Fundamentals of intensive rehabilitation. Cerebral palsy Vladimir Aleksandrovich Kachesov

7.1. ATONIC-ASTATIC FORM of cerebral palsy

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

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

The boy from the first pregnancy, which proceeded without complications in the mother of 27 years. Delivery is urgent. Long anhydrous period. Stimulation labor activity. The child was born in blue asphyxia. Apgar score - 5 points. Resuscitation within 5 minutes. Then for a month he was in the department for nursing newborns. After being discharged home, there was a decrease in the tone of all muscle groups. The child did not hold his head. When the body was verticalized, the eyes rolled under the forehead. From the moment he was discharged home, he received nootropics, cerebrolysin, vitamins, massage, and acupuncture. Repeatedly annually he was treated in various rehabilitation centers in Ukraine and Russia. There were no positive dynamics. The child was recognized as unpromising in terms of rehabilitation. Parents were repeatedly offered to take their child to a nursing home.

Upon admission to us for rehabilitation in November 1994, there was a sharp lag in weight, height, and other age-related parametric data. Teeth: 2 upper and 2 lower incisors. At the age of 5, the child looked like one and a half year old children in terms of height and weight. Active movements in the extremities are sluggish, low-amplitude. During the verticalization of the body, a short-term fixation of the eyes in the middle position for 2-3 seconds was noted, then the eyes rolled under the upper edge of the orbits. The head was held by the child for 1-2 minutes in a vertical position. In a horizontal position, lying on his stomach, the child tried to raise his head, but could not turn it. I tried to bend my legs at the hip joints and crawl, but I didn’t have enough strength. Pacifier feeding. The child, according to the mother, never cried in all 5 years of his life. All reflexes are sharply reduced. According to the parents, the last year the child began to periodically make weak sounds. During the inspection period, he did not make a sound. CT scan of the brain showed no gross pathology.

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

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

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

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

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

This text is an introductory piece.

FORM AND FIELD At the beginning of the 20th century, the German embryologist Hans Adolf Edvard Driesch performed an experiment that went down in history. Split an egg in half sea ​​urchin, a simple creature having a spherical shape. Since the sea urchin is a relatively primitive organism, this

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FORM OF COMMUNICATION If there are no objections, we will continue to communicate on "you". In the manner in which friends or close people communicate. It is a direct, open and trusting form of communication. It emphasizes the inner unity of the teacher with the student. It excludes the possibility of ambiguities,

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Form 22 Fencing Movement One Penetrating Hand and Rotation of the Arm 1. Turn the palm of your left hand up and from a position under your right wrist, move your left hand forward. Following this, open your right fist and turn your hand up. Performed

Form 23 Crossing Arms Movement One Trunk Rotation and Foot Retraction 1. Bend your right knee and squat back, shifting your body weight to your right leg. Turn your torso to the right, direction - to the south. Turn the front of your left foot

Collection output:

ATONIC-ASTATIC FORM OF CHILDHOOD CEREBRAL PALSY. CORRECTION OF MOTOR AND SPEECH DISORDERS

Dementieva Elena Valerievna

neurologist, CJSC STK Reacenter, Samara

Ukhanova Tatyana Alekseevna

cand. honey. Sci., Leading Neurologist, CJSC STK Reacenter, Samara

In the atonic-astatic form of infantile cerebral palsy (ICP), muscle tone, unlike other forms of this disease, is classified as hypotension, but their characteristic static and dynamic ataxia, hypermetry and intentional tremor significantly complicate the acquisition of new motor skills. Patients with atonic-astatic form of cerebral palsy initially find it difficult to maintain balance and master the creation and inclusion of physiological synergies in the process of movement. In most cases, morphological studies indicate underdevelopment of the cerebellum, its atrophy or dysplasia in patients with this group of cerebral palsy. However, vestibular functions, and above all, the sphere of coordination of movements and maintaining a posture, are subject to positive changes as a result of targeted training and comprehensive rehabilitation. When localized pathological process in the frontal lobes of the brain in the clinical picture, mental retardation prevails over delayed motor development with pronounced motor demotivation. In these cases, an integrated approach is required in the treatment and rehabilitation of patients in order to improve vestibular functions and increase the functional activity of motor zones located in the frontal sections of the cerebral cortex. IN last years in the rehabilitation of patients suffering from atonic-astatic form of cerebral palsy, modern methods of treatment are used not only to correct muscle tone and reflex activity, but also to have a direct impact on the restoration of neurophysiological functions of the brain due to the normalizing effect on cerebral metabolism and fine neurochemical regulation. To correct motor and speech disorders, the impact of microcurrent reflexology (MTRT) on the muscles of the musculoskeletal and articulation apparatus in a state of hypotension. Exposure to a stimulating alternating current allows you to activate trophic processes and start the mechanism of reinnervation of the hypotonic muscles of the musculoskeletal system. The impact on the zones of craniotherapy with a current of the microampere range improves the functional activity of the frontal cortex affected by hypoxia. Providing a therapeutic effect on corporal biologically active points (BAP) of the craniospinal region contributes to the stabilization of the reflex activity of the cerebellum.

In conditions of oxygen and energy deficiency that occurs with cerebrovascular lesions, the drug Actovegin is of particular value - an antioxidant, a deproteinized extract of the blood of young calves. Its main action is to improve the utilization of oxygen and glucose. Under the influence of the drug, oxygen diffusion in neuronal structures is significantly improved, which makes it possible to reduce the severity of secondary trophic disorders, cerebral and peripheral microcirculation is significantly improved against the background of improved aerobic energy exchange of vascular walls and the release of prostacyclin and nitric oxide. The use of Actovegin also contributes to an increase in the concentration of acetylcholine in the structures of the brain, which is a necessary factor for improving neuromuscular transmission. Thus, the use of the drug Actovegin will also increase the effectiveness of stimulation of hypotonic muscles using MTRT by restoring the balance of the neurotransmitter acetylcholine in the body.

However, to date, no clinical trials have been conducted to evaluate the effectiveness of Actovegin in the complex treatment of patients with atonic-astatic form of cerebral palsy.

To study the effectiveness of complex treatment in the form of a combination of Actovegin with MTRT in patients with a diagnosis of cerebral palsy, atonic astatic form, chronic residual stage, 46 children aged 3 to 7 years were examined and treated. The treatment was carried out on an outpatient basis at the Children's Department of Neurology and Reflexology of the Samara Therapeutic Complex "Reacenter".

All 46 patients underwent preliminary magnetic resonance imaging (MRI) of the brain and electroencephalogram (EEG). MRI revealed signs of organic brain damage in the form of combined hydrocephalus with a predominance of the external form, with a characteristic expansion of the subarachnoid cerebrospinal fluid spaces along the convex, up to atrophy of the frontal lobes; identified areas of demyelination and/or cystic changes in the white matter of the frontal regions of the cerebral hemispheres of the cortex; hypo- or dysplasia of the vermis and cerebellar hemispheres, expansion of the large occipital cistern or the presence of a retrocerebellar cyst. The EEG revealed signs of disorganization of the cortical rhythm, a slowdown in the development of the bioelectrical activity of the brain, the presence of dysfunction of the mid-stem structures of the brain, and, in some cases, a decrease in the threshold of convulsive readiness.

All patients in the study of neurological status underwent palpation examination of muscle tone, as well as observation of the motor activity of the child in a familiar environment to assess the volume of active movements in the limbs. In all 46 patients, neurological examination revealed signs of static and dynamic ataxia, dysmetria, intentional tremor, severe hypotension of the muscles of the upper and lower extremities. In 18 patients, signs of static ataxia predominated - balancing movements of the head and torso were noted, the children did not sit or stand on their own, when they were deprived of support, the protective reaction of the hands and compensatory movements of the torso aimed at maintaining balance were absent. In 16 patients, motor skills were formed - the children held their heads, sat independently and stood at the support, however, they had signs of dynamic ataxia (shaky gait, legs wide apart, jerky, excessive, awkward movements). In 12 patients with a predominance of organic damage to the frontal parts of the cerebral hemispheres, a sharp decrease in motor, mental and speech initiatives was also noted. In all patients, during a standard speech therapy examination, a general speech underdevelopment with elements of cerebellar dysarthria was revealed: asynergy of the muscles of the speech apparatus with characteristic signs - a weak air stream, chanted speech, and in severe cases, pronunciation of only the first syllable from the word. All 46 patients received basic treatment: MTRT, repeated courses of manual limb massage with elements of exercise therapy. They were randomized into 2 groups. The first group included 24 patients who received, against the background of the basic treatment, repeated course treatment with Actovegin according to the method described below. In the second - 22 patients who received basic treatment.

To conduct microcurrent reflexology, we used a device approved for mass production and use in medical practice “Microcurrent electroacupuncture computer stimulator “MEKS”, which allows you to use the required number of acupuncture points per treatment session, since when an acupuncture point is exposed to a constant alternating current of microampere range, there is no destruction of the structures of biologically active points (BAP), which is characteristic of acupuncture. The use of MTRT allows you to control the location of the BAP. As a monitoring of the treatment process, electropuncture diagnostics according to I. Nakatani is used, with the help of which the state of acupuncture meridians is assessed and control points are selected based on objective data on the state of the patient's autonomic nervous system.

MTRT was carried out in 3 courses, consisting of 15 procedures, the duration of each procedure was 40-50 minutes. The courses of treatment were carried out intermittently: 1 month after the 1st course and 2 months after the 2nd course of treatment. The method of treatment was as follows: the impact was carried out sequentially on the BAP of the craniospinal region, on the zones of cranioacupuncture, on the BAP over the hypotonic muscles. The impact was carried out in two modes: braking mode - a constant negative current, with a power of 80 μA; excitation mode - alternating current, with a polarity reversal frequency of 0.5 Hz, with a power of 80 μA. The exposure time for each BAT is 60 sec. The inhibition mode was applied when the corporal BAPs were exposed to the classical meridians (English abbreviation) of the craniospinal region: GB20, GB21, GB12, BL11, LI15. The excitation mode was used when acting on the zones of cranioacupuncture and when acting on local BAPs located in the center of the projections of paretic muscles on skin covering. During the MRI procedures, the patients were in a state of calm wakefulness, in the supine position.

Actovegin (Nycomed, Austria, 2 ml ampoules, 200 mg tablets) was used as intramuscular injections at a dose of 0.2 ml/kg/day, but not more than 5 ml once. The treatment course consisted of 10 injections once every other day in the morning. Drug treatment was carried out in 2 courses, after the completion of the 1st and 3rd courses of MTRT.

During the study, all patients with atonic-astatic form of cerebral palsy showed the following positive dynamics: a decrease in the phenomena of static and dynamic ataxia in the form of a decrease in the amplitude of balancing movements of the head and trunk, elements of overshooting and intentional tremor was noted in all 24 patients of group I and 22 patients of group II groups. At the same time, some patients developed new motor skills: 18 people (75%) from group I and 13 people (59%) from group II learned to hold their heads and sit independently, and 16 people (67% ) from group I and 12 people from group II (55%). Patients also noted an improvement in speech function: an increase in the air stream, an increase in the volume of speech and the appearance of the skill of continuous pronunciation of words, an expansion of vocabulary and the development of the skill of constructing phrases and simple sentences from 2-3 words. Thus, in group I, positive dynamics in the form of a decrease in the degree of speech underdevelopment was observed in 18 patients (75%), and in group II, in 11 patients (61%). A decrease in the degree of dysarthria, taking into account the severity of neurological dysfunction, was noted in I-th group from 21 ± 3 points to 7 ± 2 points, in group II from 22 ± 3 points to 17 ± 2 points.

The results of the study demonstrated the high efficiency of the combined use of actovegin and MTRT in patients with atonic-astatic form of cerebral palsy due to the correction of hypotonic muscle tone, cerebellar reflex activity, and an increase in the functional activity of the motor areas of the frontal parts of the brain.

Thus, the combined use of Actovegin with MTRT is advisable to use in the complex rehabilitation of patients with atonic-astatic form of cerebral palsy.

Bibliography:

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3. Levina R. E. Speech and writing disorders in children. M., Arkti, 2005, - 222p.
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6. Portnov FG Electropuncture reflexology. Riga: "Zinatne", 1988, - 352 p.
7. Skoromets T. A. Secondary cerebral ischemia in the acute period of traumatic brain injury. Abstract of diss. … Dr. med. Sciences. - SPb., 2002, -41 p.
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9. Stoyanovskiy D. N. Reflexology, Chisinau. Cartya Moldoveneasca 1987, - 381 p.
10. Ukhanova T. A., Gorbunov F. E., Levin A. V., Grishina I. G., Dementieva E. V. Microcurrent reflexology in the complex treatment of patients with cerebral palsy. Tez. All-Russian forum "Zdravnitsa 2010". Current trends and prospects for the development of resort business in Russian Federation. M., 2010, - 158 p.

Cerebral palsy is a serious chronic disease. combines, which are associated with a violation of the motor function of a person. Most often, the disease affects the fetus during its intrauterine development.

Cerebral palsy is non-progressive, which means that the disease does not spread inside the body, does not affect healthy areas of the nervous tissue, it damages certain areas of the brain pointwise.

Appears at the age of 5 - 7 months.

The atonic-astatic form of cerebral palsy becomes more pronounced after seven months. Differential diagnosis of this form is quite complicated, due to the similarity of its symptoms with the symptoms of other diseases.

Until the age of six months, the baby may not notice any violations, and only as it grows, symptoms gradually appear. Most often they are associated with mental development disorders, neurological disorders occur. The child has outbreaks of unreasonable aggression, increased excitability. There are motor disorders, loss of balance.

The hyperkinetic form of the disease is determined somewhat later - by the beginning of the second year of life.

Additional diagnostics is carried out using the following instrumental methods:

• ultrasound examination of the brain;
• craniography, etc.

The results of the study allow obtaining information about the depth of changes in the nervous system, determining the degree and severity of damage to a particular part of the brain, and identifying other disorders.

To make a diagnosis of cerebral palsy, it is sufficient to have specific movement disorders in a child at the initial stage of the development of the disease. As additional measures, research is being done, which allows you to assess the type of damage and determine the specific location of the brain lesion.

Such a study is necessary in order to exclude the presence of other diseases with similar symptoms. For the same purpose, differential diagnosis is carried out.

Cerebral palsy is not a progressive disease, its symptoms do not increase over time, and the patient's condition does not worsen over time. If the opposite happens, then most likely the disease has a different nature.

The following diseases have the same symptoms as in cerebral palsy:

• traumatic and non-traumatic brain damage;
• early autism;
• phenylketonuria;
• spinal cord injury;
• schizophrenia, etc.

The prevalence of various forms of violation

It is a common disease. According to approximate estimates, for one thousand healthy children there are up to 3 patients with cerebral palsy. If we consider the data on the prevalence of forms of cerebral palsy, it can be noted that

• spastic diplegia is the leader among all forms,
• second place - hemiparetic form,
• the third is double hemiplegia,
• fourth - atonic-astatic form,
• and, finally, the hyperkinetic form of the disease has the fifth place in the prevalence of cerebral palsy.

Hyperkinetic form of cerebral palsy - the lot of girls

Boys are much more likely to suffer from spastic diplegia and double hemiplegia; girls are more likely to have hyperkinetic form of cerebral palsy.

If we compare the overall ratio of boys and girls diagnosed with cerebral palsy, it turns out that boys make up 58.1%, girls - 41.9%.

Cerebral palsy is an incurable disease, but this does not mean that it should not be treated at all.

Patients need the help of both doctors and teachers so that they can achieve the best possible positive results with this disease and can adapt to the environment as far as possible. For these purposes, it is necessary to identify the disease as early as possible and begin its treatment.

The medical term cerebral palsy combines diseases associated with various motor disorders caused by anomalies in the development of the brain before birth.

Atonic - astatic form of cerebral palsy occurs when the cerebellum and frontal lobes of the brain are damaged. This is the most severe form of cerebral palsy, until recently it was considered practically incurable.

Symptoms of atonic-astatic form of cerebral palsy

Symptoms of the disease can be noticed in a child already in the first year of life.

The baby's muscles are relaxed, the tone is very weak.

The child does not hold the head for a long time, control over its movements is reduced or absent altogether.

The grasp reflex in the palms is practically absent.

Movements are fussy, their coordination is disturbed. Before performing any action, the child makes many unnecessary movements.

Pronounced tremor of the extremities.

A baby with this diagnosis develops vestibular skills very late or does not develop at all. The child cannot sit and stand on his own. An imbalance may prevent you from walking at all.

The earliest time when a child begins to sit independently is not earlier than one and a half years. The groove, at the same time, is very unnatural and unstable, the knees are strongly separated, pronounced kyphosis of the thoracic spine. A more stable fit of the body is observed only at the age of 4 years.

It constantly seems to the kid that he will lose his balance and fall, because of this, the manipulative skills of the hands (grabbing an object, holding a spoon in his hand and the ability to bring it to his mouth without spilling the contents) do not develop for a long time.

The first attempts to stand on their own or take a few steps appear at the age of 4. In this case, the child can stand for a short time, holding on to a support. Deprived of support, he immediately falls, and the balance reflex is absent. These children begin to walk no earlier than 7 years of age. Their gait is very unstable, their steps are not rhythmic, their legs are widely spaced, all muscles are very tense. The head and torso of such children make many unnecessary movements, and they can move only within the apartment.

More than 80% of children with this form of the disease have reduced intelligence. Often they are very aggressive, and tend to perceive any situation from a negative side. If the lesion has affected only the cerebellum, the children show no initiative, inability to learn to write and read. When the frontal lobes are also affected, the child cannot assess his condition and is very aggressive.

Almost half of the patients suffer from convulsions, atrophy of the optic nerves or strabismus.

Methods of treatment and rehabilitation

The treatment of such children is reduced to taking very expensive and ineffective drugs. In practice, this form of cerebral palsy is not treated. Rehabilitation measures, courses of massage and physiotherapy are carried out, which give a very low effect.

In numerous rehabilitation centers, children are massaged, they do therapeutic exercises, but this also does not give real results.

With the formation of specialized hippotherapy centers for the treatment of children with such problems, there is a real possibility of recovery in this form of the disease.

Hippotherapy treatment

The horse is the most wonderful animal that has been created in this world. The influence of a horse on sick children works wonders. Every day, the possibility of treating the most serious diseases with the help of hippotherapy is being studied more carefully and deeper.

Children with atonic-astatic form of infantile cerebral palsy, with whom classes began in the first year of life, master motor skills much faster.

Experienced instructors and doctors teach children how to properly sit in the saddle, these exercises restore muscle tone, prevent scoliosis from developing, and even out the position of the head.

After several months of classes, a one-year-old baby already sits confidently, can stand without support. The tremor is significantly reduced, the child no longer makes such a number of unnecessary movements.

The need to properly hold the reins and control the horse stimulates the development of motor skills, and consequently, mental development. The child more easily comprehends the basics of literacy, memorizes simple verses, learns to write.

The psychological impact of these noble animals significantly reduces the aggression of children, removes the feeling of fear, helps them gain confidence in themselves and in their abilities. Children become more sociable, begin to communicate with their peers. In the most favorable cases, the child can even attend kindergarten.

The most important thing for parents is to choose the right center for classes. A specialist should prescribe a course of hippotherapy, and experienced instructors should conduct training and monitor the child. Before admission to the center, the child is examined in order to exclude the presence of an allergy to animal hair, or other symptoms that may become an obstacle to classes.

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

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

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

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

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

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

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

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

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