures for the provision of medical care: Order of the Ministry of Health and Social Development of the Russian Federation of April 16, 2012 N 366n "On approval of the Procedure for the provision of pediatric care"

Medical care standards: Order of the Ministry of Health of the Russian Federation of June 16, 2015 N 349n "On approval of the standard of specialized medical care for infantile cerebral palsy (phase of medical rehabilitation)" (Registered in the Ministry of Justice of Russia on July 06, 2015 N 37911)

Appendix B. Algorithm for managing a patient with myasthenia gravis

Appendix B. Information for Patients

Cerebral palsy (CP), according to modern ideas, is a non-progressive disease of the central nervous system, the development of which is associated with perinatal brain damage at various stages of development of the fetus and child. The basis of the clinical picture of cerebral palsy is movement disorders, changes in muscle tone, impaired cognitive and speech development and other manifestations. The incidence of cerebral palsy, according to various authors, remains at the level of 2-3.6 cases per 1000 newborns, and with the use of modern technologies of intensive care of very premature infants against the background of decreasing mortality, the percentage of children with neurological deficit and cerebral palsy is growing.

The prognosis of cerebral palsy depends on the severity of clinical manifestations.

Antispastic therapy, rehabilitation treatment are the most effective methods of treating cerebral palsy.

Life expectancy and prognosis of social adaptation of patients with cerebral palsy largely depend on the timely provision of medical, pedagogical and social assistance to the child and his family.

Appendix D1. The main groups of therapeutic effects for spastic forms of cerebral palsy

Appendix D2.

Appendix D3. Advanced patient management algorithm

Appendix D3. Explanation of notes.

... g - a medicinal product included in the List of Vital and Essential Medicines for Medical Use for 2016 (Order of the Government of the Russian Federation of December 26, 2015 N 2724-r)

... VK is a medicinal product included in the List of Medicinal Products for Medical Use, including Medicinal Products for Medical Use, prescribed by decision of the medical commissions of medical organizations (Order of the Government of the Russian Federation of December 26, 2015 N 2724-r)

Attached files

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Analyzing the factors and causes of cerebral palsy, you should pay attention to the complexity of determining one specific cause. A complex of unfavorable factors that take place in the prenatal and birth period leads to pathology.

Causes of pathology

Structural disorders of neurons are the basis of any form of cerebral palsy. A complex of unfavorable factors can affect any period of brain formation - both during pregnancy and even after childbirth.

In boys, the disease proceeds with more severe consequences and occurs 1.3 times more often than in girls.

According to statistics, 80% of cases of pathology occur during pregnancy and childbirth, while postpartum period accounts for only 20% of cases.

Let's consider the main reasons:

Characteristics of the causes of cerebral palsy

The reasons discussed above can be combined into three groups, depending on the nature of the pathology - acquired or not.

One way or another, the influence of provoking factors should be complex.

Symptoms of cerebral palsy

Exactly movement disorders most often the main symptoms of cerebral palsy are presented. Depending on the age of the child, the severity and type of the disorders in question is determined, therefore it is worth considering the following stages of pathology:

The distribution of the main symptoms is also based on this classification.

Early signs of cerebral palsy

It is rare to be diagnosed with cerebral palsy at an early stage, since motor skills are essentially low at this age. However, some signs may warrant a diagnosis:

Revealing even minor deviations requires an examination of the child every 3 weeks. In the future, the dynamics of changes is monitored.

It is after the first 6 months of life that most of the symptoms can be identified, including:

The clinical form of the disease directly affects which symptoms will be paramount.

Spastic form

This form is the most common and is determined by violations of the tone in the limbs and muscle strength. Among the subtypes of the spastic form little's disease, spastic tetraplegia and hemiplegia.

Spastic diplegia

By 12 months, the signs are most evident. An increased tone is observed in all limbs, and therefore a forced position is formed. Other symptoms are also observed:

Patients are able to serve themselves, learn and adapt in society, since mental disorders are not clearly expressed. All this is possible only with the functioning of the hands and with proper treatment.

Spastic tetraplegia

The pathology is characterized by a pronounced violation of the movements of the upper limbs, while all four limbs are affected. This form is the most severe, since it is accompanied by the following disorders:

The optic nerves atrophy, and high tendon reflexes are observed. Children do not know how to walk and sit, the spine is deformed over time. Lifetime outside care is a must.

Hemiplegia

Muscle weakness is characteristic of only one side - right or left. In the hand, paresis is more pronounced. Such children later learn self-care skills, can walk and sit.

Signs of hemiplegia appear in 32% of cases of cerebral palsy diagnostics in children.

The affected limbs move inharmoniously.

Minor mental disorders, seizures are also characteristic. A decrease in intelligence is observed only with frequent convulsive seizures.

Diskinetic form

Hyperkinesis, characteristic of this form of cerebral palsy, is noticeable after the first 12 months of life. Among the involuntary movements:

• grimacing;
• twisting of the torso;
• imitation of throws and swinging hands;
• worm-like movements of the fingers.

Uncontrolled cries and sounds are caused by involuntary contraction of the muscles and larynx. Muscle tone decreases, but periodically suddenly rises ( dystonic attacks). Motor skills are formed with a delay, words are pronounced indistinctly, slowly, articulation is impaired. The level of intelligence is almost in line with the norms.

Ataxic form

This form is characterized by damage to the frontal lobes or cerebellum. Muscle tone is reduced, accuracy and coordination of movements are impaired. Often there are hyperkinesis, tremors in the limbs. A staggering gait is also characteristic. Mental abilities can reach oligophrenia, but sometimes they are not impaired at all.

When identifying symptoms characteristic of several of the forms described above, it is worth talking about a mixed form.

The use of a rehabilitation spiral suit in parallel with the main treatment in 87% of cases gives a positive result: it accelerates mental development and improves motor skills.

Prevention of cerebral palsy involves planning pregnancy, remediation of foci of chronic infections, timely examination and competent management of pregnancy, an individual approach to childbirth if necessary. Diagnosing the pathology in question is not yet a verdict. If the parents are actively involved in the rehabilitation of the child, and the treatment is started on time, the child will have a chance to work successfully in the future, start a family and raise their own children.

For such results to become a reality, treatment must be continuous, and early diagnosis.

Treatment involves attending sessions massage to normalize muscle tone, medication, exercise therapy. For the correction of motor skills, voyta therapy, bobat therapy and other special techniques. Classes with a psychologist and speech therapist are required. In some cases, surgery helps.

Cerebral palsy (cerebral palsy)

The collective name "infantile cerebral palsy" (abbreviated as cerebral palsy) denotes not one pathology, but many disorders of the nervous system (NS), malformations that form during pregnancy, in the natal and postnatal periods, united by a single complex of symptoms.

Movement disorders in cerebral palsy, often combined with mental, speech, cognitive impairments, epilepsy, visual impairments, hearing impairments, etc., are secondary symptoms arising from developmental abnormalities, trauma, and inflammatory pathologies of the brain. Although they are considered non-progressive, as the child with cerebral palsy grows and develops, the objective clinical picture may improve or worsen, depending on:

• forms of cerebral palsy, the degree of damage to the central nervous system;
• adequately selected therapy for concomitant disorders;
• the success of the rehabilitation program for cerebral palsy;
• psychoemotional state of a particular patient with cerebral palsy;
• his social environment;
• joint efforts of parents, doctors, teachers and other caring people who, by the will of fate, are near, take part in habilitation, the fate of children with cerebral palsy in the first year of life and older.

Manifesting at an early age, childhood disease (cerebral palsy) will gradually develop into an adult over the years. Congenital or acquired in natal and postnatal periods, pathologies of the central nervous system accompany a person throughout his life. If the brain damage is insignificant, it was possible to diagnose cerebral palsy on time, start symptomatic treatment and rehabilitation for up to a year, continue them if necessary throughout life, there is a chance that in adulthood, motor, cognitive and other impairments will be minimal. Modern habilitation and rehabilitation programs for cerebral palsy make it possible to level pathological symptoms with mild degrees of damage.

Some adults who were once diagnosed with cerebral palsy receive education, a variety of professions, move up the career ladder, and run in the Paralympic Games. Among them are artists and lawyers, musicians and teachers, journalists and programmers. The whole world knows the names of outstanding people who cannot be called "patients with cerebral palsy." Special people who, by the will of fate or nature, found themselves in a less advantageous position in comparison with the rest, ordinary people, were able to rise above the disease, defeat it, achieve much more in life than others.

Let's talk about some of them.

Cerebral palsy in women

Known not only on her home continent, but around the world, Australian prose writer, public figure, Anna Macdonald. She spent from 3 to 14 years in a closed institution where they did not live in isolation from society, but there were people with disabilities with cerebral palsy and other serious illnesses. This dramatic stretch of fate became the theme of the acclaimed book Anna's Coming Out, and later the script for a feature film.

Similar, but not so dramatic, is the fate of the Russian scriptwriter Maria Batalova. She has also been struggling with the symptoms of cerebral palsy for many years, but she has always had relatives and people who love her by her side. The bright lines of her works for adults, wonderful stories for children are imbued with philanthropy. In 2008, her script for the film "House on the English Embankment" was awarded the highest award at the Moscow Film Premiere Film Festival.

Anastasia Abroskina, a wonderful young mother and at the same time a successful model, won six gold medals at the Russian Paralympic Equestrian Dressage Championships. Her illness, which had long outgrown childhood (cerebral palsy, hyperkinetic form), could not break the will to win, destroy the thirst for life of an elegant, seemingly very fragile, but in fact, incredibly persistent, purposeful woman.

In the middle of the 15th century, the illegitimate son of notary Piero da Vinci, Leonardo, was born in Italy. The boy's right arm and right leg did not obey from birth, he had hemiplegic cerebral palsy. Therefore, when he grew up, he limped slightly when walking, and he learned to write, draw, etc. with his left hand. Thanks to his divine gift, numerous talents, the world cultural heritage was enriched with great canvases ("Annunciation", "Madonna with a Flower", etc.), sculptural works (unfortunately, lost), and he was also an architect, scientist, inventor.

Among our contemporaries who are diagnosed with cerebral palsy and are world-famous are actors Sylvester Stallone, R.J. Mitt, Chris Foncesca.

In 2008, one of the sensations of the Paralympic Games in Beijing was the triumph of Russian athlete Dmitry Kokarev. The young swimmer brought our team one silver and three gold medals.

The pride of all Crimeans is their fellow countryman, a legendary man, Niyas Izmailov, a special child, a disabled person with cerebral palsy, who grew up and became the world champion among ordinary bodybuilders.

Children and cerebral palsy: from birth for many years

World medical statistics claim that today children with cerebral palsy (up to one year and older) are found in the population with a frequency of 0.1 to 0.7%. Moreover, boys are victims of pathology almost one and a half times more often than girls. For every 1000 citizens in different countries, there are, on average, 2 to 3 people with damage to the nervous system, which is called "childhood" (cerebral palsy), as it occurred during intrauterine development, in the natal or postnatal period. However, in some countries, children with cerebral palsy are much more common among the population.

For example, in the United States, the numbers are much higher, and differ even for nearby states. For example, in 2002, statistics showed that children with cerebral palsy (1 year of age and older) per 1000 people occur with a frequency of:

• 3.3 - in the state of Wisconsin;
• 3.7 - in the state of Alabama;
• 3.8 - in the state of Georgia.

On average, American scientists said that children with cerebral palsy (1 year and older) occur with a frequency of 3.3 patients per 1000 population.

• In Russia, according to Rosstat, in 2014, there were 32.1 small patients with cerebral palsy per 100,000 children per 100,000 children (from 1 year of age to 14 years).
• According to the estimates of the Ministry of Health in the Russian Federation, back in 2010 there were more than 71 thousand children with cerebral palsy (1 year - 14 years).

The forecast of experts from the World Health Organization is not very comforting. Children with cerebral palsy are born more often. And in the coming years, the number of babies who have signs of cerebral palsy from birth will increase.

Despite the fact that the disease is childhood, cerebral palsy accompanies the patient from birth, relentlessly following him all his life. Therefore, the fight against the disease always continues.

If a baby has perinatal brain damage, cerebral palsy, the year (first from birth) can determine the whole future fate. Indeed, the objective clinical picture in the future will depend on how much:

• signs of cerebral palsy were quickly identified;
• the form and extent of damage to the nervous system are precisely determined;
• the selected symptomatic therapy is adequate;
• the rehabilitation and habilitation program of cerebral palsy is correctly drawn up.

Parents of children with various forms Cerebral palsy is often regretted about the time, energy and money spent in vain on psychics, traditional healers, etc., in the first years after the birth of a baby. It is important that the confused, and sometimes morally crushed, changes that have taken place in their lives, with the birth of a special child, fathers and mothers, are sent on the right path by specialists, doctors, psychologists. The road of habilitation, socialization is always very difficult, thorny for every family, which has children with special needs.

Therefore, it is better not to stray by roundabout paths, making your way by touch, experiencing alternative methods on your own son or daughter, expecting a miraculous healing and losing precious time, during which deformities, contractures have time to form, and other accompanying complications appear. And rely on the existing world experience in habilitation and treatment of cerebral palsy, enlist the support of specialists.

And the sooner the parents stop looking into the past, looking for the answer to the question “why” the cerebral palsy is sent, seeing the causes of the disease in the “evil eye” of ill-wishers or stirring up their own actions, they will understand that it is necessary to live in the present, the faster they will understand how to live in future.

Helping the baby to fight for life, rejoicing at each, albeit tiny, completely invisible to others, but such a huge victory for the family, giving, without a trace, all his love and tenderness to the most defenseless, helpless of all people, mom and dad, grandparents, other relatives and strangers by blood, but the most humane people on this earth who become foster parents, guardians, educators for abandoned children with cerebral palsy, acquire a meaning of existence. They develop spiritually, gaining invaluable experience of compassion and mercy.

Special people or patients with cerebral palsy?

Parents, doctors, teachers and other people are products and part of society. The worldview and attitude of each individual towards the disabled are formed by virtue of public opinion and the position of the state.

The moral norms of the modern human population, which distinguish people from animals, differ significantly from those that existed at the dawn of human civilization. They have changed significantly during the evolution of society.

Weaker children have always come to the world, including those with cerebral palsy. However, in addition to natural selection, in old days people tried on the role of gods, deciding who has the right to life and who is not worthy. Infanticide, the killing of infants with signs of inferiority, has existed for millennia. Only in 374, for the first time in world history, a law was issued prohibiting the physical destruction of newborns with various pathologies. But only in the 9th century the Christian world began to equate infanticide with the usual murder of its own kind.

The spiritual life of Western European society and the entire world civilization has experienced great positive changes, thanks to the great figures of the Renaissance and humanist educators who fought for the rights of the disabled during the Great French Revolution. Thanks to them, the society for the first time realized its responsibility for the disadvantaged, outcast, patients with cerebral palsy, etc.

Humanity has gone through a huge evolution of spiritual growth over the past hundred years. And this process continues today, in front of each of us.

So in 2008, an event took place that in the long term should change the life of disabled people with cerebral palsy and other pathologies in Russia. Our country has signed the Convention on the Rights of Persons with Disabilities. The new international law was ratified by the MPs in 2012. It is designed to help socialize people with disabilities, reduce discrimination against them by the state, officials and society.

The state turned its gaze towards special people. The media started talking about an accessible environment for people with disabilities, inclusion, equal opportunities. Many positive changes are taking place before our eyes. The mere fact that large and small people in wheelchairs with various orthopedic devices have appeared on the streets of Russian cities already suggests that the process has begun.

However, much remains to be changed. First of all, in the minds of each individual person. So that adults and children are not afraid of disabled people, including those with cerebral palsy, do not shy away from them in public places, do not humiliate or offend, willingly or unwittingly, do not ignore their difficulties. Society must understand that patients with cerebral palsy are ordinary people, only they have their own characteristics, like every person.

Special people have the same desires and dreams as ordinary people. Just to fulfill even the smallest of them, it is sometimes necessary to make incredible efforts. For example, to take a walk in the park on a fine day, learn to paint, or find a true friend.

Therefore, they need help, not only material, but physical, psychological. Not giving, but sincere participation of others. And also - partnership, on an equal footing.

They are the same people, just stranded.

Several diseases at once, which are based on a developmental abnormality or damage to the brain during the intrauterine development of a child, at the time of childbirth or in the postnatal period, are called cerebral palsy.

In 1861, William Little, an orthopedic surgeon from England, first described the clinical picture of one of the varieties of cerebral palsy, he saw the cause of spastic diplegia in oxygen starvation at the time of childbirth. But he believed that the defeat is not the brain, but the spinal cord. In honor of him, this form of cerebral palsy is sometimes called "Little's disease" today.

The term "infantile cerebral palsy" itself was introduced into medical practice in 1893 by Sigmund Freud, at that time already a well-known psychoanalyst. In 1897, he first compiled a classification of children, listing the signs of cerebral palsy. Freud was the first to describe the development of cerebral palsy. Unlike Little, he saw differently the etiology and pathogenesis of cerebral palsy, the causes of pathology. According to Freud, not only the spinal cord, but primarily the brain suffered from cerebral palsy, he was looking for the causes of disorders not only in birth trauma and asphyxia. Freud believed that the development of cerebral palsy begins much earlier. He was the first to name the cause of cerebral palsy in the wrong intrauterine development of the child.

Signs and manifestations of cerebral palsy

Since 1980, according to the definition of experts of the World Health Organization, signs of cerebral palsy, as a group of pathological syndromes of the nervous system, are considered non-progressive motor and psycho-speech disorders. They are a consequence of brain damage in cerebral palsy, the causes of which lie in the postnatal, intrapartum and intrauterine periods of the child's development.

Throughout history, since the definition of the signs of cerebral palsy by William Little, there have been many attempts to classify and streamline the symptom complexes of the group of syndromes. However, according to some scientists, it was not possible to compile a single, clear concept of multifaceted pathology, forms of cerebral palsy.

In general, the severity of the condition of patients with cerebral palsy is assessed according to three degrees of damage:

• easy - full socialization is possible with a given degree of damage in cerebral palsy, training, mastering not only self-service skills, but also professions, engaging in socially useful work, a full life;
• medium - partial socialization, self-service with the help of other people are possible;
• heavy - a person remains completely dependent on others, cannot serve himself without assistance.

To date, several classifications are used in medical practice, including various forms of cerebral palsy.

In Russia, they often use the classification compiled in 1972 by Professor Ksenia Aleksandrovna Semyonova, who in our country was affectionately nicknamed "the grandmother of cerebral palsy." This classification combines the following forms:

• atonic-astatic;
• hyperkinetic;
• hemiparetic;
• spastic diplegia;
• double hemipletic;
• mixed.

In Europe, the following clinical classification scheme for the signs of cerebral palsy is usually used:

• ataxic paralysis;
• dyskinetic paralysis;
• spastic paralysis.

In this case, the dyskinetic form has two types of cerebral palsy, the symptoms of which differ from each other:

• choreoathetic;
• dystonic.

The spastic form also has two options for the development of cerebral palsy:

• bilateral paralysis;
• unilateral paralysis.

Bilateral damage is divided into:

• quadriplegia;
• diplegia.

In international medical practice, the statistical classification ICD-10 has been adopted. According to her, all infantile cerebral palsy (ICP) is divided into:

• spastic - G80.0;
• spastic diplegia - G80.1;
• infantile hemiplegia - G80.2;
• dyskinetic - G80.3;
• ataxic - G80.4;
• other types of cerebral palsy - G80.8;
• unspecified cerebral palsy - G80.9.

The development of a child with cerebral palsy goes through several stages.

The first of them is called "initial", it lasts from birth to six months.

If during it, as early as possible, the correct diagnosis of cerebral palsy is established, adequate therapy is prescribed, rehabilitation begins, there are much more chances to avoid unwanted complications and extreme disability.

The next stage, the initial residual, lasts from six months to 3 years.

At this time, the diagnosis of cerebral palsy has already been made, the degree of brain damage is clear and predictions have been made. But no modern classifications and predictions are able to accurately predict the compensatory capabilities of the brain of a particular child. Moreover, if they are multiplied by the persistence of the patient himself, the efforts of his relatives, doctors, everyone who participates in the rehabilitation program of cerebral palsy. It is during this period that the rehabilitation of cerebral palsy gives its first fruits. In addition, the correct strategy for dealing with the disease at the initial residual stage lays the foundation for the development of a child with cerebral palsy in the future.

At the age of 3, the residual stage starts.

Although organic lesions of the brain are irreversible, and the symptom complex in this period is finally formed and is considered non-progressive, classes with children with cerebral palsy cannot be stopped. Persistent and consistent habilitation, rehabilitation, training in cerebral palsy are of great importance at any age, for children and adults. If you carry out regular training and classes, cerebral palsy can be corrected. A clear proof of this is many adults and grown-up children who, thanks to training, habilitation and rehabilitation, were able to defeat cerebral palsy and live a full life.

At the end of the last millennium, Ukrainian scientists, Vladimir Ilyich Kozyavkin and Vladimir Oleksandrovich Padko, proposed a new rehabilitation classification of cerebral palsy, the symptoms of motor and psycho-speech disorders were systematized for a unified assessment of the condition of patients at different stages of rehabilitation with cerebral palsy. It is based on the assessment of three main syndromes, which, combined with an additional one, make it possible to diagnose cerebral palsy. These are syndromes:

• speech disorders;
• intellectual disabilities;
• movement disorders.

Speech disorder syndrome can be characterized by:

• delayed speech development;
• sensory, motor, or mixed alalia;
• dislalia;
• ataxic, spastic, hyperkinetic or mixed dysarthria.

The syndrome of intellectual disabilities is defined as a mental retardation of two degrees:

• easy;
• pronounced.

The syndrome of movement disorders, at various stages of the development of cerebral palsy, is assessed based on:

• severity - plegia (complete absence) or paresis (limitation, weakness);
• prevalence - by the number of involved limbs;
• the nature of the violations - by the type of changes in muscle tone.

Based on the assessment of the syndrome of motor disorders, the following stages are distinguished, which the development of cerebral palsy takes place:

• stages of locomotion;
• verticalization phase.

The stage of locomotion is subdivided into several segments, each of which is characterized by a certain way of movement in space:

• impossibility of movement in space;
• movement by turning the body;
• simple crawling (on bellies);
• spasmodic, non-alternating crawl;
• alternating, reciprocal, or alternating crawl;
• walking on your knees;
• walking in an upright position, with the help of special devices and devices;
• independent walking (pathological).

The verticalization phase also has several stages:

• lack of head control while lying down;
• having head control while lying down;
• the ability to sit independently;
• the skill of standing up with support;
• the ability to get up without support.

Assessment of the state at different stages of rehabilitation, taking into account the development of a child with cerebral palsy, allows us to trace the dynamics of neurological syndromes, to outline the immediate goals and prospects.

Each form of cerebral palsy has symptoms that distinguish it from others. The differences are due to the specific causes of cerebral palsy, the nature and extent of lesions of the nervous system. Therefore, even within the framework of the general form, children of the same age can have significant differences in development, even against the background of a single rehabilitation program.

Let us dwell, optionally, on the basic forms and their features.

The hyperkinetic, athetosis form (3.3% of patients) undergoes two phases of the formation of neurological syndromes - the hyperkinetic one replaces the dystonic one. Muscle tone is significantly different - from severe spasticity to hypotension-dystonia. As a rule, dyskinesias, ataxia, psychoverbal retardation are diagnosed. Despite rehabilitation, training and classes with children with cerebral palsy of this form, limb deformities and scoliosis form over time.

The atactic form (9.2% of patients) manifests itself as a “flaccid baby” syndrome in the first weeks after birth. With this form of cerebral palsy, the causes of pathological syndromes are hidden in lesions of the frontal lobes of the brain. The delay in motor development is combined with a decrease in muscle tone. With brisk tendon reflexes, the following are noted:

• intentional tremor of the upper limbs;
• ataxia of the trunk;
• dysmetria;
• discoordination.

Despite the efforts of rehabilitation, regular classes, with cerebral palsy of this form:

• great difficulties are observed, often the impossibility of verticalization of the body, since the mechanism of postural control is disturbed;
• often develops astasia-abasia syndrome (inability to sit and stand);
• gross mental retardation is recorded.

Spastic forms (up to 75% of patients) are characterized by:

• increased muscle tone;
• an increase in tendon reflexes;
• clonuses;
• pathological reflexes of Rossolimo, Babinsky;
• suppression of surface reflexes;
• lack of muscle control;
• suppression of normal synkinesis;
• the formation of pathological friendly movements.

The clinical picture is different for different spastic forms of cerebral palsy.

Quadriplegia (tetraplegia) is characterized by a violation of the muscle tone of the whole body, more often the hands are more affected. If significant differences are recorded in the lesion, with a predominance in the upper limbs, we are talking about bilateral hemiplegia.

The signs of this spastic form are:

• lack of head control;
• impossibility of visual-spatial coordination;
• due to violations of the mechanisms of the formation of postural reflexes, there are big problems with the verticalization of the body;
• have difficulty swallowing;
• articulation is difficult;
• speech problems;
• despite classes with children with cerebral palsy of this spastic form, as a rule, deformities of the limbs and spine, contractures develop;
• delays in psycho-speech development of various degrees.

Paraplegia is a predominant lesion of the lower extremities, in combination with preserved motor function of the hands, minor or moderate impairment of the functional capabilities of the upper extremities. With safe speech and perfect control of the head, despite training and classes, with cerebral palsy of this spastic form, a "ballerina's pose" is formed and there are:

• flexion contractures in knee joints;
• equino-varus or equino-valgus deformities of the feet;
• dislocation of the hip joints:
• hyperlordosis of the lumbar spine;
• kyphosis of the thoracic spine, etc.

Paraplegic patients have difficulty mastering skills:

• seating;
• standing;
• walk.

Hemiplegia is a spastic lesion on one side of the body, in which the hand is more affected. Noted:

• violation of the grasping function;
• extension with external rotation of the leg on the affected side;
• in addition to increased tone, there is an increase in tendon reflexes;
• even under the condition of systematic classes, cerebral palsy of this form is complicated by the shortening of the affected limbs as the child grows;
• contractures of the shoulder, elbow joints, hand, thumb can form;
• contractures develop in the lower limb, horse foot;
• high risk of scoliosis.

The prognosis for consistent habilitation, regular classes with children with cerebral palsy of this spastic form is more favorable in comparison with others. The success of social adaptation correlates with the syndromes of psycho-speech disorders and intellectual disabilities.

Cerebral Palsy Diagnosis: The Importance of Early Diagnosis

Rehabilitation of cerebral palsy is the more successful the earlier the correct diagnosis is made. An experienced pediatrician or neurologist may notice even minor neurological disorders in a newborn based on:

• careful inspection;
• reflex assessments;
• measuring visual acuity, hearing;
• determining the functionality of muscles.

High-tech modern examination methods help to confirm or refute the fears of doctors:

• magnetic resonance imaging;
• cT scan;
• electromyography;
• electroneurography;
• electroencephalography, etc.

Since the neurological symptom complex in cerebral palsy is accompanied by various disorders and pathologies, in addition to observation by a neuropathologist, patients need consultations:

• psychotherapists;
• epileptologists;
• speech therapists;
• otolaryngologists;
• oculists, etc.

Just like the forms of cerebral palsy, the causes of chronic symptom complexes of motor disorders are very diverse. Among the most common are called:

• premature birth of a small person into the world, prematurity (according to world statistics, about half of all episodes of cerebral palsy are associated with it);
• malformations of the central nervous system;
• brain damage as a result of hypoxia and ischemia;
• intrauterine viral infections, including herpes;
• postnatal infectious diseases;
• toxic lesions;
• rh-conflict between the blood of the mother and the fetus;
• cNS injuries during childbirth and in the postnatal period, etc.

Interesting statistics have been collected on the popular "Children-Angels" forum. Parents of children with cerebral palsy call today among the common causes of damage to the nervous system:

• incorrect delivery - 27.1%;
• premature pregnancy - 20.2%;
• errors in resuscitation and treatment - 11%;
• vaccination - 8%;
• diseases of the mother during pregnancy and taking medications - 6.6%;
• psycho-emotional stress of expectant mothers - 5.7%, etc.

Complex treatment of cerebral palsy

When we talk about the treatment of cerebral palsy, we mean a complex of therapeutic and rehabilitation measures that can improve the clinical picture and reduce the severity of pathological symptoms.

Complex treatment of cerebral palsy may include:

• drug therapy;
• physiotherapy methods;
• rehabilitation measures;
• in some cases, surgical treatment is indicated.

Cerebral palsy is usually complicated by many other pathologies:

• epilepsy;
• scoliosis, arthritis and other diseases of the musculoskeletal system;
• hydrocephalus;
• atrophy of the optic nerve and other visual disturbances;
• disorders of coordination of movements;
• hearing impairment;
• psychoemotional disorders;
• behavioral disorders;
• speech disorders, etc.

The goal of symptomatic therapy is not the causes, but the complications of cerebral palsy

Medical treatment for cerebral palsy and non-drug therapy are usually designed to combat common complications. An integrated approach allows you to avoid undesirable scenarios for the development of pathology, reduce the pathological symptoms of concomitant diseases.

So drug treatment allows:

• stop epileptic seizures;
• minimize metabolic disturbances as much as possible;
• remove muscle tone;
• reduce pain symptoms;
• stop panic attacks, etc.

Habilitation and rehabilitation of cerebral palsy is based on three main principles:

• early onset;
• a complex approach;
• duration.

The initial residual stage is the most promising for compensating for neurological deficits. It is between the ages of 6 months and 3 years that the most active response to rehabilitation programs is observed.

Individual rehabilitation programs for cerebral palsy

Comprehensive rehabilitation programs for small and mature patients with CNS lesions are made taking into account:

• forms of the disease;
• the extent of perinatal lesions;
• individual characteristics;
• concomitant diseases, etc.

Comprehensive rehabilitation for cerebral palsy may include:

• medical methods;
• methods of social and environmental adaptation;
• speech therapy classes;
• psychotherapy sessions;
• educational programs for patients with cerebral palsy, training, occupational therapy, etc.

Most patients with cerebral palsy need special devices, devices, orthopedic products that make life easier, make it possible to move in the space of special people. If a disability is established, for a person with cerebral palsy, during the examination by specialists of medical and social expertise, an individual rehabilitation program is drawn up, which may include various technical means or assistive devices.

They are conventionally divided into three groups:

• providing the ability to move in space (wheelchairs, walkers, verticalizers, seats);
• designed for the development of motor capabilities (verticalizers, bicycles, chairs, orthoses, tables, orthopedic shoes, etc.);
• facilitating patient hygiene (toilet chairs, bath seats, etc.).

Exercise therapy for cerebral palsy

Physiotherapy or kinesiotherapy for various forms of cerebral palsy can mitigate the negative consequences of hypodynamia, forced movement deficit, and correct motor disorders.

Classes should be regular, systematic, throughout the life of a person with cerebral palsy. Types of fitness, alternation of exercises, loads are selected by kinesiotherapists, exercise therapy instructors, together with neuropathologists, pediatricians, psychotherapists and other specialists.

Specific fitness workouts for different forms and grades can include:

• remedial gymnastics;
• gymnastic exercises;
• sports and applied training;
• training on simulators, etc.

Massage for cerebral palsy helps:

• optimize blood circulation;
• improve lymph flow;
• normalize metabolic processes in muscle tissue;
• improve the functionality of various systems and organs.

In clinical practice, the following massage techniques are widely used in rehabilitation programs for children and adults with cerebral palsy:

• classic;
• segmental;
• point;
• sedative;
• tonic;
• monakov system.

Speech development

Many patients with cerebral palsy have speech impairments of varying degrees. Regular and consistent sessions with speech therapists help:

• normalize the tone of the muscles that provide articulation;
• improve the motor skills of the speech apparatus;
• to form correct speech breathing and synchronize it with articulation and voice;
• develop optimal sound, voice strength;
• smooth out phonetic defects, improve pronunciation;
• achieve intelligibility of speech;
• facilitate verbal communication, etc.

In order for a patient with cerebral palsy to adequately perceive the surrounding world, objects, people, to form an idea of \u200b\u200btheir shapes, sizes, position in space, smells, taste characteristics, etc., it is necessary to form a full-fledged perception of information by his senses. The importance of sensory education (correction) is that it allows:

• develop tactile-motor, auditory, visual and other types of sensory perception;
• generate sensory samples of shapes, colors, sizes, etc .;
• improve cognitive abilities;
• correct speech disorders, enrich vocabulary.

Animal therapy

For the rehabilitation of children with cerebral palsy, classes with animals are successfully used:

• dolphin therapy;
• canistherapy;
• hippotherapy, etc.

In the process of communicating with smaller brothers, the child receives not only positive emotions, vivid impressions, which in themselves are an excellent medicine. During training with horses, dogs, dolphins in children with various forms of cerebral palsy:

• motor capabilities expand;
• new skills and abilities appear;
• muscle tone is normalized;
• the range of motion increases;
• reduced hyperkinesis;
• coordination improves;
• speech skills are improved;
• fears and consequences of stress go away;
• decrease in psychological and behavioral disorders, etc.

Classes in creativity with cerebral palsy, training in drawing, modeling, applied arts:

• enrich the spiritual world of kids and adults;
• are great sensory training;
• develop fine motor skills;
• contribute to the correction of psycho-emotional disorders;
• form figurative thinking;
• improve the ability to concentrate;
• help get rid of behavioral disorders.

Little artists, sculptors, craftsmen see the fruits of their labor, get satisfaction from creativity, joy from communication with beauty, gain confidence in their own capabilities. Many children find their favorite hobby, and for some, the hobby for needlework and drawing develops into the main business of their whole life.

Habilitation for cerebral palsy and socialization of disabled people

Today the term “habilitation” is often used for children with cerebral palsy. It is more accurate, since it reflects the fact that, in contrast to, the complex of medical and pedagogical measures is aimed not at restoring the lost skills and abilities (motor, speech, cognitive), but at their acquisition, for the first time. Habilitation serves the socialization of children with various forms of cerebral palsy. In the process of training and learning, the child masters:

• movement;
• self-service skills;
• labor activity;
• speech;
• sensory perception, etc.

The ultimate goal of habilitation, which, unfortunately, is not always achievable due to the degree and scale of damage to the nervous system, is the integration of patients with cerebral palsy into society.

Persistence in achieving the goal, daily work can change a lot in the life of a child with cerebral palsy. Unlike ordinary children, their development is hampered by labyrinth and cervical tonic reflexes. Pathologies of vision, hearing, psycho-speech disorders, difficulties with spatial analysis and synthesis, which are associated with movement disorders, complicate learning. But thanks to the joint efforts of the patient himself, relatives, doctors, teachers, speech therapists, today it is possible to change the lives of many people with cerebral palsy. Those who, remaining in social isolation, without having the opportunity to get habilitation, education, used to become helpless people with severe disabilities, today they often gain independence, master professions, create their own families.

Special child and regular school

Until recently, the education of children with cerebral palsy in our country, with the exception of isolated cases, was carried out in specialized boarding schools. In correctional educational institutions children with special needs who cannot attend regular school continue to receive education.

But today the right to inclusive education is enshrined in the strategic National Doctrine of the Russian Federation. Therefore, a child with motor and psycho-speech disorders, with limited ideas about the world around him, can receive an inclusive education, study in a regular, general education school.

The element of competition, the desire to be equal among equals is a great stimulus for learning. Daily activities, homework, allow you to expand your horizons, improve thinking, memory and other cognitive abilities. In addition, getting the first experience of independent life outside the home, communicating with peers, teachers, the child expands the boundaries of the spiritual world, learns to exist in society, interact with other members of the team.

And this is a great experience not only for a special boy or girl, but also for quite ordinary children. Along with mathematics, languages, biology and other sciences, they have the opportunity to receive a free lesson in kindness, mercy, compassion, and mutual assistance. Provided that adults, teachers, psychologists, who must provide support for a child with cerebral palsy in a regular school, will help them understand what is “good” and what is “bad”, will show an example of philanthropy.

If for some objective reason a child with cerebral palsy cannot attend general education or correctional institutions, today there is the possibility of home schooling.

During individual home lessons, the teacher can devote his attention and time entirely to one student. The child feels protected, which means he is more calm at home, so it is easier for him to concentrate on the learning process.

However, being homeschooled, he will be deprived of the opportunity to communicate with peers, life in a team, independence in decision-making, etc.

Therefore, if the child's condition, the form of the disease and the degree of injury allow him to receive an inclusive education, parents and other adults should do everything possible for his successful integration into the children's team.

Sometimes the pregnancy does not end as expected, the baby is born with a developmental pathology, for example, cerebral palsy (cerebral palsy). It should be noted that the disease is not inherited, but occurs during the gestation of a child or during childbirth. Cerebral palsy is a disease that is a series of syndromes that have arisen due to brain damage, signs of the disease are associated with a violation of the human motor sphere.

History of disease detection

Cerebral palsy was identified and studied at the beginning of the 19th century by the British doctor Little, which is why cerebral palsy is also called "Little's disease." The British scientist and doctor believed that the main cause of cerebral palsy is abnormal labor, during which the child experiences severe oxygen starvation (hypoxia). Sigmund Freud also studied cerebral palsy at one time. He put forward the assumption that the cause of the disease is damage to the central nervous system of the child during intrauterine development. This assumption was proven in 1980. But subsequent studies have revealed that complicated labor is the most common cause of cerebral palsy.

General characteristics of the state

Currently, doctors say that cerebral palsy occurs immediately after birth or during pregnancy. There are many causes of the disease. But mainly this is damage to the central nervous system and related problems of a neurological nature. With the disease, a wide variety of disorders of motor functions are observed. Muscle structures are maximally affected, this manifests itself in a violation of coordination. Motor activity is impaired due to damage to the structures of the brain. The localization and volume of these lesions determine the shape, nature and severity of muscle disorders, which can be single or in combination. Variants of major muscle disorders:

• Muscle tension.
• Movements of an involuntary chaotic nature.
• Various gait disturbances.
• Limited mobility.
• Muscle contractions.

In addition to violations of motor function, cerebral palsy may be accompanied by impairment of hearing and speech activity. In addition, very often the disease is accompanied by epilepsy, deviations in psychological and mental development. Children have impairments in sensation and perception.

Cerebral palsy does not progress, since the damage to the brain is punctual, it does not spread and does not invade new areas.

The reasons

Cerebral palsy is caused by damage to specific areas of the brain that develop. This damage can occur during pregnancy, when the baby's brain is just beginning to form, during childbirth, in the first years of life. In most cases, the exact cause is very difficult to establish. In the scientific literature, the reasons for the development of cerebral palsy are divided into several groups:

• Genetic causes (damage to the chromosomes of the mother or father, can occur due to aging of the body).
• Oxygen starvation of the brain (placental insufficiency both during childbirth and during the period of gestation). Factors for the development of oxygen deficiency: placental abruption, long or, conversely, rapid labor, entanglement of the umbilical cord, abnormal fetal presentation.
• Infectious diseases, for example, encephalitis, meningitis, cause cerebral palsy. It is especially dangerous if the infection proceeds with a high fever.
• Toxic effect on the child (work in hazardous work, smoking, drugs, alcohol).
• Physical impact (if the child was exposed to X-rays or radiation).
• Mechanical causes, a consequence of birth trauma.

Also, factors that give rise to cerebral palsy are:

• Premature birth.
• Low weight of the newborn.
• Large baby weight or large fruit.
• Chronic diseases of a woman.
• Multiple pregnancy.

The risk of developing the disease increases if several factors act at once that affect the baby's brain and his nervous system.

Factors in the development of the disease in the first days of life can be:

• Hemolytic disease (congenital ailment that develops due to the incompatibility of the blood of the mother and child).
• Asphyxia of the child during labor.
• The ingress of amniotic fluid into airways fetus.
• Respiratory developmental defects.

Children's cerebral palsy is a consequence of the effects of various factors that lead to disruption of the normal functioning of the child's brain. Oxygen starvation has the greatest influence, which develops due to premature placental abruption, gluteal position of the fetus, rapid or prolonged labor, entanglement with the umbilical cord. Risk factors are the Rh-conflict between mom and baby, infection.

Sometimes the cause of the development of cerebral palsy is considered various pathologies of the vascular system. This is an erroneous opinion, since the child's vessels are elastic and soft, they cannot rupture without a reason. That is why damage to blood vessels in a child can occur only as a result of severe trauma.

It is important to establish in a timely manner the cause of the development of cerebral palsy, as this determines the further tactics of working with the child and his treatment.

Signs

Cerebral palsy symptoms are divided into late and early. Early scholars include:

• Child's lag in physical development (does not hold his head, does not crawl, does not sit, does not walk on time).
• Reflexes that are characteristic of babies persist with the child's growing up (movement of the limbs is chaotic for a long time, grasping reflex, step reflex).
• The child uses only one hand, this is clearly noticeable during the game or in everyday life.
• The child is not interested in toys.
• If you put a child on his feet, he only stands on his toes.

Late signs of cerebral palsy are:

• Deformation of the skeleton, the limb is much shorter in the affected area.
• Impaired coordination, low mobility of the child.
• Frequent cramps in the limbs.
• Difficulty walking, mostly on toes.
• Swallowing problems.
• Salivation.
• Speech problems.
• Myopia, squint.
• Disease of the gastrointestinal tract.
• Involuntary defecation and urination.
• Emotional and psychological problems.
• It is difficult for children to write, read, and count.

The degree of disability depends on the level of development of the child and the efforts of family members. The higher the level of intelligence, the less violations of motor functions in the baby.

Forms

There are two classifications of the disease - the first is based on the age of the baby, the second on the form of the disorder.

The disease is subdivided by age:

• Early - symptoms appear before 6 months of life.
• Residual initial - the disease is detected from 6 months to 2 years.
• Residual later - after 2 years.

With regard to the forms of cerebral palsy, they are classified:

• Spastic tetraplegia - areas of the brain that are responsible for motor function are affected. This happens, as a rule, in the prenatal period of the child's development due to oxygen deficiency. This type of cerebral palsy is one of the most severe and serious forms of the disease. The disease manifests itself in the form of problems with swallowing, disturbances in the formation of sounds and their reproduction, paresis of the muscles of the limbs, problems with attention, visual impairments, strabismus, mental retardation.
• Spastic diplegia is the most common type of disease, accounting for about 75% of all cases. As a rule, it is detected in children who were born as a result of premature birth. The disease manifests itself in the form of damage to the lower extremities, mental and mental retardation, and speech problems. But, despite all the manifestations of the disease, patients with cerebral palsy of this type successfully study at school, are adapted in society. They do certain types of work.
• The hemiplegic form is more often seen as disturbances in the movement of the upper limbs. The reason for the appearance of this form of cerebral palsy is cerebral hemorrhage or heart attacks in the brain. Such children have good learning abilities, they can learn a number of actions, but their speed will not be great. Children who suffer from this form of the disease often have mental retardation, delayed speech development, mental problems, and frequent epileptic seizures.
• The dyskinetic form is the cause of hemolytic disease (a congenital disease that develops with the Rh-conflict between the blood of the mother and the baby). In such children, involuntary body movements, paresis and paralysis appear in all parts of the body. Limb positions are abnormal. Moreover, this type of cerebral palsy is considered the mildest form. Children can study at school, not inferior in intellectual abilities to their peers, they can graduate from a higher educational institution, live a normal life in society.
• Ataxic form - the main causes of the disease are fetal hypoxia or trauma to the frontal lobes of the brain. A sign of this form is paresis of the vocal cords and muscles of the larynx, trembling of the limbs, involuntary movements. As a rule, children suffer from mental retardation. With the right work with the child, he can learn to stand and even walk.
• Mixed form - when the patient has symptoms of several forms of the disease.

It should be noted that in newborns it is difficult to reliably diagnose the form of cerebral palsy, characteristic signs are detected by 6 months of the baby's life.

Condition diagnostics

The disease is diagnosed based on the identified characteristic signs. Conditioned reflexes and muscle tone are checked, and an MRI of the brain is also done. If there is a suspicion of brain damage, EEG and ultrasound are performed.

A timely diagnosis is very important for a small patient. It is important to recognize the disorder. Children should be examined even in the hospital, doctors pay special attention to children:

• Lightweight.
• Those born prematurely.
• Having defects and developmental anomalies.
• Diagnosed with neonatal jaundice.
• Born as a result of difficult and prolonged childbirth.
• With infectious diseases.

Cerebral palsy is diagnosed by a neurologist, but he may additionally prescribe other tests to clarify the diagnosis.

Features of children with cerebral palsy

The main cause of cerebral palsy is a change in the structure of the brain, and the main symptoms are impaired motor activity. Movement disorders occur due to impaired transmission of signals from the brain to the muscles. Cerebral palsy is characterized by the presence of speech, motor, emotional, mental disorders. They are associated with damage to various muscle groups and brain tissue.

Difficulties in the development of such children are due to enormous difficulties during the implementation of complex or coordinated movements. Such children have limited independence, the ability to move freely, and only a partial ability to self-service.

Any movements of children are slowed down, which is why there is a disproportion between thinking and the idea of \u200b\u200bthe surrounding reality. Logical thinking and abstract knowledge in such children is formed perfectly, and the idea of \u200b\u200bthe world around them is formed only in conditions of constant movement of the child, as a result of which muscle memory is developed.

Children with cerebral palsy are not able to practice for a long time, they absorb less information than their peers. These children have difficulties with counting, it is very difficult for them to learn mathematical operations.

Emotionally, they are vulnerable, impressionable, very attached to their parents and guardians.

They, as a rule, have a speech disorder, which is why the circle of communication with peers is always limited.

Treatment and rehabilitation of cerebral palsy

The goal and main task of all therapeutic measures is to reduce the manifestations of signs and symptoms of the disease. It is impossible to completely cure the ailment, but with the right methodology, it is possible to ensure that the child acquires the necessary skills and abilities for life.

To choose the nature of treatment, the doctor needs to know the form of cerebral palsy, concomitant diseases and the severity of the disease.

As a rule, medications are prescribed anticonvulsants, which are relaxing.

Does not currently exist universal methods treatment of cerebral palsy. The following methods have worked well:

• Massage.
• Physiotherapy.
• Medical drugs that are aimed at normalizing muscle tone (Dysport, Midocalm, Baclofen).

The following methods and techniques have a positive effect in the treatment of the disease:

• Bobat tarapia.
• Voight's method.
• Loading suit "Gravistat" or "Adele".
• Air suit "Atlant".
• Speech therapy classes.
• Assistive devices (chair, walkers, verticalizers, exercise equipment, bicycles).

Balneotherapy and hydrotherapy in the pool are successfully applied. It is easier for a child to move in water, he first learns to walk in water, after that it is easier for him to perform the same actions on land. Water treatments are completed with a hydromassage.

Mud therapy has a good effect, which has a stimulating effect on nerve cells and relieves muscle tone. In addition, hypertonicity is well normalized with the help of electrophoresis, magnetotherapy, paraffin therapy.

If the changes in the muscle structure could not be corrected, then they resort to surgical treatment of cerebral palsy. The operations are aimed at performing plastic surgery of muscles and tendons. If it is possible to correct disorders in the tissues of the nervous system, then neurosurgical interventions, spinal cord stimulation, and removal of damaged areas are performed.

According to reviews, cerebral palsy must be treated as early as possible, as the condition may worsen due to the gradual development of an orthopedic problem. This can be a curvature of the spine, flat feet, clubfoot, hip dysplasia, and others. If you miss the time, you will have to treat not only cerebral palsy, but also correct orthopedic disorders by putting on spacers, splints, splints.

Principles of working with children

With children who have cerebral palsy, it is necessary to deal with both doctors and teachers. It is better to start working from an early age of children - from 1 to 3. It is necessary to take them to classes, where they will be taught to speak, perform everyday activities, and teach self-service skills. These cerebral palsy training centers develop the ability to interact and communicate with peers.

When working with such children, much attention is paid to the development of speech and behavior in society. Each child has an individual approach that takes into account age, the form of pathology. Teaching children, as a rule, is carried out in groups in the form of a game, which is led by a competent specialist. The movements of each child are carefully observed, incorrect movements are corrected, and the correct ones are encouraged.

To develop the correct movement skills, special devices and devices are used to support the head, limbs, trunk in the desired position. The child trains and explores the surrounding space.

Exercise therapy and massage

Massage for cerebral palsy begins from 1.5 months. The course is conducted only by a specialist who can assess muscle tone, frequency of sessions, and the degree of impact. It is not recommended to do the massage yourself.

Physiotherapy exercises include a complex of therapy, classes should be regular. The difficulty of the exercises is set for each child individually, taking into account age, abilities, level of mental and emotional development. The load should be increased gradually as the child's condition improves.

As a rule, with cerebral palsy, the following exercises are performed:

• Stretching.
• Decreased muscle tone.
• Strengthening certain muscle groups.
• Endurance exercise.
• For balance.
• To increase muscle strength.

Complications

Cerebral palsy does not progress over time. But the danger of the disease is that additional pathologies develop against its background. Complications of cerebral palsy:

• Disability.
• Eating problems.
• Epilepsy.
• Delayed growth and development.
• Scoliosis.
• Incontinence.
• Salivation.
• Psychological and mental disorders.

Prevention of cerebral palsy

During pregnancy, you must strictly monitor your health. It is important to exclude bad habits, regularly go to appointments with your doctor, and strictly follow his recommendations. Timely diagnose conditions dangerous to the fetus, for example, hypoxia. The doctor should correctly assess the condition of the mother and choose the correct route of delivery.

Disability

Disability with cerebral palsy is assigned depending on the severity and forms of the disease. Children can receive the status of "disabled child with cerebral palsy", and after 18 years - the first, second or third group.

To obtain disability, it is necessary to undergo a medical and social examination, as a result of which it is established:

• The degree and form of the disease.
• The nature of the lesion of the musculoskeletal system.
• The nature of speech disorders.
• The degree and severity of mental damage.
• Power mental retardation.
• Having epilepsy.
• The degree of loss of vision, hearing.

Parents of a disabled child can receive the necessary means of rehabilitation and vouchers to sanatoriums at the expense of the state budget.

Special products that make life easier for a child

Such devices and special equipment can be obtained from the state budget. This is possible only if the doctor entered their list into a special rehabilitation card, and the ITU commission, when confirming the disability, recorded all the funds as necessary for the child's rehabilitation.

Such devices are divided into 3 groups:

• For hygienic purposes: toilet chairs, bathing chairs. These devices are equipped with special seats, comfortable belts for securing the child.
• Devices designed for moving: wheelchairs for children with cerebral palsy, parapodium, walkers, verticalizers. All these devices allow the child to move in space and explore it. A child who is unable to walk on their own will need a stroller (cerebral palsy is the diagnosis in which this item is often extremely necessary), and more than one. For moving around the house - a home option, and for walking along the street, respectively, street. A stroller (cerebral palsy), for example, "Stingray" is the most lightweight, equipped with a removable table. There are very convenient and comfortable strollers with an electric drive, but their price is quite high. If a child can walk but cannot maintain balance, he will need a walker. They train well coordination of movements.
• Accessories for child development, medical procedures, training: splints, tables, exercise equipment, bicycles, special toys, soft rollers, balls.

In addition, a child with cerebral palsy will need special furniture, shoes, clothes, and dishes.

Live fully

Many children with cerebral palsy successfully adapt in society, some manifest themselves in creativity. For example, a seven-year-old boy with cerebral palsy (severe form), who cannot walk at all, but loves to sing very much, has become a real star. The Internet was literally blown up by a video where he made a cover of the track "Minimal" by rapper Aljay. Cerebral palsy diagnosis does not at all interfere with creativity and self-realization. This talented child was visited by the rapper himself, their joint photo is very popular among fans of both Eljay and the boy Sergei.

The first signs of cerebral palsy can be found in newborns in the first days of life and up to a year. Professional specialists and even parents can determine the presence of the disease in the early stages of development, which is necessary to prevent exacerbations. Cerebral palsy in children is often manifested by a complex of symptoms that must be recognized in a short time.

Doctors do not always properly examine the child in order to timely identify the symptoms of cerebral palsy. Parents spend a lot of time with their baby, which gives them a chance to independently detect the disease. The most typical appearance of cerebral palsy at an early age:

1. Inability to detect folds between the buttocks.
2. Lack of lumbar bend.
3. Asymmetry of the two sections of the body.

In the first days of life with severe cerebral palsy, the following symptoms can be diagnosed:

1. Excessive muscle tone or being too relaxed.
2. In the first days of life, the optimal muscle tone is traced, but after a while it disappears.
3. If hypertonicity occurs, the child's movements look unnatural, often too slow.
4. Unconditioned reflexes do not disappear, and the child does not start sitting for too long, holding his head on his own.
5. Asymmetry of different parts of the body. On the one hand, symptoms of hypertonicity arise, on the second, muscle weakening may follow.
6. Muscle twitching, in some cases, complete or partial paralysis is possible.
7. Unreasonably increased anxiety, frequent loss of appetite.

On a note!If a child actively uses only one side of the body, on the other part, a gradual atrophy of the muscles occurs, the limbs develop incompletely, often do not grow to the required parameters. There is a curvature of the spine, disturbances in the work and structure of the hip joints.

Most often, cerebral palsy in children is detected quickly, as they make active movements with limbs located on one side. Often, patients almost never use a hand with a weakened tone, which rarely separates from the body. The baby does not turn its head without great effort, even several months after birth. Parents often need to turn the baby over from time to time on their own.

Even if you do not notice dangerous signs or doubt their presence, it is necessary to regularly conduct diagnostic examinations. Be attentive to the baby's health, if he was born prematurely, develops too slowly, you notice problems during childbirth.

On a note!If you find serious deviations in the development, behavior of the baby, you need to consult a doctor for advice.

Methods for self-diagnosis of cerebral palsy:

Method	Features:
Lack of characteristic reflexes	After birth, babies develop characteristic reflexes, which then gradually disappear. If the child is healthy, the blink reflex appears in response to loud noise. With cerebral palsy, this feature is often not manifested.
Same type of movement	If you suspect your child has cerebral palsy, check for repetitive movements. The presence of cerebral palsy is often indicated by constant nodding, freezing in a particular position for a long period of time. If you notice such deviations, it is advisable to consult a pediatrician
Reaction to touch	To check if your child has a dangerous disease, you can put your palms on his stomach. If you have not noticed a special reaction in the child, most likely the disease is absent, at least it does not manifest itself in a pronounced form. In the presence of pathology, the legs will be lifted in opposite directions. The severity of negative symptoms depends on the level of brain damage

How to identify cerebral palsy in a three-month-old child?

In the period from 3 months to six months, the child manifests congenital reflexes, including the palmar-oral, heel reflexes. The presence of the first can be checked by pressing fingers on the inside of the hand, while the child opens his mouth. To check for a heel reflex, you need to lift the child by placing it on his feet. Usually, babies try to move around. In a healthy state, the child stands on a full foot. If cerebral palsy manifests itself, he relies only on the tips of his toes or cannot use his legs at all for support.

At 3 months, cerebral palsy can be quickly diagnosed if the child actively uses only one side of the body. In many cases, this symptom can be detected within a few days after the baby is born. Insufficient muscle tone on the one hand and hypertonicity on the other are caused by pathologies of the relationship between the two hemispheres of the brain.

If the innervation is not carried out correctly, the child's movements become awkward, he uses opposite parts of the body in different ways, and a slowed down reaction appears. Cerebral palsy can be seen even on the face. Perhaps the complete absence of the chewing muscles, which causes the asymmetry of the facial muscles. Strabismus often develops.

On a note!Sick children often cannot sit on their own, and this deviation can persist up to six months or longer.

How to recognize cerebral palsy in a baby?

If the brain damage is minimal, typical symptoms are difficult to identify not only for parents, but even for professional specialists. Awkward movements, overstrain of muscle tissue are noted only with severe damage to brain cells.

It is possible to suspect the presence of disturbances in the activity of the brain in the presence of the following symptoms:

1. Sleep pathologies.
2. Inability to roll over on your own.
3. The child does not hold his head.
4. Conditioned reflexes extend only to one side of the body.
5. The kid is often in one position, without moving for a long time.
6. Periodically there are cramps in the limbs.
7. Facial asymmetry of varying severity.
8. The limbs vary in length.

Video: Early detection of cerebral palsy in children under 1 year of age based on motor development

Common signs of cerebral palsy

The clinical picture may vary depending on the form of the disease. Each of them is characterized by specific symptoms that affect the child's life in different ways.

Diplegic form

It occurs when the formation of brain damage during intrauterine development. These disorders can be seen in muscle hypertonicity. Sick children are in a characteristic position, as their legs are extended, often crossed.

Up to one year old, you can see that the child practically does not use the lower limbs when moving. Children often do not try to sit down, even roll over. With the aggravation of the course of the disease, the development of serious deviations in physical development is possible.

It is quite easy to identify the presence of this form of the disease. To do this, it is enough to try to put the child on his feet. In this case, a sharp increase in muscle tone appears. The child moves, while leaning only on tiptoes. The gait is not firm, with each new step the child touches one foot with the other, moving the limbs straight in front of him.

On a note! With the diplegic form of the disease, mental abnormalities are often manifested.

Hemiplegic form

The disease often occurs when one of the cerebral hemispheres is affected. A high risk of developing hemiplegic cerebral palsy remains in children with intrauterine infection. This disease can occur even with a small hemorrhage during childbirth.

The hemiplegic form of cerebral palsy is manifested by limited movement in the limbs, while maintaining a constantly increased muscle tone. The child is actively moving, but at the same time, he is diagnosed with too frequent muscle contraction in the part of the trunk, for the innervation of which the affected area of \u200b\u200bthe brain is responsible.

Video - How to recognize cerebral palsy

Hyperkinetic form

It occurs with structural disorders of the subcortical ganglia, which are responsible for innervation. Often, the disease manifests itself with negative immune activity in the mother's body in relation to the child. In this case, the symptoms of cerebral palsy are also pronounced. Muscle tone in a child often stabilizes, but after a while it increases. In some cases, muscle tone does not increase, but decreases. The child's movements become awkward, he assumes uncomfortable and unnatural positions. In many cases, with this form of the disease, intelligence is retained, which is why the prognosis with timely treatment is considered conditionally favorable.

When should you be alert?

There are several types of symptoms by which you can determine the severity, form of the disease. Often negative signs appear very brightly, which is why it is almost impossible not to notice them even at the age of one year. In most cases, cerebral palsy is manifested by severe symptoms, violations often lead to impaired motor, coordination functions.

Motor signs of cerebral palsy:

1. The hyperkinetic form of this disease.
2. Dystonia, related disorders.
3. Development of motor skills in only one limb.
4. Muscle spasticity.
5. Periodic appearance of paresis, paralysis.

Dystonia with cerebral palsy is steadily progressing, after a while additional negative symptoms appear, which can lead to a number of complications. Often it is not cerebral palsy that progresses, but the disorders and diseases associated with it. During the active growth of the child, the intensity of negative symptoms can both increase and decrease.

Often cerebral palsy after a while is complicated by structural pathology of the joints, muscle disorders. These deviations are almost impossible to stop if you refuse to use surgical intervention.

On a note!Often pathologies arise as a result of disruption in the work of certain parts of the brain. As a result, patients suffer from improper muscle function, and abnormalities in the functioning of internal organs are also possible.

In the event of disturbances in the work of the brain, the formation of such disorders is possible:

1. Non-standard, illogical behavior.
2. Inability to learn something new, to speak simple words.
3. Intellectual failure.
4. Hearing impairment, speech pathology.
5. Regular swallowing problems.
6. Lack of appetite.

If muscle and neurological disorders occur with cerebral palsy, the quality of life of babies is greatly reduced. In some cases, concomitant diseases affect the human body more strongly than primary pathologies. Often, cerebral palsy is accompanied by a decrease in intelligence, defeat various structures brain.

Cerebral palsy in children is often characterized by standard features, but it can proceed in a unique pattern. To determine the presence of cerebral palsy, especially in milder forms, special tests are used. On the basis of a group of symptoms, the disease is detected. Doctors take into account a combination of symptoms from the muscle tissue and the nervous system.

To make an accurate diagnosis, to determine the dynamics of the development of the disease, doctors use various diagnostic measures. Negative signs often appear from the first days or weeks of a baby's life. It is possible to make a diagnosis, to characterize the course of the disease up to a year, however, the information obtained is specified at an older age.

Cerebral palsy is diagnosed by assessing the general state of the brain. Modern instrumental technologies are used, including MRI, CT, ultrasound. With the help of these diagnostic studies, it is possible to identify pathological foci, abnormalities in the structure of the brain, as well as areas of hemorrhage.

The aggravation of the clinical picture can be traced using neurophysiological research methods. Electromyography and similar activities are performed. Laboratory and genetic diagnostic methods are used to determine the symptoms characteristic of cerebral palsy.

Cerebral palsy in severe stages often manifests itself in conjunction with such deviations:

1. Epileptic seizures.
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