CHILDREN'S PARALYSES — the diseases arising at children owing to various defeats of a nervous system and which are shown disturbance of the motive and reflex sphere, and in certain cases disturbance of mentality and the speech.
Distinguish children's cerebral (spastic) and flaccid (sluggish) paralyzes.
- 1 Cerebral palsy
- 2 Children's flaccid paralyzes
Cerebral palsy develops owing to damages of a brain — pre-natal, in labor, and also in the period of a neonatality, t, e. when the main structures of a brain did not ripen yet. Frequency of a disease, according to M. N. Nikitina (1972), 1,71 on 1000 children's population.
An etiology and a pathogeny
Major importance in an origin of cerebral palsy till 60th 20 century were attached to a pre-natal hypoxia, asphyxia in labor, to a mechanical birth trauma, a hematencephalon. Further intoxications of a fruit, the disturbances of food of mother transferred it diseases began to be considered. With 60 — the 70th there is more and more clear a role of pre-natal neuroinfections in an origin of cerebral pathology of a fruit — listerellezny, collibacillary, staphylococcal, streptococcal, influenzal and other encephalitis and meningoentsefalit.
Morphological data demonstrate that at the children having a cerebral palsy, the process which began vnutriutrobno can continue for years, napr, inertly current hron, an encephalomeningitis of an infectious or neuroallergic origin.
A row a wedge, and experimental observations suggests that patol, autoimmune processes can also cause pre-natal encephalopathies. It is established that under influence hron, a pre-natal hypoxia exchange processes at a fruit, first of all oxidizing exchange, intracellular protein synthesis, formation of vascular system of a brain are broken; thereof there can be a disturbance of participation of a fruit in a childbed and there is asphyxia in labor and a birth craniocereberal trauma.
Dependence of a certain localization of motive frustration from listed etiol, factors is studied insufficiently, however is established that the hyperkinetic form of cerebral palsy is most often caused by bilirubinovy encephalopathy (as a result of incompatibility of blood of mother and a fruit on a Rhesus factor or on a blood group and so forth), and also the hemorrhage to the area of a body having a tail resulting from a birth trauma.
the Most characteristic patomorfol, changes at cerebral palsy — malformations of a brain: microgyria or agiriya, dysplasia or aplasia of small sites of a brain, agenesia of bark, true porencephalia, underdevelopment of pyramidal ways, corpus collosum, subcrustal kernels etc. The diffusion, lobar or lobulyarny sclerosis of a raincoat can be observed; crinkles in these cases are flattened, thinned, furrows are expanded. The cerebral sclerosis can be a consequence hron, or an intersticial inflammation or diffusion vascular defeat. Quite often in a brain of the children who died at the age of 5 — years, the fresh centers of a necrosis are found. White matter of a brain can be condensed and reduced in volume. Growth of a glia can take place. Covers of a brain are condensed, quite often spliced with bark. Subarachnoid spaces, especially in front departments, are increased, ventricles are stretched, cysts can be found.
In a basis a wedge, pictures of cerebral palsy lie the motive frustration forming as paralyzes and paresis (see. Paralyses, paresis ), more rare hyperkinesias (see), ataxy (see), and also various disturbances of the speech and mentality.
The difficult pathogeny of pre-natal and patrimonial damage of a brain involves also variety a wedge, manifestations. Allocate three stages of a disease.
In the first, early stage acute disorders haemo - and the likvorodinamik which arose at a fruit with pre-natal damage of a brain or in the course of childbirth can cause considerable disturbances of regulation of a tone of muscles, is more often as ex-tensor rigidity and to suppress congenital motive reflexes. Such symptoms as the general serious condition, bradycardia or tachycardia which is speeded up or the slowed-down breath, the nystagmus, convulsive twitchings of face muscles and extremities expressed are characteristic of this stage gipertenzionny syndrome (see), discrepancy of bones of a skull, tension of a big fontanel, early sklerozirovaniye of its edges, and then seams (first of all coronary). The convulsive syndrome can appear right after the birth, then disappear or keep with firmness, can appear in the first weeks or months of life; spasms usually happen polymorphic (see. Spasms ); emergence of initial elements of mental and prespeech development in the child sharply is late. From motive system oppression of all or parts of congenital reflexes is noted: there is no protective — turn of the head aside (fig. 1,7) which happens at the healthy newborn; there is no reflex of a support — reflex straightening of legs (fig. 1, 2), prehensile, crawling, etc.
In the most hard cases oppression of deglutitory, search and palmar and oral reflexes is observed. Dissociation between the accruing tonic cervical and labyrinth reflexes (fig. 1,3 — 5) and poorly developing congenital motive reflexes comes to light. The underdevelopment or the wrong formation of gluteuses — they flabby is characteristic, on a consistence remind the punctured ball. Than the form of a disease is heavier, edges will develop further at the child, especially the symptom of «the punctured ball» is accurately expressed. Gastrocnemius muscles are condensed, displaced to popliteal spaces, calcaneal (akhillova) sinews are extended. Calcaneuses are underdeveloped, often developed asymmetrically. On that party where the calcaneus is developed more weakly, motive pathology is further more expressed. Very much early, sometimes by the end of the second month of life, the functional kyphosis or a kyphoscoliosis in lumbar and lower chest departments of a backbone forms (see. Kyphosis , Scoliosis ). The ekstenziya of hands is limited or is absent, the musculocutaneous fold between I and II fingers of a brush is shortened. One of the heaviest symptoms concerning the forecast are the torsion spasms (see. the Torsion dystonia ), which are implemented on the mechanism of a labyrinth tonic reflex: if the child lies on spin, there is an intensive zakidyvaniye of the head and a shoulder girdle, often very painful, with their distortion in this or that party back; if the child lies on a stomach, there are spasms preferential in the muscles bending a trunk and causing its rotation.
The structure of the articulation device — the high sky, rather small volume of an oral cavity, big slow-moving language is sometimes broken. Absence or insufficiency of priming visual and acoustical orientation responses which emergence in the healthy child is observed in the first weeks of life, and also absence or insufficiency of the primitive emotional reactions which are a part of «a complex of revival» at children of the first weeks of life is noted.
The second stage of a disease, to-ruyu depending on the reasons of cerebral pathology consider as initial residual or initial residual and chronic, begins after the termination of the acute phenomena. In clinic of this stage there are those symptoms of a dizontogenez which are caused by pathology of pre-natal development if it took place, and also effects of a hypoxia or asphyxia in labor, disturbance of cerebral circulation with the subsequent development of cicatricial and atrophic processes in nervous tissue and other its changes.
If cerebral pathology of a fruit is connected with the defeat in childbirth caused by obstetric pathology of mother, then the acute phenomena abate within the first four months of life of the child and on this background the initial residual phenomena develop. The initial residual phenomena caused by a birth trauma can arise against the background of already available pathology of pre-natal development caused by influence of such disturbing factors as neuroinfection, intoxication etc. If patol, the process which began vnutriutrobno does not come to an end in labor, then further it proceeds against the background of the residual phenomena caused by pathology of pre-natal development and a birth trauma. In these cases speak about an initial residual and chronic stage of a disease.
The initial residual stage of a disease is characterized by the fact that at the tonic reflexes remaining active righting reflexes do not form or form insufficiently. Normal process of vertical installation of a body is provided with emergence by 2 months of a labyrinth righting reflex from the head on a neck (the child begins to hold a head), to month — cervical chain symmetric and asymmetric righting reflexes. The cervical chain symmetric righting reflex provides increase in a tone of razgibatel both at horizontal, and at vertical position of a body, as does possible installation of a body in space. The cervical chain asymmetric righting reflex provides preservation of balance of a body.
Children with a cerebral palsy have these reflexes and some other righting reflexes or are late in development up to 2 — 5 years and more, or do not appear absolutely while tonic reflexes continue to accrue. The negative symptom of Landau (fig. 1,6) is indicative: the healthy child supported on weight in horizontal position with 5 — raises the 6th month the head, unbends a trunk, takes out hands forward; the child with a cerebral palsy cannot make it, it hangs on hands of the doctor (a symptom of «the lowered linen»). Any motility sharply is late in the development. Accrue and patol, synergies, defining in total with tonic and patholologically the developing righting reflexes formation patol, a motive stereotype. The contractures appearing in this stage of a disease as well as scoliosis, still functional.
On the basis of the available motive and kinaesthetic disturbances pathology of an optiko-space gnozis (visual orientation in space), body schemes, a praksisa (the sequences of actions in various situations), a stereognosis begins to form (definition of a form of a subject to the touch). Disturbance of mental development is aggravated with the forming speech pathology and weakness of contacts with people around. At children with an initial residual stage of a disease quite often after 2 — 5 years motive, mental and speech functions gradually begin to develop, and especially it is active, than systematic treatment is begun earlier.
The residual and chronic stage of cerebral palsy flows much heavier — the inflammatory, allergic, atrophic and destructive processes which began vnutriutrobno in a brain continue to develop, the symptomatology progresses nevrol.
The third stage of a disease which is conditionally called by a final residual stage is characterized by final registration patol, a motive stereotype, the organization of contractures and deformations. Clear is a nature of mental and speech disorders. Pseudobulbar belong to speech frustration dysarthtias (see) or, depending on a form of a disease, a hyperkinetic or cerebellar dysarthtia, proceeding against the background of the general delay of speech development. Mental disturbances develop on psychoorganic type. Along with disturbance of the emotional and strong-willed sphere and astenisation disturbances of cortical functions — a dizgrafiya, an acalculia take place (see. Aphasia ), etc., interfering training of the child. In this stage of a disease children regarding cases can keep ability independently or with support to move, seize the letter, these or those elements of self-service, labor processes. In other cases multiple artrogenny contractures, heavy deformations, fibrous regeneration of muscles, joints and sheaves quickly accrue; as a rule, the speech and mentality do not develop,
Depending on the preferential nature of motive frustration allocate various forms of cerebral palsies.
Spastic diplegia — a form, at a cut legs preferential are surprised — it is known under the name of a syndrome of Littl (fig. 1,7). Tonic reflexes usually disappear at this form by 2 — 4 years. Righting reflexes develop late, after 1,5 — 2 years. Take place patol, the synergies promoting, as well as tonic reflexes, to formation of vicious installations of a trunk and extremities, contractures and deformations that interferes with full mastering motility.
At children with a spastic diplegia the secondary delay of mental development, edge, according to M. N. Nikitina (1972) most often takes place, at early the begun and correctly carried out treatment by 6 — 8 years it can be eliminated; the child in these cases can study in a special nursing home for children with cerebral paralyzes or at mass school. 30 — 35% of children with a spastic diplegia suffer oligophrenia (see), most often in degree of unsharp moronity; they are trained according to the program of special schools for mentally retarded children. At 70% of children with a spastic diplegia speech frustration in the form of a dysarthtia are observed, motor is much more rare alalia (see).
Hemiplegic or gemiparetichesky form develops in 80% of cases postnatalno, in the period of a neonatality.
Depending on intensity of motive frustration the hemiplegia or a hemiparesis is noted. Hemiplegia (see) most often takes place at children of early age, then in process of development of a brain and under the influence of treatment motive frustration become considerably less expressed, especially in the lower extremity and proximal departments of an upper extremity, and can be regarded as the phenomena of a hemiparesis.
Displays of a hemiparesis at children and at adults are various. At children delay of growth of bones and shortening of length of paretichny extremities is observed. At 25 — 35% of children at this form the oligophrenia in degree of moronity takes place, is more rare than a deficiency of intellect, at 45 — 50% — a secondary delay of mental development, surmountable at timely begun recovery therapy.
Speech frustration are observed at 25 — 35% of children, most often as a pseudobulbar dysarthtia, is more rare as a motor alalia.
The double hemiplegia is a spastic tetraparesis, at Krom of a hand are struck as much as legs, or in bigger (fig. 1,8). The rigidity of a muscle amplifying under the influence of the tonic reflexes remaining for many years (cervical and labyrinth) which at the healthy child disappear for the first weeks of life prevails. Righting vypryamitelny reflexes absolutely or are almost as well as any — children do not sit not developed, do not stand and do not go. As a rule, the oligophrenia in degree of heavy moronity, a deficiency of intellect or even an idiocy, a heavy dysarthtia or an anarthria is observed.
Hyperkinetic form. The involuntary movements — hyperkinesias (a choreoathetosis, an athetosis, the torsion dystonia, a choreiform hyperkinesia) are characteristic of this form, along with to-rymi there can be paralyzes and paresis. Hyperkinesias in articulation and skeletal muscles begin to come to light with 4 — the 6th month of life. The reduction of tonic reflexes and development of righting reflexes are late to 2 — the 3rd year of life; then righting reflexes and any motility begin to develop well at all types of hyperkinesias, except athetotic and the torsion dystonia.
Speech disturbances are observed at 90% of patients most often in the form of a hyperkinetic dysarthtia. Development of intelligence goes in most cases well. Children cannot sometimes study in connection with the heavy alalias and any motility caused by hyperkinesias.
Atonic - an astatic form cerebral palsy it is characterized by a low tone of muscles, existence patol, tonic reflexes, absence or an underdevelopment of righting reflexes both high tendon and periosteal jerks. By 3 — 5 years at systematic treatment children, as a rule, seize autokinesias though an ataxy, the gipermetriya, an intentsionny tremor can remain.
The most resistant is the truncal ataxy (fig. 1,0). Speech frustration in the form of a cerebellar or pseudobulbar dysarthtia are observed at 60 — 75% of these children. At this form of Dative the arrest of development of intelligence is noted, and in 55% of cases the oligophrenia in degree of deep moronity or a deficiency of intellect takes place.
The syndromes accompanying the main forms of a disease
to the Main forms of a disease can accompany convulsive, pseudobulbar, diencephalic gipertenzionny syndromes; they define this or that orientation of recovery therapy.
Convulsive syndrome it can be observed from the first days of life. Newborns usually tonic, can have spasms and clonic, especially in upper extremities less often. At children of early age of a spasm, as a rule, happen polymorphic. Absentias epileptica (short-term «hardenings» of a look, an amimia), «salaamova» of a spasm — «nods» are often observed. The convulsive syndrome which began with the first weeks of life and remaining resistant for the next years testifies to a severe disease; the spasms developing after 2 — 3 years of a disease to a thicket proceed as the developed epileptic attacks.
Pseudobulbar syndrome it is shown in the first weeks of life by silent, hoarse shout, a poperkhivaniye during the swallowing, disturbance of suction. Further the pseudobulbar dysarthtia — the speech of the child greased, not clear, a voice silent develops, nasal hypersalivation, as a rule, takes place. Chewing is broken (children quite often up to 3 — 5 years eat only the wiped or semi-fluid food).
Diencephalic syndrome it is shown at early age by a hyperthermia, thirst, decrease and lability of the ABP, disturbance of shchelochnokislotny balance in the form of the metabolic or mixed acidosis, is more rare than an alkalosis, a giporeksiya, hron, a delay of a chair.
Hypertensive syndrome at children of the first months of life it is shown by protrusion of a front fontanel, in hard cases — discrepancy of seams, psychomotor excitement or block, increase nevrol, symptoms. At the senior children headaches, an adynamy, exhaustion are observed, is more rare — excitement, a sleep disorder; the symptomatology accrues nevrol.
The diagnosis and the differential diagnosis
the Diagnosis of cerebral palsy in initial stages of a disease is made on the basis of the described symptomatology. The careful research of the reflex sphere, prespeech development, features of pathology of initial mental manifestations in comparison to the anamnesis of pregnancy and childbirth allows to be guided early enough in character patol, process.
The differential diagnosis in initial stages of a disease is carried out with rickets (see); at the same time the main diagnostic characters of cerebral palsy — maldevelopment of motive system, existence of tonic reflexes, dissociation between increase tonic and absence or weakness of righting reflexes, specific vicious installations of forearms, brushes, feet.
In a final residual stage the diagnosis of cerebral palsy does not cause difficulties. Disturbance of any motility, quite often residual activity of tonic reflexes, an underdevelopment of righting reflexes, hyperkinesias, an ataxy, a «mosaic» delay or an underdevelopment of mentality, existence of speech frustration in this stage rather accurately characterize its wedge, a picture. The differential diagnosis of a disease in this stage depends on its form. The double hemiplegia, a spastic diplegia and a gemiparetichesky form have characteristic clinic and the anamnesis.
Atonic - the astatic form in early stages needs to be differentiated with myopathy (see) and Oppengeym's myatonia (see. Myatonia ). Existence of tonic, high tendon and periosteal jerks, the raised tone in adductors of hips, pronators of a forearm is characteristic of cerebral palsy that causes formation of vicious installations of a trunk and extremities; at children with a myopathy and Oppengeym's myatonia oppression of tendon and periosteal jerks, uniform decrease in a tone of muscles, more correct mental prespeech and speech development is noted.
The hyperkinetic form should be differentiated with hereditary diseases of a nervous system on the basis of clinic, the anamnesis and data of some biochemical, researches, napr, researches of ceruloplasmin at differential diagnosis with hepatocerebral dystrophy (see). Cerebral palsy in any stage needs to be differentiated from effects meningitis (see) and the meningoentsefalit postponed on the first year of life and later. Existence patol, tonic reflexes is not characteristic of the last; disturbances of mentality and the speech at them along with smaller weight of disorders of motility quite often heavier, than at cerebral palsies.
In an early stage the main attention should be directed on prevention of development of a gipertenzionny syndrome, normalization of blood circulation, the termination of inflammatory and allergic processes, elimination of a convulsive syndrome.
For these purposes complex therapy is carried out. In case of discrepancy of seams, protrusions of fontanels, bystry increase in the size of a head, i.e. increase of intracranial pressure, appoint 25% solution of magnesium sulfate intramusculary at the rate of 1 ml to a year of life a day, only 5 — 7 injections, and then for 1 — 2 month mixture with 1% solution of citral; in hard cases lasixum on 0,5 ml of 1% of solution intramusculary according to the scheme, only 10 — 15 injections, or 74 tab., i.e. 0,01 g a day; Diacarbum according to the scheme. For recovery of exchange processes in nervous tissue and especially oxidizing and protein metabolism B12 vitamin intramusculary, in the beginning 3 — 4 injections on 100 — 150 mkg, and then on 200 mkg every other day, only 15 — 20 injections is entered. This drug as well as pyrogenal, promotes processes of myelination of nerve fibrils. Pyrogenal is entered on 25 — 200 MPD (minimum pyrogenic dose), gradually raising a dose, intramusculary every other day, only 20 — 25 injections. Administration of pyrogenal can be alternated to administration of vitamin B 12 .
At an arrest of development of priming acoustical and visual orientation responses, primary complex of emotional revival, and also at signs of disturbance of prespeech development it is necessary to use Aminalonum (1/4 tab. 1 — 2 of time a day), Cerebrolysinum (0,5 ml intramusculary every other day, only 10 — 15 injections), alternating to polyneuramin 12 (in a dose of 100 — 150 mkg).
At early emergence of muscle tension, the increasing activity of tonic cervical and labyrinth reflexes appoint on 1/4 — 1/2 tab. of Mydocalmum of 1 — 2 time a day within 2 — 3 months. Emergence of a convulsive syndrome demands introduction of Radedormum (0,025 — 0,005 g twice a day), sodium borate (on 0,1 g 2 times a day), a hexamidine (0,01 g 2 times a day) and others anticonvulsant drugs, along with dehydrational means; if necessary carry out antiinflammatory treatment.
In residual stages of a disease apply B12 vitamin to 500 mkg to stimulation of exchange processes, every other day, a course of 25 injections, Aminalonum according to 1 tab. 2 times a day within 2 — 3 months; ATP intramusculary on 1 ml every other day, a course 20 — 25 injections; pyrogenal — from 100 to 400 MPD intramusculary every other day, only 20 injections; for regulation of a muscle tone — skutamil-Ts on 0,25 g 2 times a day, Mydocalmum on 0,025 — 0,05 g 2 times a day within 2 — 3 months. Cortinum and dexamethasone are applied according to the same indications and in the same dosages, as at an early stage of a disease, but for 2 — 3 months, antikholinesterazny drugs — an ambenonium chloride on 0,002 — 0,005 g 2 times a day within 1 — 2 month, Galantaminum on 0,3 — 1 ml of 0,25% of solution intramusculary, every other day, of only 20 injections (in the presence of convulsive attacks it is contraindicated). Appoint Dibazolum on 0,002 g 2 times a day within 2 — 3 months.
The choice of drug and duration of its use entirely depend on a condition of the child. Follows periodically, 1 — 2 time a year, to carry out dehydrational therapy, using Diacarbum, citral, magnesium sulfate.
In cases when at children in an initial residual and rezidualnokhronichesky stage of a disease the delay of mental development takes place, use of Cerebrolysinum (on 0,5 — 1 ml intramusculary every other day, only 10 — 20 injections), Aminalonum and Prephysonum gives effect (on 1 ml intramusculary, every other day, of only 15 — 20 injections). The korrektsionnovospitatelny work aimed at the development of coordination, the first elements of game activity is at the same time carried out. At children in a final residual stage at preschool age it is necessary to carry out at the same time work on education of optiko-space, temporary, subject and space and other representations, paying special attention to a condition of hearing since with disturbance of phonemic hearing (see) lag in speech and mental development can be connected. At school students character of correctional actions shall change depending on requirements of age, education and career guidance.
In an early stage if there is no accruing gipertenzionny or convulsive syndrome, with 2 — 3rd week of life it is necessary to begin massage and gymnastics. After relaxation by means of «a pose of an embryo» (fig. 2,1), acupressure, exercises on a ball (fig. 2, 2—4) development of placing reactions, a righting reflex from the head on a neck (fig. 2, 5) is stimulated, the reciprocal movements of extremities necessary for this act passively are reproduced. Special attention is paid to development of an ekstenziya of hands, assignment of thumbs, and also education of fixing of a look on objects, to development of keeping track of by moving objects.
From first weeks of life special massage of articulation muscles, especially language, training of the child in voice reactions, breath is made.
The orthopedic mode providing special laying of the head, top and bottom extremities corrective their vicious installations is obligatory.
To lay down. the physical culture in an initial residual stage of a disease shall be directed to suppression patol, primitive tonic reflexes — cervical and labyrinth (fig. 2, 6 and 7), education of righting reflexes. The technique offered Bobatami is widely applied to this purpose (V. of Bobath, To. Bobath, 1956), a cut is stimulation of motive development irrespective of age the basis, by the same principle, on Krom it occurs in post-natal ontogenesis. E.g., if the child is not able to hold the head in 3 months and in 5 years, then in either case occupations begin with stimulation of the labyrinth righting reflex providing deduction of the head, and already then work on formation of other consistently developing righting reflexes and these or those forms of a statics and the movement.
For this purpose aim to develop first of all the correct installation of a body of the child in a sitting position (fig. 2, 8 and 9). The scheme of position of a body at a required pose is brought up passively — exercises for stimulation of development of vertical installation of a body (fig. 2, 10 and 11). Then aim at that the child mastered these movements actively, only after it start development of the scheme of the required movement then pass to working off of the necessary active movement (fig. 2, 12). It is necessary to remember value patol, synergies in formation at the child of vicious installations of a trunk and extremities and to eliminate them before working off of the necessary movement. So, tension of a tone of a big pectoral muscle at weakness of muscles of shovels and spins leads to the fact that the shoulder girdle rises up and is removed forward. As the big pectoral muscle is synergist poyasnichnopodvzdoshny, there is tension of a tone of the last and bending in hip joints; in patol, synergy also big adductors of hips therefore there is «decussation» of legs at the level of hips or shins — «a pose of the ballerina» join. For elimination of this patol, synergy (fig. 2, 13 and 14) has enough to make the correct installation of a shoulder girdle in one cases, having unbent it and having reduced corners of shovels in their normal situation; in other cases several passive movements of the maximum reduction of hips and bending in hip and knee joints are made in addition.
There is also some other techniques to lay down. physical cultures, aimed at the development and correction of movements taking into account the nature of disturbance of a tone of muscles, involuntary movements, an ataxy, contractures and deformations. Along with to lay down. physical culture it is necessary to apply acupressure (fig. 2, 15) that provides a possibility of normalization of a tone of muscles, stimulation of reflex movements, simplification of mastering any motility.
The training of movements on a special wheelchair, on live rolls, on a trampoline (fig. 2, 16—18), the suspended road and other devices is made for development of a correct posture of a body and movements; group classes and choreographic gymnastics (fig. 2, 19 and 20) for development of movements of hands and legs, formation of a bearing are given.
Physical therapy figures prominently in the general complex of recovery treatment and it is carried out in initial and final residual stages. At the choice of treatment it is necessary to consider age, a condition of the child and existence of associated diseases. The dosage is recommended to be increased gradually.
krovo-and lymphokineses in a brain, for a rassasyvaniye of decomposition products and an inflammation, the prevention of development of cicatricial and atrophic process in nervous tissue, and also for regulation of a tone of muscles it is recommended to apply to improvement galvanization (see) — a galvanic collar on Shcherbaka, novocaine - magnesium - calcium electrophoresis of a collar zone, endonazalno and by a cervical and front technique, application of dirt, paraffin on cervical and collar area; electrosleep. During the holding the specified electroprocedures density of current shall not exceed 0,01 — 0,03 ma/cm 2 .
For decrease in a tone of muscles and stimulation of a physical activity of the child pulse therapy (by K. A. Semenova's technique), novocaine electrophoresis on an extremity (by I. M. Levin's technique), on the course of a backbone and a reflex and segmented zone is widely used (by D. A. Novozhilov's technique), inductothermy (see) and mud applications on the course of a backbone (see. Mud cure ), hot wrappings of extremities and balneotherapy (bathtubs, underwater shower massage).
Influences by an impulse current carry out by electrodes 0,3 — 0,5 cm wide in the form of semi-arches which impose on a dorsum of nail phalanxes of all fingers of hands and legs. Apply impulses exponential and with a squared duration of 3 — 5 ms, with a frequency of 70 — 80 Hz, with a frequency of modulations of 36 of 1 min. Current to children up to 3 years 2 — 5 ma, is more senior than 3 years —-10 — 12 ma. Duration of impact on each pair of extremities from 10 to 20 min. depending on a condition of the child. Procedures are carried out daily, on a course 20 — 30. Repeated courses are appointed in 1,5 — 3 months. Pulse therapy is effective at all forms of a disease, especially at hyperkinetic and atonic - astatic. Use of impulse currents is contraindicated at frequent epileptic seizures (more than 3 — 4 in a month) and at sharply expressed and widespread contractures.
Novocaine electrophoresis is carried out on area of nail phalanxes of fingers of hands and legs.
The general fresh, coniferous and mineral (radonic, hydrosulphuric, chloride sodium, etc.) bathtubs have the calming, weakening and soothing effect. They will be out on 5 — 10 — 15 min. at water temperature 36 — 38 °, every other day, on a course of treatment 10 — 12. During a bathtub active or passive corrective exercises are carried out. The combination of balneotherapy to pulse therapy is effective. Mineral bathtubs are shown to children 3 years are more senior.
For alignment of a ratio of a tone of muscles, for development of idea of the child of function of muscles, and also for prevention and fight against vicious provisions, contractures and deformations of extremities it is recommended electrostimulation (see) the weakened and hyperinflate muscles of extremities and trunk. Before electrostimulation — locally thermal procedure or Nivalinum (Galantaminum) - an electrophoresis. It is more reasonable to use a bipolar technique, edges are excluded by involvement spastic of the reduced muscles. Stimulation can be carried out by tetanizing current, but is more effective, especially at children up to 3 years, stimulation by the harmonic modulated currents. Electrostimulation of muscles of the senior children shall be carried out with active participation them. Splintage and laying of extremities, and also LFK are carried out after electrostimulation Electrostimulation is not shown at a hyperkinetic form and at frequent epileptic seizures.
In a final residual stage for reduction of expressiveness of reflex and artrogenny contractures, for preparation of an extremity for the conservative orthopedic mode, as well as for operational treatment the thermotherapy — mud, paraffin and ozokeritovy applications, hot wrappings of an extremity is recommended. The thermotherapy is carried out just before imposing of a plaster bandage.
Sanatorium treatment in specialized local sanatoria it is shown to children aged after a year, on mud and balneol. resorts (lake. Bitter, Dzhermuk, Druskininkai, Yevpatoria, Odessa, Tsqaltubo) 3 years are aged more senior.
The orthopedist - surgical treatment
When, despite the carried-out drug treatment, at children resistant contractures and deformations develop, resort to conservative and operational orthopedic treatment.
Treatment by stage plaster bandages during which imposing consider not only severity, but also a pathogeny of the contractures and deformations caused substantially patol, the installations evolving from not reduced tonic primitive reflexes belongs to conservative orthopedic treatment.
So, at a prevalence of a labyrinth tonic reflex there are flexion installations in all three joints of the lower extremities. In these cases plaster bandage impose from the lower third of a shin to a groin, at the same time the knee joint is fixed according to the available flexion contracture with insignificant, to 3 — 5 °, reduction of a corner. Then a plaster bandage fix foot in ekvinusny situation with the purpose of correction of side curvatures. Each 12 — 14 days extension in knee joints is made further, step-by-step. In 12 — 14 days after correction of contractures in knee joints in the same way make correction of contractures in ankle joints and continue correction of deformation of feet. Imposing of plaster bandages on knee and talocrural joints promotes correction of contractures in a hip joint. If it did not occur, then step-by-step plaster bandages are applied also a hip joint — to a belt. Such method of imposing of plaster bandages gives the chance to avoid restretching sural and especially kambalovidny muscles and formation further of the hardest deformation — calcaneal foot. Treatment is carried out 2 — 3 months.
Dominance of a primitive tonic symmetric cervical reflex causes development extensive patol, synergies in joints of the lower extremities and in this regard the corresponding contractures and deformations. During the imposing of the first plaster bandage knee joints are fixed in the provision of nek-ry bending, at an angle 165 — 170 °, and at the available recurvation (considerable overextension) — at an angle 160 °, foot is fixed in the provision of an ekvinus, without correction. In the subsequent each 12 — 14 days stages of correction are made only in ankle joints, i.e. foot is gradually brought out of an ekvinusny state to a corner 90 — 85 °. Formation of the correct position of a heel and formation of the arch of foot is at the same time made. For creation of outside rotation of the lower extremities in several days on a front surface of a plaster bandage in an upper third of a shin plaster bandage the strut becomes stronger, but so that the child did not feel a tension of adductors of hips. Assignment of hips increases gradually. Treatment provoditeya 2 — 3 months.
During treatment by plaster bandages it is necessary to show consideration for complaints to pain, it is special the pain arising at night since they testify to errors of imposing of bandages. It is necessary that the head and a trunk were in situation, at Krom the weakened and overstrained muscles would not be exposed patol. impulsation.
The treatment by stage plaster bandages which is carried out 3 — 6 times reduces number of a recurrence of contractures twice.
When all types of conservative treatment are ineffectual, resort to operational treatment. It should be done not earlier than 8 — 10-year age. Carefully it is necessary to treat an achillotomy since after it calcaneal foot — deformation quite often forms, at a cut the child can move only on halfbent legs.
If necessary (permanent ekvinusny installation of feet, the shortened tense heelstring) resort to Strayer's operation. The essence of operation consists in a z-shaped section of heelstring. Correction ekvi-Noosa should be made only to a corner 90 — 95 ° since at hyper correction calcaneal foot can develop.
A number of operations is offered for elimination of the fixed contracture of a knee joint, but the most effective is Eggers's operation, the purpose cover movement of points of an attachment of a sgibately shin of a hip. At this operation semitendinous, gentle and semimembranous muscles are carefully excreted. They are cut from a shin at the level of distal sinews of «a goose pad». Bare back department of an internal epicondyle of a hip and prepare a bone and periosteal bed or do intra bone the tunnel. Here move the free ends of the dissected-away muscles and fix them either podnadkostnichno, or vnutrikostno. After operation the extremity to inguinal area is fixed for 1 month gypsum. Then train the patient in walking.
For treatment of a spastic flexion contracture of a hip joint also a number of surgical interventions from which the spinotomiya or a subspinal myotomy of the muscles bending a hip are most accepted is offered. After operations apply a bilateral plaster bandage, fix an extremity in the provision of overextension in hip joints. Besides, using a deep relaxation in the period of an anesthesia, aim to korrigirovat as much as possible deformations of knee and ankle joints with the subsequent fixing by their stage plaster bandages. In 2 weeks begin to train the patient in standing and walking.
To and especially after operation it has to be carried out to lay down. the physical culture, treatment by all necessary medicamentous means, is desirable psychotherapy and training in auto-training. The combination of surgical intervention to preliminary medicamentous therapy is obligatory, to lay down. physical culture, acupressure, balneo-and mud cure.
Assessment of efficiency of treatment. Early and correct systematic treatment when anti-and intranatal damage of a brain was not too heavy, is usually effective, completely or to some extent saves the child from motive, mental and speech disability.
Criterion of efficiency of recovery therapy is reduction of disorders of motive functions, and also improvement of the speech.
the Forecast depends on a form of a disease, timeliness and correctness of treatment. The possibility of training and social adaptation in many respects depends on completeness of compensation and extent of disturbances of mental activity (disturbance of the speech, the account, the letter, space perception and so forth). The spastic diplegia predictively is favorable concerning overcoming mental and speech disorders, is less favorable concerning formation of motive functions. In the absence of an oligophrenia in degree of heavy moronity, a deficiency of intellect or an idiocy, patients would have to be treated actively for a number of years in recovery type, sanatoria, policlinics, in a special day nursery, kindergartens, boarding schools. The child with this form of a disease can learn to service himself, to write, can seize a number of labor skills. In optimum cases such patients can become completely able-bodied and seize any profession.
«the double hemiplegia» indicates the diagnosis full or almost full disability of the child and quite often is the basis for the direction it in a nursing home psikhonevrol. profile of the Ministry of Social Welfare.
The hyperkinetic form of cerebral palsy predictively is favorable concerning training and social adaptation. Children with this form of a disease are subject to the direction in a special day nursery, kindergartens, and further in nursing homes for children with cerebral paralyzes of the Ministry of Public Education or in mass schools. In rather exceptional cases when the hyperkinetic form of paralysis is combined with an oligophrenia in degree of deep moronity, a deficiency of intellect or an idiocy, children go to nursing homes psikhonevrol. profile of the Ministry of Social Welfare.
Children with atonic - an astatic form of a cerebral palsy shall is long and be treated systematically in hospitals, a special day nursery, kindergartens, and then at special boarding schools of the Ministry of Public Education where they can study according to the program of mass or auxiliary school. If this form is combined with an oligophrenia in degree of deep moronity or a deficiency of intellect, then such children shall go to nursing homes psikhonevrol, a profile of the Ministry of Social Welfare.
The Gemiparetichesky form of children's paralysis predictively is favorable concerning training and adaptation to work. Early prolonged treatment of such children in special hospitals and their stay in sanatoria is necessary for children with cerebral paralyzes.
Children's flaccid paralyzes
carry the paralyzes arising owing to damage of cranial nerves or their kernels, front horns of a spinal cord, neuroplexes and peripheral nerves To children's flaccid paralyzes.
The etiology and a pathogeny
the Flaccid paralyzes arising at the newborn can be caused by a variety of reasons. At the fruit submitted influence infections or intoxications, formation of both a nervous system, and vascular occurs insufficiently fully therefore anomalies of development of kernels of separate cranial nerves can be observed. A birth trauma at a fruit, development to-rogo was broken, can cause hemorrhage, including and in the field of kernels of cranial nerves; at the same time the facial nerve most often suffers.
When the weight of a fruit reaches 4 — 5 kg, and also at pelvic, front or foot presentation in the course of childbirth spontaneously, and especially at an application of forceps, at removal for the pelvic end, removal of a coat hanger, hemorrhage can develop in a trunk of a peripheral nerve, the perineural hematoma, can happen traumatizations of humeral or cervical textures, stretching of nervous trunks, in the most hard cases a severe mechanical injury of a nerve to its crush.
More or less extensive hemorrhages in the field of cervical segments of a spinal cord most often cause death of a fruit (proximity of a myelencephalon). At disturbance of blood circulation in the pool of a vertebral artery and its branches there can be paresis, a wedge which displays depend on the level of damage of a spinal cord. There can be combined injuries in the field of cervical or verkhnegrudny segments and a brachial plexus.
Flaccid paralyzes of an infectious or intoksikatsionny etiology arise usually postnatalno. The paralyzes caused by defeat of cells of front horns of a spinal cord develop at poliomyelitis (see).
When paralysis or paresis of a cranial nerve is caused by inborn defeat of its kernel, signs of anomaly of its development take place: reduction of the sizes of a kernel, reduction of number and structural change of cells etc. As a rule, such changes are noted against the background of inflammatory process in tissue of a brain, and defeat of a kernel of a facial nerve often happens separately.
Hemorrhages to the area of nervous trunks, their stretching and bruises as a result of a bruise in labor can cause vallerovsky regeneration of distal sites of nerves (see. Valera regeneration ). Besides, retrograde regeneration of axons and their cells can be the remote effect of the described damages. At defeat of a brachial plexus structural change and death of cells of front horns of a spinal cord of the corresponding segments of cervical and chest department of a spinal cord can take place.
A clinical picture
On localization of process allocate the following forms of flaccid paralyzes: damages of motor cranial nerves, plexites, defeats of peripheral nerves.
Damages of motor cranial nerves
One of the most often found defeats is defeat of a third cranial nerve (an ocular form), a cut can be isolated or be combined with damage of a facial or block nerve. Defeat of a third cranial nerve is clinically shown one - or bilateral paresis of internal muscles of an eye. One is usually observed - or bilateral ptosis (see). Squint in the first days of life when the child does not focus a look yet, happens hardly noticeable, then by the end 1 — the 2nd month it becomes clear and resistant. The ptosis can be accurately expressed in the first days after the birth and remain resistant or weaken in the first weeks and months of life that depends on weight of defeat. Usually the ptosis is combined with paresis of the muscle lifting up an eyeglobe (m. rectus superior). The isolated damages of other muscles of an eye are observed seldom. As a rule, the combination of paresis of the lateral direct muscle (innervated by the taking-away nerve) to paresis of the upper oblique muscle (innervated by a block nerve) and a ptosis (the caused damage to a third cranial nerve) takes place. Damage of muscles of an eye, being combined quite often with paresis of the mimic muscles (innervated by a facial nerve), does a child's face amimichny, a look slow-moving, and the wrong impression of a delay of its mental development can be made. If defeat of a facial nerve inborn, then paralysis of facial muscles is usually connected with defeat of a kernel of a facial nerve and is combined with other defects of development of a brain. Clinically paresis or paralysis of facial muscles of an inborn etiology is shown already at the newborn by weakness or lack of mimic movements of lips during the crying though the movements of muscles of the lower half of the face usually suffer to a lesser extent, than upper. At the same time reflex movements — suction, the search movements of oral muscles, their movements at a palmar roto - a head reflex do not suffer. Eyelids of the child during the closing of an eye are closed leaky. In hard cases the child cannot narrow eyes, at a nakhmurivaniye of a forehead skin gathers in folds only on one its party. Inflation of a cheek is impossible or weakened on the party of defeat, the child cannot squeeze a lip. The person at a quiet condition of muscles is a little asymmetric, but the slightest mimic movement does asymmetry accurate.
At inborn bilateral defeat of kernels or branches of a facial nerve the person completely amimichno, corners of lips and an under lip droop, the upper part of the face is not mobile; such defeat is often combined also with damage of the nerves innervating muscles of an eye (fig. 3).
Intranatal defeat of a facial nerve usually unilateral (fig. 4). At the same time the mimic movements on one half of the face are broken, and flavoring sensitivity on the half of language of the same name does not suffer.
most often occur At newborns traumatic defeats of a brachial plexus, usually unilateral. They have several forms.
Upper type of a humeral plexitis (fig. 5) — Dyushenn's form — Erba (see. Dyushenna-Erba paralysis ) — arises at traumatic defeat of the V—VI cervical roots or an upper trunk of a brachial plexus. Paresis or paralysis extends to a deltoid muscle (that sharply limits a possibility of lifting of a shoulder), to a biceps of a shoulder and a humeral muscle (that causes weakness of flexion function of a shoulder), to a humeroradial muscle and an instep support of a shoulder (the child cannot bend a hand in an elbow joint, carry out rotation — supination of a forearm of a knaruzha, to bend fingers). Muscles of a gipotonichna, their atrophy and lag in growth quickly develops. Rough disorders of sensitivity usually do not come to light. The handle of the child freezes up along a body, its immovability, and more senior children have a lag in growth and a hypotrophy are evident at once. The privodyashche-rotational contracture in a shoulder joint and flexion and pro-national ion — in radiocarpal can early develop.
The lower humeral plexitis Dezherin-Klyumpka (see. Dezherin-Klyumpka paralysis ) arises at defeat of the VIII cervical and I chest root or lower trunk of a brachial plexus. Quite often along with an injury of these roots the fracture of a humeral bone and an akromion takes place. At paralysis Dezherin-Klyumpka paralyzed there are muscles innervated elbow and median by nerves. The brush of the child is unbent, its bending, as well as bending of fingers, is weakened or it is impossible, supination of a brush as well as at Dyushenn's paralysis — Erba, is limited or impossible, is absent or bending in an elbow joint is weakened. Disturbance of sensitivity is localized on an inner surface of a shoulder and forearm. Atrophies of muscles, a qualitative change of electroexcitability, a growth inhibition of a hand, and later — contractures are observed. On the party of a plexitis Bernard's syndrome — Horner is noted (see. Bernard-Horner syndrome ).
The described forms of traumatic plexites separately meet seldom. Usually traumatic patrimonial defeats have the mixed character. At the same time at the child osteoporosis of a humeral bone and shovel very much can early develop, the joint crack of a shoulder joint is expanded.
Great diagnostic value has emergence of the phenomena of a plexitis right after the birth and existence of instructions on difficult childbirth, is frequent with artificial intervention. It is necessary to differentiate plexites with pseudoparalyses of Paro which are observed in the first weeks of life at inborn syphilis (see) and at which the passive movements are sharply painful, and paralyzes have sluggish character. Changes of bones — syphilitic an osteochondritis are the cornerstone of these paralyzes, the swelling of joints and crepitation is often noted.
Infectious, intoksikatsionny and traumatic defeats of a brachial plexus in the post-natal period of life are observed seldom.
Treatment of all forms of children's flaccid paralyzes should be begun perhaps earlier. At all forms of a disease vitamin therapy shall be appointed: vitamins B 1 , In 6 , In 12 in the standard doses. Pyrogenal (from 30 to 400 MPD, gradually raising a dosage, only 25 — 30 injections) actively promotes a miyelinoobrazovaniye, increases intensity of oxidizing processes in nervous cells.
Are applied Galantaminum (0,5 — 1,0 ml of 0,25% of solution intramusculary daily, only 20 — 25 injections), Dibazolum inside (on 0,001 g 2 times a day within 2 — 3 months), an ambenonium chloride in tablets (on 0,001 g 2 times a day within 2 — 3 months) etc. At defeat of a brachial plexus massage is carried out, to lay down. the physical culture and treatment by situation — a hand of the child keeps within for 1,5 — 2 hours on the special tire. The shoulder is located in a condition of outside rotation, assignment and extension; a forearm — at right angle in relation to a shoulder; the brush is straightened or is established in the provision of an easy ekstenziya, fingers — easy bending. Such laying is carried out 3 — 4 times a day on 1kh/2 — 2 hours, in hard cases the hand of the child stays overnight on the tire.
Physiotherapeutic treatment is carried out, since second week of life.
At defeat of a facial nerve and brachial plexus for rendering soothing, resorptional action and for improvement of blood circulation the area of defeat is irradiated with a small lamp solyuks or Minin's lamp 10 — 15 min. by 2 — 3 times a day. At a hematoma or its residual phenomena carry out UVCh-therapy with power no more than 15 W on 5 min. daily prior to 5 — 6 procedures. With 10 — the 15th day it is possible to apply applications of paraffin, ozokerite on a zone of defeat (a salfetno-application technique), hot wrappings of an extremity. With 3 — the 4th week the thermotherapy is alternated on days to an electrophoresis of medicinal substances (1 — 2% of solution of potassium iodide, lidaza) by a cross and longitudinal technique.
For improvement of conductivity and excitability of nervous trunks and for prevention of an atrophy of muscles with 3 — the 4th month carry out Nivalinum - or Galantaminum electrophoresis, an inductothermy) (a dosage sredneteplovy) it is longitudinal on an extremity with the subsequent electrostimulation of muscles of a hand the harmonic modulated currents. Electrostimulation) muscles currents of low frequency appoint to children 1 years are more senior. At defeat of a facial nerve electrostimulation of mimic muscles and an electrophoresis on the person are carried out only in the absence of elektrodiagiostichesky and a wedge, signs of a contracture. Electrostimulation of muscles is contraindicated at epilepsy with frequent attacks, at sharp overexcitation of the child. In the absence of contraindications electrostimulation shall be carried out to children 1 years in each subsequent course of treatment are more senior.
At the residual phenomena of paresis of muscles children from 3-year age can carry out ultrasonic therapy for stimulation of regeneration of a nerve; intensity of influence small (0,05 — 0,2 W/cm 2 ), pulsed operation, radiating surface of an ultrasonic head of 1 and 4 cm 2 (at impact respectively on the face and a hand), duration of influence is 3 — 5 min. on the person and 10 min. on a hand, on a course of treatment of 8 — 12 procedures. During this period mud cure, the general mineral (radonic, hydrosulphuric, etc.) bathtubs, an underwater shower massage is shown. Efficiency water - and thermotherapies increases at a combination to an electrotherapy.
Sanatorium treatment is carried out to children 3 years on mud and balneol are more senior. resorts (Anapa, lake. Bitter, Jalal-Abad, Dzhermuk, Druskinpnkay, Yevpatoria, lake of Karachi, Odessa, Pyatigorsk, Tsqaltubo).
At inborn post-natal defeat of kernels of facial and oculomotor nerves, and also front horns of a spinal cord adverse — persistent paralysis. Not rough traumatic defeats of a facial nerve of an intranatal etiology can be eliminated at the child during the first trekhchetyrekh of weeks of life, however the distortion of the person at a smile or crying can remain long time. The possibility of a smykaniye is recovered a century much quicker.
The forecast at the plexites caused by stretching of nervous trunks, favorable. At rough traumatic damage of a brachial plexus the forecast is usually worse — recovery of activity of muscles of an upper extremity can occur only at not severe injury and early, from the first days of life the begun treatment.
the Prevention of diseases and intoxications of mother during pregnancy, the balanced diet, the hygienic mode are a basis of prevention of pre-natal defeats of a nervous system of the child. Overseeing by mother during pregnancy, the early room in a hospital in the presence of aberrations in its state or in the provision of a fruit, the correct and timely delivery is of great importance for prevention of a birth trauma.
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