cerebral palsy in adults. Signs and causes of cerebral palsy in a child, methods of treatment of cerebral palsy What is cerebral palsy in a child

The first signs of cerebral palsy can be detected 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 need to 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 the baby, which is why they have a chance to independently detect the disease. The most characteristic appearances of cerebral palsy at an early age:

1. Inability to detect folds between the buttocks.
2. No lumbar curve.
3. Asymmetry of two parts of the body.

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

1. Excessive muscle tone or being too relaxed.
2. In the first days of life, the optimal muscle tone can be traced, but disappears after a while.
3. If hypertonicity occurs, the child's movements look unnatural, often too slow.
4. Unconditioned reflexes do not disappear, and the child does not begin to sit for too long, to hold his head on his own.
5. Asymmetry of various parts of the body. On the one hand, there are symptoms of hypertonicity, on the other, 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, gradual muscle atrophy occurs on the other side, 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 their limbs located on one side. Quite often patients almost do not use a hand with a weakened tone, which rarely separates from the body. The baby does not turn his head without great effort even several months after birth. Often parents need to turn the baby over on their own from time to time.

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

On a note! If you find serious deviations in the development, behavioral characteristics of the baby, you should consult a doctor for advice.

Methods for self-diagnosis of cerebral palsy:

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

In the period from 3 months to six months, the child manifests congenital reflexes, including hand-mouth, heel. The presence of the first can be checked by pressing the 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, placing it on its feet. Babies usually try to move around. In a healthy state, the child becomes on a full stop. If cerebral palsy appears, he relies only on the tips of his fingers or cannot use his legs for support at all.

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 birth of the child. 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 carried out incorrectly, the child's movements become clumsy, he uses opposite parts of the body in different ways, and an inhibited reaction is manifested. Manifestations of cerebral palsy can be seen even on the face. Perhaps the complete absence of chewing muscles, which causes asymmetry of the muscles of the face. Often strabismus develops.

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

How to recognize cerebral palsy in infants?

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

You can suspect the presence of disorders of the brain if you have the following symptoms:

1. sleep pathology.
2. Inability to roll over on their own.
3. The child does not hold his head.
4. Conditioned reflexes apply only to one side of the body.
5. The baby is often in one position, not moving for a long time.
6. Periodically there are cramps in the limbs.
7. Facial asymmetry of varying severity.
8. The limbs differ in length.

Video: Early detection of cerebral palsy in children under 1 year old 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 life of the child in different ways.

diplegic form

Occurs with the formation of brain damage during fetal development. These disorders can be seen in muscle hypertonicity. Sick children are in a characteristic position, as their legs are extended, often crossing.

Up to a year, you can notice that the child practically does not use the lower limbs when moving. Often children 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.

To identify the presence of this form of the disease is quite easy. To do this, it is enough to try to put the child on his feet. In this case, a sharp increase in muscle tone is manifested. The child moves, while relying only on tiptoes. The gait is unsteady, with each new step the child touches the other with one foot, moving the limbs straight in front of him.

On a note! In the diplegic form of the disease, deviations in mental development are often manifested.

Hemiplegic form

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

The hemiplegic form of cerebral palsy is manifested by limited movements in the limbs, while maintaining a constantly increased muscle tone. The child actively moves, however, at the same time, too frequent muscle contraction in the part of the body is diagnosed, for the innervation of which the affected area of ​​\u200b\u200bthe brain is responsible.

Video - How to recognize cerebral palsy

Hyperkinetic form

Occurs with structural disorders of the subcortical ganglia responsible for innervation. Often, the disease manifests itself with negative immune activity in the body of the mother 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 movements of the child become awkward, he takes uncomfortable and unnatural postures. In many cases, with this form of the disease, intelligence is preserved, which is why the prognosis for timely treatment is considered conditionally favorable.

When should you be concerned?

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 up to a year. In most cases, cerebral palsy is manifested by severe symptoms, disorders often lead to impaired motor and coordination functions.

Motor signs of cerebral palsy:

1. Hyperkinetic form of this disease.
2. Dystonia and related disorders.
3. Development of motor skills in only one limb.
4. Spasticity of muscles.
5. Periodic appearance of paresis, paralysis.

Dystonia in 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 either increase or decrease.

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

On a note! Often, pathologies occur as a result of a violation 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.

If there are 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 occurrence of problems with swallowing.
6. Insufficient appetite.

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

Cerebral palsy in children is often characterized by standard features, but may follow a unique pattern. To determine the presence of cerebral palsy, especially in mild forms, special tests are used. Based on the group of symptoms, the disease is identified. Doctors take into account a combination of signs from the side of 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, characterize the course of the disease up to a year, however, the information obtained is specified at an older age.

Diagnosis of cerebral palsy is carried out 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, disorders 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 carried out. 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.
2. Hearing loss.
3. pathology of vision. Caused by atrophic processes in the optic discs.

Cerebral palsy often manifests itself in conjunction with a complex of accompanying symptoms, which is why it is often diagnosed in the first year of life. If cerebral palsy occurs with a genetic predisposition to disorders of the brain, the disease is steadily progressing. In many cases, you can eliminate the negative symptoms of the disease if you seek medical help in a timely manner. check out the link. read on our website.

Cerebral palsy (CP) is not one disease, but a group of movement disorders. Deviations occur during the perinatal period (from 22 weeks of pregnancy to the seventh day after birth). In sick children, there are delays in physical development, speech disorders, dysfunction of the motor system.

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General characteristics of cerebral palsy

Cerebral palsy may include different types of deviations: paralysis and paresis, changes in the musculoskeletal system, speech disorders, unsteady walking, etc.

Children with cerebral palsy may develop mental disorders, epilepsy. Vision and hearing deteriorate. These problems arise as a result of brain damage.

The more extensive and serious the lesion, the more dangerous the disturbances in the body. Cerebral palsy cannot develop because damage to brain structures is always limited.

Note! As he grows older, it may seem that his condition has only worsened. In fact, impairments become more pronounced against the backdrop of learning and communication difficulties. These problems are invisible until the baby can walk and eat on his own.

Diagnosis of deviation is made using clinical and anamnestic data. People who have been diagnosed with a pathology must continuously undergo rehabilitation. They need permanent treatment.

World statistics registers 1 case of pathology per 1000. In Russia, this figure is 2-6 cases per 1000. Premature babies suffer from this deviation 10 times more often. Recent studies have shown that half of all children with cerebral palsy were born prematurely.

Cerebral palsy is one of the leading problems in modern pediatrics. Scientists argue that sick children appear more often not only because of the deterioration of the environment, but also because of the medical methods of neonatology, which allow nursing babies with various serious pathologies.

Forms of cerebral palsy

This form is characterized by damage to the lower extremities, hands and face are not so badly damaged. Spastic diplegia treatable. Rehabilitation is the faster, the better the hands are developed.

Quite common and atactic form of cerebral palsy. In patients, muscle tone is very low, but tendon reflexes are quite pronounced. In children, speech is poorly developed due to damage to the vocal cords. The reason for this condition is insufficient oxygen supply to the fetus during pregnancy, trauma to the frontal lobe of the brain.

Causes of cerebral palsy in newborns

Sick children usually appear due to prematurity. Immediate causes of cerebral palsy during pregnancy:

1. Violations in the structure of the brain.
2. Oxygen starvation of the fetus during pregnancy.
3. Venereal diseases in the mother (the most dangerous infection is genital herpes).
4. Incompatibility of maternal and fetal blood groups.
5. Brain injuries received during gestation or during childbirth.
6. Toxic poisoning brain in infancy.
7. Incorrect birth.

It is believed that the presence of chronic serious diseases in the mother and the use of harmful substances are the main causes of cerebral palsy in newborns. Diseases such as anemia, hypertensive crisis, rubella, etc. cause lesions brain in the fetus.

Each case of cerebral palsy is individual. The exact cause of the appearance of deviations is usually not exactly known, since, as a rule, several adverse factors act on the body of the mother and fetus.

There is a misconception that pathology occurs due to problems with blood vessels. But this is not true, since all the vessels in young children are very pliable and extensible, they cannot be damaged on their own. Violations in the vascular system of an infant can appear only as a result of traumatic exposure.

To successfully treat cerebral palsy, specialists need to establish root cause occurrence of deviations.

Symptoms of cerebral palsy

It is very important to identify the main symptoms as early as possible and make a diagnosis. Doctors recommend having a special baby diary where it is necessary to record all the achievements of the child.

Parents should carefully monitor the manifestation of absolute reflexes that occur immediately after birth. Attention should also be paid to fading reflexes.

For example, the palmar-mouth reflex should disappear in the second month. If it remains until the sixth month, then the baby most likely has a dysfunction of the nervous system. It is important to monitor the development of the baby's speech, his mobility and the emergence of various skills. The diary should include any suspicious behavior:

• head nodding;
• uncontrolled movements;
• staying in one position for a long time;
• lack of contact between mother and baby.

Children's doctors are not always in a hurry to diagnose cerebral palsy. Most often, when specific signs are found, the pediatrician puts encephalopathy to a child under the age of one year. The baby's brain has great compensatory abilities, it can completely get rid of the consequences of damage.

If there are no changes in development (the child does not speak, does not walk, does not sit, etc.), then cerebral palsy is diagnosed.

Treatment

Most often, the diagnosis of "Infantile cerebral palsy" is not a sentence. If you approach the treatment of deviations in a comprehensive and correct way, conduct active rehabilitation. Adult with cerebral palsy can be a perfect person able to start a family and achieve career success. Paralysis remains with a person forever, but its negative impact can be minimized by timely treatment. To achieve a good result, it is necessary to diagnose the pathology in time and start therapy as soon as possible.

Adults with cerebral palsy who have completed the main intensive course of treatment in childhood, they can become full members of society.

The sick pass a course of treatment special preparations, they are given massages that normalize muscle tone.

Regular exercise therapy is needed, as well as exercises that help adjust motor skills. Classes with a speech therapist and a psychologist are required. In some cases, surgical intervention is required.

Intensive rehabilitation measures should be carried out up to up to eight years when the brain is in the stage of active development. At this time, healthy parts of the brain take over the functions of the damaged ones.

The treatment course is almost always aimed at improvement of motor skills for every patient. Restorative measures need to be carried out throughout life, but in childhood they should be given the most attention. Only in this way will rehabilitation be as effective as possible.

Recently, therapeutic methods are often practiced, which are built in contact with animals. Such communication positively affects the mood, his psyche. Such methods can be switched only with the permission of a doctor.

Doctors often prescribe voit and bobat therapy. These are healing practices aimed at stimulating movements associated with unconditioned reflexes. The purpose of these techniques is to bring the patient's motor activity to a normal state, to form habits.

There are special tracksuits, designed for children with disorders in the musculoskeletal system. For example, Adele or Gravistat. They help to correct incorrect positions of the limbs, bring muscle tone back to normal due to their stretching. The correct position of the torso, legs, arms is established with the help of special clamps, springs. The patient is in a medical suit for some time and tries to move. Treatment with this method is carried out in courses, staying in a suit becomes longer with each subsequent session.

Operations of this kind are very complex, their essence lies in the destruction of certain brain structures that are responsible for the production of pathological signals. Implants that suppress impulses are sometimes implanted.

Surgical intervention an orthopedist is needed in cases where it is necessary to eliminate deformities of the arms, legs and joints. They are made in order to facilitate walking and any other movement. For example, surgery on the Achilles tendon helps to restore the correct position of the foot.

Most of the therapeutic measures are applied in special medical institutions for children with cerebral palsy. Treatment methods should be practiced at home.

Note! The most favorable is sanatorium treatment. Sanatoriums specializing in children with paralysis have special equipment and the best conditions for effective treatment.

Cerebral palsy needs to be treated as soon as the diagnosis is made. If nothing is done, then condition may worsen due to developmental disorders. Such a baby will need to be treated not only for paralysis, but also for acquired orthopedic problems.

Video: cerebral palsy - causes, symptoms and treatment

Cerebral palsy (CP) is a separate disease, but a whole range of movement disorders that occur due to brain damage in the perinatal period.

It is customary to include in the group of disorders that the term Cerebral Palsy combines:

• mono-, hemi-, para-, tetra-paralysis and paresis,
• pathological changes in muscle tone,
• hyperkinesis,
• speech disorders,
• unsteady gait,
• movement coordination disorders
• frequent falls
• lagging behind the child in motor and mental development.

Separately, all these conditions can talk about other neurological or mental problems. That is why it is so important that it is the doctor who gives the conclusion about the presence or absence of cerebral palsy. The material is for informational purposes only.

Examination for cerebral palsy

With cerebral palsy, intellectual disorders, mental disorders, epilepsy, hearing and vision disorders can be observed, diagnostics will help clarify. The diagnosis of cerebral palsy is based on clinical data and examination results. The algorithm for examining a child with cerebral palsy is aimed at identifying additional health problems and excluding other congenital pathologies. The range of studies recommended by the doctor, they are individual.

Risk factors for cerebral palsy

The causes of cerebral palsy are early damage to brain structures. During pregnancy or, as is often the case, difficult childbirth, brain cells die for some reason. During pregnancy, the causes of toxic damage can be:

• fetoplacental insufficiency,
• premature detachment of the placenta,
• toxicosis (but not any, but very severe forms),
• nephropathy in pregnancy
• infections (cytomegalovirus, rubella, toxoplasmosis, herpes, syphilis),
• rhesus conflict,
• threatened miscarriage,
• maternal somatic diseases (diabetes mellitus, hypothyroidism, congenital and acquired heart defects, arterial hypertension),
• injuries suffered by a woman during pregnancy.

During childbirth, other risk factors for cerebral palsy include:

• breech presentation of the fetus,
• rapid birth,
• premature birth,
• narrow pelvis,
• large fruit,
• excessively strong labor activity,
• protracted birth,
• discoordinated labor activity,
• long waterless period before childbirth,
  
• birth injury.

In the postpartum period, such factors are:

• asphyxia,
• hemolytic disease of the newborn.

All these are only risk factors, and not mandatory conditions for the development of cerebral palsy.

Types of Cerebral Palsy

There are several types of cerebral palsy:

1. spastic diplegia
2. hemiparetic form
3. hyperkinetic form
4. double hemiplegia
5. atonic-astatic form
6. mixed forms.

Spastic diplegia is the most common form of cerebral palsy. This form of cerebral palsy is based on damage to the motor centers, which leads to the development of paresis, which is more pronounced in the legs. When the motor centers of only one hemisphere are damaged, a hemiparetic form of cerebral palsy occurs, which is manifested by paresis of the arms and legs on the side opposite to the affected hemisphere.

In about a quarter of cases, cerebral palsy has a hyperkinetic form associated with damage to subcortical structures. Clinically, this form of cerebral palsy is manifested by involuntary movements - hyperkinesias, aggravated by excitement or fatigue of the child. With disorders in the cerebellum region, an atonic-astatic form of cerebral palsy develops. This form of cerebral palsy is manifested by violations of statics and coordination, muscle atony. It accounts for about 10% of cases of cerebral palsy.

The most severe form of cerebral palsy is called double hemiplegia. In this variant, cerebral palsy is the result of a total lesion of both hemispheres of the brain, leading to muscle rigidity, due to which children cannot not only stand and sit, but even hold their heads on their own. There are also mixed variants of cerebral palsy, combining different forms.

How can you suspect Cerebral Palsy? The first signs, if the form of cerebral palsy is not so severe that it can be recognized immediately, are often noticed by the mother or father of the child, another relative. The child must develop at a certain pace and, if there is a delay in psycho-motor development:

• a child at a certain age does not hold his head,
• does not follow the toy,
• does not turn
• not trying to crawl
• does not hum, etc.

This may not be a symptom of cerebral palsy, but it is definitely a reason to visit a specialist to correct possible deficits.

Another alarming symptom is that it is difficult for the child to swallow, he has problems with speech. Paresis in children with cerebral palsy can be only in one limb, have a one-sided character (arm and leg on the side opposite to the affected area of ​​the brain), cover all limbs. Lack of innervation of the speech apparatus causes a violation of the pronunciation side of speech (dysarthria) in a child with cerebral palsy. If cerebral palsy is accompanied by paresis of the muscles of the pharynx and larynx, then there are problems with swallowing.

A child with cerebral palsy usually has low muscle tone. Skeletal deformities typical for cerebral palsy (scoliosis, chest deformities) are formed. In addition, cerebral palsy occurs with the development of joint contractures in the paretic limbs, which exacerbates movement disorders. Motility disorders and skeletal deformities in children with cerebral palsy lead to the appearance of a chronic pain syndrome with localization of pain in the shoulders, neck, back and feet.

Cerebral palsy of the hyperkinetic form is manifested by sudden involuntary movements: turns or nods of the head, twitches, the appearance of grimaces on the face, fanciful postures or movements. The atonic-astatic form of cerebral palsy is characterized by discoordinated movements, instability when walking and standing, frequent falls, muscle weakness and tremor.

Accompanying cerebral palsy may be manifestations such as strabismus, functional disorders of the gastrointestinal tract, respiratory disorders, urinary incontinence, epilepsy, hearing loss, ZPR and ZRR.

How to cure Cerebral Palsy?

Since cerebral palsy is not a separate disease, but a whole group of conditions obtained at the earliest stages of a child's development, it is impossible to cure it, like cerebral palsy disease. But thanks to rehabilitation, the ability of the child's brain to recover, many manifestations of cerebral palsy disappear over time, the child's condition improves. As the child grows and his CNS develops, previously hidden pathological manifestations can be revealed, which create a feeling of the so-called "false progression" of the disease. In fact, Cerebral Palsy does not progress over a lifetime. Only under the influence of additional somatic diseases can deterioration occur. But constant rehabilitation, on the contrary, will improve the condition and give a chance for a significant increase in the quality of life. The child's brain is flexible and plastic; healthy tissues can take over the functions of damaged structures.

Cerebral palsy () is a disease that causes disturbances in the functioning of the motor system, which occur as a result of damage to areas of the brain or their incomplete development.

Back in 1860, Dr. William Little took up the description of this disease, which was called Little's disease. Even then it was revealed that the cause is oxygen starvation of the fetus at the time of birth.

Later, in 1897, the psychiatrist Sigmund Freud suggested that the source of the problem could be a violation of the development of the brain of a child in the womb. Freud's idea was not supported.

And only in 1980 it was found that only in 10% of cases of cerebral palsy occurs due to birth injuries. Since that moment, experts began to pay closer attention to the causes of brain damage and, as a result, the appearance of cerebral palsy.

Provoking intrauterine factors

Currently, more than 400 causes of cerebral palsy are known. The causes of the disease are correlated with the period of gestation, childbirth and in the first four weeks after (in some cases, the period of the possibility of manifestation of the disease is extended to the age of three years).

It is very important how the pregnancy progresses. According to studies, it is during fetal development that in most cases violations of the fetal brain activity are observed.

The key reasons that can cause dysfunction in the work of the developing child's brain, and the occurrence of cerebral palsy during pregnancy:

Postnatal factors

In the postpartum period, the risk of occurrence decreases. But he also exists. If the fetus was born with a very low body weight, then this can pose a danger to the health of the child - especially if the weight is up to 1 kg.

Twins and triplets are more at risk. In situations where a child receives at an early age, this is fraught with unpleasant consequences.

These factors are not the only ones. Experts do not hide the fact that in every third case it is not possible to identify the cause of cerebral palsy. Therefore, the main points that you should pay attention to first of all were listed.

A curious observation is the fact that boys are 1.3 times more likely to be affected by this disease. And in males, the course of the disease manifests itself in a more severe form than in girls.

Scientific research

There is evidence that particular importance in considering the risk of occurrence should be given to the genetic issue.

Norwegian doctors from the field of pediatrics and neurology conducted a major study, as a result of which they revealed a close relationship between the development of cerebral palsy and genetics.

According to the observations of qualified specialists, if parents already have a child suffering from this disease, then the possibility of having another child in this family with cerebral palsy increases by 9 times.

The research team led by Professor Peter Rosenbaum came to these conclusions as a result of studying data on more than two million Norwegian babies who were born between 1967 and 2002. 3649 babies were diagnosed with cerebral palsy.

Cases with twins were considered, situations with relatives of the first, second and third degree of kinship were analyzed. Based on these criteria, the incidence of cerebral palsy in infants belonging to different categories of kinship was revealed.

As a result, the following data was provided:

• if a twin is ill with cerebral palsy, then the probability of having another twin is 15.6 times higher;
• if a sibling is sick, then the risk of another child suffering from cerebral palsy increases by 9 times; if single uterine - 3 times.
• in the presence of cousins ​​and sisters with a diagnosis of cerebral palsy, the risk of the baby having the same problem increases by 1.5 times.
• parents with this disease increase the likelihood of having a child with the same diagnosis by 6.5 times.

It is necessary to know the causes and risk factors for cerebral palsy, since its development can be prevented, if prematurely take care of the health of the mother and fetus.

To do this, it is worth not only visiting a doctor regularly, but also observing a healthy lifestyle, avoiding injuries, viral diseases, the use of toxic substances, pre-treatment and do not forget to consult on the safety of the drugs used.

Understanding the importance of precautions is the best prevention of cerebral palsy.

Cerebral palsy (G80)

Neurology for children, Pediatrics

general information

Short description

Union of Pediatricians of Russia

ICD 10: G80

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

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

Classification

ICD-10 coding

G80.0 - Spastic cerebral palsy

G80.1 Spastic diplegia

G80.2 - Childhood hemiplegia

G80.3 - Dyskinetic cerebral palsy

G80.4 - Ataxic cerebral palsy

G80.8 - Other 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 author's clinical and functional classifications. The most widespread in Russia are the classifications of K.A. Semenova (1978):

double hemiplegia;

Hyperkinetic form;

Atonic-astatic form;

Hemiplegic form;

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

Table 1 - Classification of cerebral palsy

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

Semenova 1976):

Early: up to 4-5 months;

Initial residual stage: from 6 months to 3 years;

Late residual: older than 3 years.

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

Greater unanimity was achieved with the introduction of the functional classification of cerebral palsy - GMFCS (Gross Motor Function Classification System - Classification system for large motor functions), 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 gross motor development:

Level I- walking without restrictions;

Level II- walking with restrictions;

Level III- walking with the use of hand-held devices for movement;

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

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

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

Etiology and pathogenesis

Cerebral palsy is a polyetiological disease. The leading cause of cerebral palsy is damage or anomalies in the development of the brain of the fetus and newborn. The pathophysiological basis for the formation of cerebral palsy is brain damage in a certain period of its development, followed by the formation of pathological muscle tone (mainly spasticity) while maintaining postural 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 the 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 that cause cerebral palsy occur during fetal development; in the future, 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. Often there is a combination of several adverse factors both during pregnancy and childbirth. The intrauterine causes of cerebral palsy, first of all, include acute or chronic extragenital diseases of the mother (hypertension, heart defects, anemia, obesity, diabetes mellitus and thyroid disease, etc.), medication during pregnancy, occupational hazards, parental alcoholism, stress, psychological discomfort, physical trauma during pregnancy. A significant role belongs to the effect on the fetus of various infectious agents, especially of viral origin. Among the risk factors, there are also uterine bleeding, anomalies of the placental circulation, placenta previa or its abruption, immunological incompatibility of the blood of the mother and fetus (according to the ABO, Rh factor and others systems).

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

Various complications in childbirth: weakness of the contractile activity of the uterus, rapid or prolonged labor, caesarean section, a long anhydrous period, breech and breech presentation of the fetus, a long period of standing of the head in the birth canal, instrumental obstetric care, as well as premature birth and multiple pregnancy are also considered factors high risk of developing cerebral palsy.

Until recently, birth asphyxia was considered the leading cause of brain damage in children. A study of the anamnesis of children who underwent birth asphyxia showed that 75% of them had an extremely unfavorable background of intrauterine development, aggravated 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 (brain compression, crushing and necrosis of the medulla, tissue ruptures, hemorrhages in the membranes and substance of the brain, disturbances in the dynamic circulation of the brain). However, one cannot ignore the fact that birth trauma most often occurs against the background of a previous defect in the development of the fetus, during pathological, and sometimes even during 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 kernicterus, in the absence of reliable anamnestic data, may have a genetic basis. Even the “classic” spastic forms of cerebral palsy with a clear progression (and, even more so, the appearance of new) 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 births and is the main cause of childhood neurological disability in the world. Among premature babies, the frequency of cerebral palsy is 1%. In newborns weighing less than 1500 g, the prevalence of cerebral palsy increases to 5-15%, and with extremely low body weight - up to 25-30%. Multiple pregnancy increases the risk of developing cerebral palsy: the frequency of cerebral palsy in a singleton pregnancy is 0.2%, with twins - 1.5%, with triplets - 8.0%, with quadruple pregnancy - 43%. However, over the past 20 years, in parallel with the increase in the number of children born from multiple pregnancies with low and extreme 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

Spasmodic 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 arms, early formation of deformities and contractures. Common associated symptoms are delayed mental and speech development, the presence of pseudobulbar syndrome, pathology of the cranial nerves, 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 children 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 the result of anomalies 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. It is 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: the consequences of damage to the cranial nerves (strabismus, atrophy of the optic nerves, hearing impairment, pseudobulbar syndrome), pronounced cognitive and speech defects, epilepsy, early formation of severe secondary orthopedic complications (joint contractures and bone deformities). Severe motor defect of the hands and lack of motivation for treatment and training severely limit self-service and simple labor activity.

Spastic unilateral cerebral palsy G80.2

It is characterized by unilateral spastic hemiparesis, in some patients - a delay in mental and speech development. The arm is usually more affected than the leg. Spastic monoparesis is less common. Focal epileptic seizures are possible. The cause is a hemorrhagic stroke (usually unilateral), and congenital anomalies in the development of the brain. Children with hemiparesis master age-related motor skills somewhat later than healthy ones. Therefore, the level of social adaptation, as a rule, is determined not by the degree of motor defect, but by the intellectual capabilities of the child.

Dyskinetic cerebral palsy G80.3

It is characterized by involuntary movements, traditionally called hyperkinesis (athetosis, choreoathetosis, dystonia), changes in muscle tone (both an increase and decrease in tone can be noted), speech disorders, more often in the form of hyperkinetic dysarthria. There is no proper installation of the trunk and limbs. In most children, the preservation of intellectual functions is noted, which is prognostically favorable in relation to social adaptation and learning, violations in the emotional and volitional sphere more often prevail. One of the most common causes of this form is the transferred hemolytic disease of the newborn 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 and the auditory analyzer are damaged. 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. Speech disorders in the form of cerebellar or pseudobulbar dysarthria are not uncommon. Coordination disorders are represented by the presence of intentional tremor and dysmetria when performing purposeful movements. It is observed with predominant damage to the cerebellum, fronto-bridge-cerebellar tract and, probably, the frontal lobes due to birth trauma, hypoxic-ischemic factor or congenital anomalies. The 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

With cerebral palsy, clinical symptoms and the degree of functional impairment vary significantly in different patients and depend on the size and topography of brain damage, as well as on the intensity and duration of previous 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 "motor disorder that is part of the upper motor neuron lesion syndrome, characterized by a rate-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 the inconsistent nature of its changes (dyskinetic cerebral palsy) are possible. With all forms of cerebral palsy, there may be:

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

Pathological synkinetic activity during 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 settings, the development of articular contractures, and a progressive limitation of the child's functional capabilities. Brain damage in cerebral palsy can also initially be accompanied by cognitive and sensory impairments, convulsions.

Complications are formed mainly in the late residual stage and include, first of all, orthopedic pathology - the formation of joint-muscular contractures, deformities and shortening of the limbs, subluxations and dislocations of the joints, scoliosis. As a result, motor 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 diagnosing brain damage in the early stages, detecting posthypoxic brain damage, liquorodynamic disorders, congenital anomalies of 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 certain areas and zones of the brain.

Comments: X-ray of the bones of the skeleton is necessary to identify and assess the deformities of the structures of the osteoarticular system that occur secondary to muscle spasticity.

Other diagnostics

Comments: shown to all patients with an established diagnosis of cerebral palsy withfrequency, determined by the severity of the motor defect and the speedprogression of musculoskeletal pathology

Comments: indicated in the presence of dysembryogenesis stigmas, with clinicalpicture of the sluggish child syndrome.

Differential Diagnosis

Differential diagnosis.

Cerebral palsy is, first of all, a descriptive term, in this regard, for the diagnosis of cerebral palsy, as a rule, manifestations of specific non-progressive motor disorders are sufficient, 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, require a thorough diagnostic search for any differences in clinical symptoms and anamnesis from the "classic" picture of cerebral palsy. The “alarming” factors include: the absence of perinatal risk factors in the patient, the progression of the disease, the 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), a consultation with a geneticist, followed by additional laboratory tests, is required. In the presence of hemiparesis, signs of stroke, a study of the factors of the blood coagulation system, including polymorphism of coagulation genes, is indicated. All patients with cerebral palsy require examination for the presence of visual and hearing impairments, delayed mental and speech development, assessment of nutritional status. The exclusion of hereditary metabolic diseases, in addition to specialized biochemical tests, implies the visualization of internal organs (ultrasound, MRI of internal organs, according to indications). If the clinical picture is dominated by the “sluggish child” symptom complex (“spread out” posture, reduced resistance in the joints during passive movements, increased range of motion in the joints, delayed motor development), a thorough differential diagnosis of cerebral palsy with hereditary neuromuscular diseases should be carried out.

Treatment

Conservative treatment

According to the European consensus on the treatment of cerebral palsy using botulinum therapy, published in 2009, there are several main groups of therapeutic effects in spastic forms of cerebral palsy. (Appendix G1).

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

It is recommended to prescribe an oral drug with a muscle relaxant effect: Tizanidin g, vk (ATX code: M03BX02) (drugs that affect neuromuscular transmission, a centrally acting muscle relaxant, in the Russian Federation are not recommended for use under 18 years of age). By stimulating presynaptic α2 receptors, it 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 (ATX code: M03BX01) (a derivative of γ-aminobutyric acid that stimulates GABAb receptors, a centrally acting muscle relaxant): tablets of 10 and 25 mg.

Comments: The initial dose is 5 mg (1/2 tab. 10 mg each) 3 times a day. WhenIf necessary, the dose can be increased every 3 days. Commonly Recommendeddoses for children: 1-2 years - 10-20 mg / day; 2-6 years - 20-30 mg / day; 6-10 years - 30-60mg/day For children older than 10 years, the maximum dose is 1.5-2 mg / kg.

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

hemagglutinin complex w,vc (ATC code: M03AX01).

Comments: Intramuscular administration of BTA allows local, reversible,dose-dependently reduce muscle tone for up to 3-6 months or more. In Russia instandards for the treatment of cerebral palsy botulinum toxin therapy has been introduced since 2004, for use inchildren, two BTA preparations are registered: Dysport (Ipsen Biopharm Ltd.,United Kingdom) - according to indications, dynamic deformity of the foot caused byspasticity in cerebral palsy, in children older than 2 years and Botox (ATX code: M03AX01)(Allergan Pharmaceutical Ireland, Ireland) - by indication: focalspasticity associated with dynamic foot deformity by type"horse foot" due to spasticity in patients 2 years and older with pediatriccerebral palsy in outpatient treatment.

The calculation of the dose of BTA is based on determining 1) the total dose per 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 injection point; 5) number of unitsdrug per kilogram of body weight per muscle.

According to Russian recommendations, the dose of Botox is 4-6 units / kg of body weight.child's body; the total total dose of the drug per procedure should notexceed 200 units. When using the drug Dysport, the total amountthe drug during the first injection should not exceed 30 units / kg per child's body weight (no more than 1000 units 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 notexists.

Decreased spasticity, by itself, has minimal effect onthe acquisition by a child with cerebral palsy of new functionality, and forupper extremities "high level of evidence of effectivenessBTA injections have only been identified as adjuncts to physical rehabilitation in childrenwith spastic forms of cerebral palsy. When compared to placebo or notreatment, 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 in cerebral palsy may include antiepileptic drugs, M- and H-anticholinergics, dopaminomimetics used for dystonia and hyperkinesis. Nootropics, angioprotectors and microcirculation correctors, drugs with a metabolic effect, vitamins and vitamin-like drugs 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 no less important role in the restoration and preservation of 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, the use of neurosurgical methods for the treatment of spasticity is recommended:

Selective dorsal rhizotomy

Chronic epidural spinal cord stimulation

Intrathecal baclofen pump settings
(Strength of recommendation - 1; strength of evidence - B)

medical rehabilitation

Methods of physical rehabilitation are traditionally represented by massage, therapeutic exercises, hardware kinesiotherapy, in a number of centers - robotic mechanotherapy using specialized simulators, including those based on the principle of biofeedback (for example, Lokomat - a robotic orthopedic device for restoring walking skills, Armeo - a complex for functional therapy of the upper extremities, etc.). Therapeutic exercises for cerebral palsy, especially for children of the first years of life, are effectively supplemented by techniques based on the inhibition of pathological reflexes and the activation of physiological movements (methods of Voigt, Bobat, etc.). A domestic development that 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 with the help of specialized suits (for example, Adele, Gravistat, Atlant) - systems consisting of supporting elastic adjustable elements, with the help of which a targeted correction is created postures and dosed load on the musculoskeletal system of patients in order to normalize proprioceptive afferentation.

Traditionally in Russia, in the rehabilitation of patients with cerebral palsy, physiotherapeutic methods are widely used, including those based on natural factors of influence: applications of mud, paraffin, ozocerite with an antispastic purpose, 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 methods of rehabilitation. Functional therapy is also a priority method of rehabilitation for forms of cerebral palsy that are not accompanied by a change in muscle tone according to the spastic type.

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 methods have not yet been evaluated.

Forecast

Outcomes and forecast

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

The mortality rate among patients with cerebral palsy is also directly dependent on the degree of motor deficit and concomitant diseases. Another predictor of premature death is a decrease in intelligence and inability to self-service. Thus, 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 years, while with an IQ of more than 35 - 92% of patients with cerebral palsy lived for more than 20 years.

In general, life expectancy and the 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 unavailability of comprehensive care can have a negative impact on the development of a child with cerebral palsy, perhaps even more significant than the initial structural damage to the brain.

Prevention

Prevention and dispensary observation

Prevention of cerebral palsy includes both antenatal and postnatal activities. Antenatal include 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, promoting a healthy lifestyle for both parents. Timely detection and prevention of a complicated course of childbirth, competent obstetric care can significantly reduce the risk of intrapartum damage to the central nervous system of a newborn. Increasing importance has recently been given to the study of the role of hereditary coagulopathy 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 when nursing premature infants, controlled use of steroids in premature newborns (reducing the risk of developing bronchopulmonary dysplasia, corticosteroids increase the risk of developing 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 by a team of medical, pedagogical and social specialists who focus 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 a patient's life, taking into account the following medical and social aspects:

Movement, maintaining posture and physical activity of the child;

Communication;

Accompanying illnesses;

daily activity;

Baby care;

Quality of life of the patient and family members.

At an early stage of development of cerebral palsy (up to 4 months, according to the classification of K.A. Semenova), 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 a neurologist. Assistance to newborns threatened by the development of cerebral palsy begins in 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 clinics under the supervision of a pediatrician, neurologist and medical specialists (orthopedist, ophthalmologist, etc.). ). The initial examination of a patient with cerebral palsy (Appendix B) and further treatment can be carried out in a hospital, day hospital and outpatient 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 duration of the continuous stay of a child with cerebral palsy in a medical institution depends on the severity of motor disorders and comorbidities. It is important not only to conduct courses of complex rehabilitation treatment in a medical institution, but also to follow the 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 early onset, continuity and succession 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, however, the principal 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 deformations and social consequences of the disease. If a pathogenetic effect on the cause of cerebral palsy is impossible, the task is to optimally adapt the child to an existing defect, based on the principles of plasticity of the nervous system.

Information

Sources and literature

1. Clinical recommendations of the Union of Pediatricians of Russia
   1. 1. Badalyan L.O., Zhurba L.T., Timonina O.V. Children's cerebral palsy. Kyiv: Zdorov "ya. 1988. 328 p. , Zherdev K.V., Kuzenkova L.M., Bursagova B.I. Comprehensive assessment of motor functions in patients with cerebral palsy: study guide / Baranov A.A. [et al.]; budgetary scientific institution Scientific center of children's health. - M.: Pediatr, 2014. - 84 pp. 3. Klochkova O.A., Kurenkov A.L., Namazova-Baranova L.S., Mamedyarov A.M., Zherdev K.V. General motor development and formation of hand function in patients with spastic forms of cerebral palsy on the background of botulinum toxin therapy and complex rehabilitation // Bulletin of the Russian Academy of Medical Sciences, 2013. - V. 11. - P. 38-48. 4. Kurenkov, A. .L., Batysheva, T.T., Vinogradov, A.V., Zyuzyaeva, E.K. Spasticity in cerebral palsy: diagnosis and treatment strategies / A.L. Kurenkov / / Journal of Neurology and Psychiatry. - 2012. - Vol. 7. - No. 2. - P. 24-28. 5. Klochkova O.A., Kurenkov A.L., Karimova Kh.M., Bursagova B.I. ., Namazova-Baranova L.S., Mamedyarov A.M., Kuzenkova L.M., Tardova I.M., Falkovsky I.V., Dontsov O.G., Ryzhenkov M.A., Zmanovskaya V.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., Vladykina L.N., Kenis V.M., Kiseleva T.I., Krasavina D.A., Vasilyeva O.N., Nosko A.S., Zykov V.P., Mikhnovich V. .I., Belogorova T.A., Rychkova L.V. Multilevel injections of botulinum toxin type A (Abobotulinum toxin) in the treatment of spastic forms of cerebral palsy: a retrospective study of the experience of 8 Russian centers. Pediatric pharmacology. 2016;13(3): 259-269. 6. 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 cerebral palsy. Journal of Neurology and Psychiatry. S.S.Korsakov. 2016; 11 (116): pp. 98-107. 7. Semenova K.A., Mastyukova E.M., Smuglin M.Ya. Clinic and rehabilitation therapy of cerebral palsy. M.: Medicine. 1972. 328 p. 8. Boyd R.N., Graham H.K. Objective measurement of clinical findings in the use of Botulinum toxin type A for the management of children with cerebral palsy. Eur J Neurol. 1999; 6 (Suppl. 4): 23–35. 9. Bax M., Goldstein M., Rosenbaum P., Leviton A., Paneth N., Dan B., Jacobsson B., Damiano D. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol. 2005; 47 (8): 571-576. 10. Delgado M.R., Hirtz D., Aisen M., Ashwal S., Fehlings D.L., McLaughlin J., Morrison L.A., Shrader M.W., Tilton A., Vargus-Adams J. Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Practice parameter: pharmacological treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society// Neurology. 2010; 74(4): P. 336-43. 11. Heinen F., Desloovere K., Schroeder A.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 Pediatric 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

movement disorder,

Spasticity

Delayed psychoverbal development,

Poor posture maintenance

Pathological reflexes,

incoordination,

Epilepsy.

List of abbreviations

cerebral palsy - cerebral palsy

MRI - magnetic resonance imaging

Criteria for assessing the quality of medical care

Annex A1. The composition of the working group:

Baranov A.A., acad. RAS, Professor, MD, 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, MD, member of the Union of Pediatricians of Russia

Kurenkov A.L., professor, MD, 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., candidate of medical sciences, member of the Union of Pediatricians of Russia

Karimova Kh.M., Ph.D.

Bursagova B.I., Ph.D.

Vishneva E.A., candidate of medical sciences, member of the Union of Pediatricians of Russia

Annex A2. Methodology for the development of clinical guidelines

Target audience of these clinical guidelines:

1. Pediatricians;

2. Neurologists;

3. General practitioners (family doctors);

4. Rehabilitologists, exercise therapy doctors, physiotherapists;

5. Medical students;

6. Students 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 the evidence: The evidence base for recommendations are publications included in the Cochrane Library, the EMBASE, MEDLINE and PubMed databases. Search depth - 5 years.

Methods used to assess the quality and strength of evidence:

Expert consensus;

Significance assessment in accordance with the rating scheme.

Methods used to analyze the evidence:

Systematic reviews with tables of evidence.

Description of the methods used to analyze the evidence

When selecting publications as potential sources of evidence, the methodology used in each study is reviewed to ensure its validity. The outcome of the study affects the level of evidence assigned to the publication, which in turn affects the strength of the recommendation.

To minimize potential errors, each study was evaluated independently. Any differences in the estimates were discussed by the whole group of authors in full. 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 intelligibility 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 the 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 reviewed by independent experts who were primarily asked to comment on the clarity and accuracy of interpretation of the evidence base 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 indicators of good practice (Table 1) - good practice points (GPPs) are given when presenting the text of the recommendations.

*In the table, the numerical value corresponds to the strength of recommendations, the letter 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 medicines, medical devices, as well as the results of clinical testing.

Annex A3. Related Documents

Orders 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 Providing Pediatric Care"

Medical care standards: Order of the Ministry of Health of the Russian Federation of 16.06.2015 N 349n "On approval of the standard of specialized medical care for cerebral palsy (phase of medical rehabilitation)" (Registered in the Ministry of Justice of Russia on 06.07.2015 N 37911)

Appendix B. Algorithm for managing a patient with myasthenia gravis

Appendix B. Information for Patients

Cerebral palsy (CP), according to modern concepts, is a non-progressive disease of the central nervous system, the development of which is associated with perinatal brain damage at various stages of fetal and child development. 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 frequency of occurrence 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 for intensive care of very preterm infants, against the background of a decrease in mortality, the percentage of children with neurological deficits and cerebral palsy is increasing.

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.

Annex G1. The main groups of therapeutic effects in spastic forms of cerebral palsy

Annex D2.

Annex G3. Advanced Patient Management Algorithm

Annex G3. Deciphering notes.

... g - a drug included in the List of vital and essential drugs for medical use for 2016 (Decree of the Government of the Russian Federation of December 26, 2015 N 2724-r)

... vk - a medicinal product included in the List of medicinal products for medical use, including medicinal products for medical use, prescribed by decision of medical commissions of medical organizations (Decree of the Government of the Russian Federation of December 26, 2015 N 2724-r)

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