Cerebral palsy is a concept that unites a group of motor disorders that occur as a result of damage to various brain structures in the perinatal period. Infantile cerebral palsy may include mono-, hemi-, para-, tetra- paralysis and paresis, pathological changes in muscle tone, hyperkinesis, speech disorders, unsteadiness of gait, movement coordination disorders, frequent falls, lagging of the child in motor and mental development. With cerebral palsy, intellectual disorders, mental disorders, epilepsy, hearing and vision disorders can be observed. Disease is diagnosed mainly according to clinical and anamnestic data. The algorithm of examination of a child is aimed at identifying concomitant pathology and excluding other congenital or postpartum pathology. People should undergo rehabilitation therapy for life, receive medication, surgical and physiotherapy treatment as necessary.
G80 Cerebral palsy
According to world statistics, disease occurs with a frequency of 1.7-7 cases per 1000 children under a year. In the USA, according to various data, this figure is 2.5-6 cases per 1000 children. Among premature infants, the incidence is 10 times higher than the average. According to recent studies, about 40-50% of children were born as a result of premature birth.
If we talk about chronic diseases of childhood, then in modern pediatrics, cerebral palsy is one of the leading problems. Among the reasons for the increase in the number of patients, not only environmental degradation is rightly called, but also the progressive development of neonatology, which now allows nursing infants with various pathologies, including premature newborns weighing from 500g.
According to modern concepts, pathology occurs as a result of the impact on the child’s central nervous system of various damaging factors that cause the improper development or death of individual parts of the brain. Moreover, the effect of these factors occurs in the perinatal period, i.e. before, during and immediately after the birth of a child (the first 4 weeks of life). The main pathogenetic link in the formation is hypoxia, the development of which is caused by various causal factors. First of all, hypoxia affects those areas of the brain that are responsible for maintaining balance and providing motor reflex mechanisms. As a result, muscle tone disorders typical, paresis and paralysis, pathological motor acts occur.
The etiological factor, acting during intrauterine development, is a different pathology of pregnancy:
- fetoplacental insufficiency
- premature placental abruption
- nephropathy of pregnant
- rhesus conflict
- the threat of termination of pregnancy
Somatic diseases of the mother (diabetes mellitus, hypothyroidism, congenital and acquired heart defects, arterial hypertension) and injuries suffered by a woman during pregnancy can also cause the development of disease.
Risk factors for the development of pathology affecting the child during childbirth include:
- pelvic presentation of the fetus
- rapid labor
- premature labor
- narrow pelvis
- large fruit
- excessively strong labor activity
- prolonged labor
- discoordinated labor activity
- a long anhydrous period before childbirth.
Only in some cases, birth trauma is the only cause. Often, severe childbirth, leading to the occurrence, becomes a consequence of an already existing intrauterine pathology.
The main risk factors for the appearance in the postpartum period are asphyxia and hemolytic disease of the newborn. Asphyxia of a newborn resulting may be associated with aspiration of amniotic fluid, various lung malformations, and pregnancy pathology. A more common postpartum cause is toxic brain damage in hemolytic disease, which develops as a result of blood incompatibility or immunological conflict of the fetus and mother.
In accordance with the location of the affected area of the brain in neurology, disease is classified into 5 types. The most common form is spastic diplegia. According to various data, disease of this form is from 40 to 80% of the total number of cases. At the heart of this form is the defeat of the motor centers, leading to the development of paresis, more pronounced in the legs. When the motor centers of only one hemisphere are damaged, a hemiparetic form occurs, manifested by paresis of the arm and leg on the side opposite to the affected hemisphere.
In about a quarter of cases, pathology has a hyperkinetic form associated with damage to subcortical structures. Clinically, this form is manifested by involuntary movements — hyperkinesis, which increases with excitement or fatigue of the child. With disorders in the cerebellum, an atonic-astatic form develops. This form is manifested by violations of statics and coordination, muscle atony. It accounts for about 10% of cases of this disease.
The most severe form is called double hemiplegia. In this variant, disease is a consequence of total damage to both hemispheres of the brain, leading to muscle rigidity, due to which children are unable not only to stand and sit, but even to hold their heads independently. There are also mixed variants, including clinical symptoms characteristic of different forms. For example, a combination of a hyperkinetic form with spastic diplegia is often observed.
Cerebral palsy symptoms
Cerebral palsy can have a variety of manifestations with varying degrees of severity. The clinical picture and its severity depend on the localization and depth of damage to brain structures. In some cases, cerebral palsy is noticeable already in the first hours of a child’s life. But more often the symptoms become apparent after a few months, when the child begins to lag significantly in neuropsychiatric development from the norms accepted in pediatrics. The first symptom may be a delay in the formation of motor skills. A child does not hold his head for a long time, does not turn over, is not interested in toys, cannot consciously move his limbs, does not hold toys. When trying to put a child on his feet, he does not put his foot on the full foot, but stands on tiptoe.
Paresis in cerebral palsy can be only in one limb, have a unilateral character (arm and leg on the side opposite to the affected area of the brain), cover all limbs. Insufficient 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 (dysphagia). Often cerebral palsy is accompanied by a significant increase in muscle tone. Pronounced spasticity in cerebral palsy can lead to complete immobility of the limb.
In the future, paretic limbs lag behind in physical development in children, as a result of which they become thinner and shorter than healthy ones. As a result, skeletal deformities typical are formed (scoliosis, chest deformities). In addition, disease occurs with the development of joint contractures in paretic limbs, which exacerbates motor disorders. Motor disorders and skeletal deformities in children lead to the appearance of 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 motor acts: turns or nods of the head, twitching, the appearance of grimaces on the face, pretentious poses or movements. The atonic-astatic form is characterized by discoordinated movements, instability when walking and standing, frequent falls, muscle weakness and tremor.
With disease, strabismus, functional disorders of the gastrointestinal tract, disorders of respiratory function, urinary incontinence can be observed. Approximately 20-40% of cases of cerebral palsy occur with epilepsy. Up to 60% of children have vision problems. Hearing loss or complete deafness is possible. In half of cases, cerebral palsy is combined with endocrine pathology (obesity, hypothyroidism, growth retardation, etc.).
Often disease is accompanied by varying degrees of oligophrenia, mental retardation, perception disorder, learning disabilities, behavioral abnormalities, etc. However, up to 35% of children have normal intelligence, and in 33% of cases of cerebral palsy, intellectual disabilities are mild.
Cerebral palsy is a chronic, but not progressive disease. As the child grows and develops his central nervous system, previously hidden pathological manifestations may be revealed, which create a feeling of the so-called “false progression” of the disease. The deterioration of the condition of a child may also be due to secondary complications: epilepsy, stroke, hemorrhage, anesthesia or severe somatic disease.
There are no special diagnostic criteria for cerebral palsy yet. However, some typical symptoms immediately attract the attention of a pediatrician. These include: a low score, set on the Apgar scale immediately after the birth of the child, abnormal motor activity, muscle tone disorders, the child’s lag in psychophysical development, lack of contact with the mother. Such signs always alert doctors regarding cerebral palsy and are an indication for mandatory consultation of a child by a pediatric neurologist.
If cerebral palsy is suspected, a thorough neurological examination of the child is necessary. Electrophysiological examination methods are also used in the diagnosis of cerebral palsy:
- electromyography and electroneurography
- investigation of evoked potentials
- transcranial magnetic stimulation.
They help differentiate cerebral palsy from hereditary neurological diseases that manifest themselves in the 1st year of life (congenital myopathy, Fredreich ataxia, Louis-Bar syndrome, etc.). The use of neurosonography and MRI of the brain in the diagnosis makes it possible to identify organic changes associated with cerebral palsy (for example, optic nerve atrophy, foci of hemorrhages or ischemia, periventricular leukomalacia) and diagnose brain malformations (microcephaly, congenital hydrocephalus, etc.).
A complete diagnosis may require the participation of a pediatric ophthalmologist, a pediatric otolaryngologist, an epileptologist, a pediatric orthopedist, a speech therapist and a psychiatrist. If necessary, to differentiate from various hereditary and metabolic diseases, appropriate genetic studies and biochemical analyses are used.
Unfortunately, while disease belongs to an incurable pathology. However, rehabilitation measures initiated in a timely manner, comprehensively and continuously carried out can significantly develop motor, intellectual and speech skills available to a child with cerebral palsy. Thanks to rehabilitation treatment, it is possible to compensate as much as possible for the neurological deficit existing, reduce the likelihood of contractures and skeletal deformities, teach the child self-service skills and improve his adaptation. The most active brain development, cognitive process, skill acquisition and learning occur at the age of 8 years. It is during this period that in case of cerebral palsy, it is necessary to make maximum efforts for rehabilitation.
The program of complex rehabilitation therapy is developed individually for each patient. It takes into account the localization and severity of brain damage; the presence of concomitant cerebral palsy, hearing and vision disorders, intellectual disorders, epileptic seizures; individual capabilities and problems of a child with cerebral palsy. It is most difficult to carry out rehabilitation measures when cerebral palsy is combined with cognitive impairment (including as a result of blindness or deafness) and intelligence. For such cases of cerebral palsy, special techniques have been developed that allow the instructor to establish contact with the child. Additional difficulties in the treatment arise in patients, in which active stimulating therapy of cerebral palsy can cause the development of complications. For this reason, children with cerebral palsy and epilepsy should undergo rehabilitation using special “soft” methods.
The basis of rehabilitation treatment is physical therapy and massage. It is important that children have them daily. For this reason, parents of a child with cerebral palsy should master the skills of massage and physical therapy. In this case, they will be able to independently engage with the child in the period between courses of vocational rehabilitation of cerebral palsy.
For more effective physical therapy and mechanotherapy with children suffering from cerebral palsy, special devices and devices are available in the appropriate rehabilitation centers. Of the latest developments in this field, pneumocombinizones have been used in the treatment, fixing joints and providing muscle stretching, as well as special suits that allow for some forms of cerebral palsy to develop the correct motor stereotype and reduce muscle spasticity. Such means help to maximize the compensatory mechanisms of the nervous system, which often leads to the development of new movements by a child, previously inaccessible to him.
Rehabilitation measures for cerebral palsy also include so-called technical means of rehabilitation: orthodontics, inserts into shoes, crutches, walkers, wheelchairs, etc. They make it possible to compensate for motor disorders present in cerebral palsy, shortening of limbs and deformities of the skeleton. It is important to individually select such tools and teach a child with cerebral palsy the skills of using them.
Cerebral palsy treatment
Treatment of cerebral palsy with medications is mainly symptomatic and is aimed at relieving a specific symptom of cerebral palsy or complications that have arisen. Thus, in combination with epileptic seizures, anticonvulsants are prescribed, with increased muscle tone — antispasmodic drugs, with cerebral palsy with chronic pain syndrome — painkillers and antispasmodics. The drug therapy of cerebral palsy may include nootropics, metabolic drugs (ATP, amino acids, glycine), neostigmine, antidepressants, tranquilizers, neuroleptics, vascular drugs.
Indications for surgical treatment are contractures formed as a result of prolonged muscle spasticity and limiting the patient’s motor activity. Most often, with cerebral palsy, tenotomies are used, aimed at creating a supporting position of the paralyzed limb. Bone elongation, tendon transplantation, and other operations can be used to stabilize the skeleton. If cerebral palsy is manifested by gross symmetrical muscle spasticity, leading to the development of contractures and pain syndrome, then a spinal rhizotomy can be performed to interrupt the pathological impulses emanating from the spinal cord to a patient.
The methods of physiotherapy used in the treatment are perfectly combined with physical therapy and massage. They have proven themselves well in cerebral palsy
- electrical stimulation of nerves and muscles
- medicinal electrophoresis
- treatment thermal procedures
The use of shared baths with warm water in cerebral palsy reduces the severity of hyperkinesis and reduces muscle tone in spasticity. Of the water procedure, coniferous, oxygen, radon, turpentine and iodine-bromine baths, phytovannas with valerian are prescribed.
A relatively new way of treating cerebral palsy is animal therapy — treatment through communication between the patient and the animal. The most common methods of animal therapy today include hippotherapy (treatment using horses) and dolphin therapy of cerebral palsy. During such treatment sessions, an instructor and a psychotherapist work simultaneously with a child with cerebral palsy. The therapeutic effect of these techniques is based on:
- a favorable emotional atmosphere
- establishing a special contact between a patient with cerebral palsy and an animal
- stimulation of brain structures through intense tactile sensations
- gradual expansion of speech and motor skills.
Despite significant motor disorders, many children can be successfully adapted to society. Parents and relatives of a child with cerebral palsy play a huge role in this. But to effectively solve this problem, they need the help of specialists: rehabilitologists, psychologists and correctional teachers who directly deal with children with cerebral palsy. They are working to ensure that a child has mastered the self-service skills available to him as much as possible, acquired knowledge and skills appropriate to his capabilities, and constantly received psychological support.
Social adaptation in the diagnosis is greatly facilitated by classes in specialized kindergartens and schools, and later in specially created societies. Their visits expand cognitive opportunities, give a child and an adult the opportunity to communicate and lead an active life. In the absence of disorders that significantly limit motor activity and intellectual abilities, adults can lead an independent life. Such patients work successfully and can create their own family.
Prognosis and prevention
The prognosis for cerebral palsy directly depends on the form, the timeliness and continuity of rehabilitation treatment. In some cases, cerebral palsy leads to profound disability. But more often, through the efforts of doctors and parents of a child with cerebral palsy, it is possible to compensate for the existing disorders to a certain extent, since the growing and developing brain of children, including a child with cerebral palsy, has significant potential and flexibility, thanks to which healthy areas of brain tissue can take over the functions of damaged structures.
Prevention in the prenatal period consists in the correct management of pregnancy, which allows timely diagnosis of conditions threatening the fetus and prevent the development of fetal hypoxia. Subsequently, the choice of the optimal method of delivery and proper management of labor is important for the prevention of this disease.