How does infantile cerebral palsy manifest in different forms and what complications can there be?

Childhood disability is increasing by 10% annually. Worldwide, diseases of the nervous system in children are one of the leading causes of disability. Children with cerebral palsy make up 24% of the structure of childhood neurological disabilities.

Cerebral palsy is one of the most severe consequences of perinatal damage to the nervous system.

What is Cerebral Palsy?

Cerebral palsy is the result of brain damage that occurs during pregnancy, childbirth and during the first 28 days of a baby's life. The disease is manifested by movement disorders, speech disorders, psyche and perception of the surrounding world, which do not progress, but can only be partially corrected and restored.

For modern medicine, cerebral palsy is a complex disease that is difficult to treat, despite its scientific and practical achievements.

The manifestations of cerebral palsy have been known for a long time, since 1843, when they were first described by Little. In those days, it was called Little's disease. The modern name was proposed by Sigmund Freud, and it rather accurately characterizes the manifestations of the disease.

Factors contributing to the development of cerebral palsy

Effects on the fetus during pregnancy:

the mother has serious diseases that may adversely affect the development of the unborn child;
complications of the course of pregnancy;
hypoxia, infections, toxins and other factors that can cause the child to develop abnormally.

Factors affecting the baby at the time of delivery:

asphyxia arising during childbirth;
birth injury.

Impact on the child during the neonatal period:

various injuries;
poisoning of the body;
infections;
lack of oxygen in the child's body.

Types of cerebral palsy

Forms of cerebral palsy by clinical manifestations:

Double hemiplegia.
Spastic diplegia, also called Little's syndrome.
Hemiparetic or spastic hemiplegia.
Hyperkinetic.
Atonic-astatic.

During the course of the disease:

Early stage. Develops in the first four months of life. It is characterized by a severe general condition of the baby, a malfunction of the internal organs caused by a malfunction of nervous regulation (giving signals to action from the nervous system to the organs), increased intracranial pressure, nystagmus (involuntary eye movement), seizures and movement disorders.
Initial stage (chronically residual). It starts at 5 months and lasts up to 4 years of age. It proceeds against the background of residual phenomena after the transferred pathology with the formation of persistent neurological disorders.
Late residual stage (final). The stage when the wrong motor stereotypes with contractures and deformities are finally formed.

According to the severity of the process

Easy degree. With this degree, independent movement and self-service skills are possible.
Average degree. Children require partial mobility and self-care assistance.
Heavy. Children are completely dependent on the people around them.

There is another classification for assessing motor disorders that occur in cerebral palsy. This is an international classification of motor (motor) functions, a world standard that is used all over the world to assess the level of movement disorders in children, taking into account their capabilities and needs for devices that help to move.

This classification includes 5 levels:

The child moves without assistance and has no restrictions.
Can move around without assistance within the premises.
The child moves using assistive devices (walkers, crutches).
Moves in a wheelchair. Independent movement is limited.
Movement is severely restricted.

Children and teenagers of the second level cannot run and jump like children of the first level. They need special devices to help them get around when they go a long way out into the street (wheelchair, handrails for descending or climbing stairs).

Children of the third level need special devices both for moving around the house and for moving around the street and in public places.

Children of the fourth level can sit if supported, they move in an electronically controlled stroller.

Level 5 children cannot sit and move without help or special technology.

In addition to movement disorders, children with cerebral palsy in 90% of cases have changes in the structure of the brain.

There are two groups of changes.

Death and destruction of brain cells.
Violation, abnormal development of the brain.

Early detection of the disease is especially important for the prognosis and preparation of a rehabilitation program. Most children with cerebral palsy can be diagnosed as early as the first year of life.

Early manifestations of cerebral palsy

The first signs that allow one to suspect the development of cerebral palsy in a child can be seen even in the first year of life.

Delayed development of the motor sphere, speech and psyche of the baby.
Delay or complete absence of extinction of innate reflexes.
Delayed development or complete absence of reflexes, which should be formed together with the motor development of the baby in the first year of life.
Impaired muscle tone.
Enhanced tendon reflexes.
The appearance of unnecessary involuntary movements and muscle contractions (synkinesis).
Formation of incorrect positions of the limbs.

In order to make a diagnosis as early as possible, the pediatrician and the neurologist must clearly know the sequence and be able to correctly assess the neuropsychic development of the baby in the first year of life.

The child's motor development proceeds in a certain sequence, while innate reflexes fade away and straightening reflexes are formed, the child learns to keep balance. It is the violation of the timely development sequence that is one of the earliest signs of cerebral palsy.

When assessing development, it is also necessary to take into account that the rates of development of premature babies are several months behind (depending on the degree of prematurity) from the rates of development of full-term babies.

Another early sign of cerebral palsy is muscle tone disorder. The muscles of a healthy newborn are in physiological hypertonicity (increased tone), so the arms and legs of the baby are always bent, and the fists are compressed and it is rather difficult to straighten and unclench them. This condition lasts up to 3 - 4 months.

If increased muscle tone persists after 4 months, this indicates perinatal damage to the central nervous system (from week 28 of pregnancy to the first week of life) and the threat of cerebral palsy. Decreased muscle tone in a newborn is also a sign of perinatal damage to the central nervous system, but in premature babies, it can be considered the norm in the first few months of life.

Early diagnosis of cerebral palsy is possible and should be carried out in order to start a complex of rehabilitation treatment as early as possible and prevent the development of severe forms of cerebral palsy, significantly reduce the risk of complications and disability.

How does infantile cerebral palsy manifest?

The clinical manifestations of cerebral palsy depend on its form.

Spastic diplegia

This form is considered the most common type of cerebral palsy, it accounts for 60 - 65% of all cases of the disease. Moreover, 70% of children suffering from spastic diplegia were born prematurely, and more than 70% have a change in the brain in the area of the ventricles (periventricular changes).

The main manifestations of spastic diplegia:

Tetraparesis. Translated from Greek means "weakening". This is a partial paralysis of both arms and legs, with this shape the legs suffer more than the arms.
The muscle tone of the arms and legs, the whole body and tongue is sharply increased.
There are no congenital motor reflexes, or they are there, but very weak. Reflexes, which are responsible for the position of the body (tonic), are increased, due to which the development of reflexes that bring the body to a normal position from an unnatural one (setting) is disturbed.
Tendon reflexes are increased, spontaneous, convulsive movements (clonuses), there are reflexes that should not be normal (pathological). For example, the Babinsky reflex, caused in a healthy baby up to four months of age.
An impaired gait in which the legs cross one another. This is called a spastic gait. At the same time, 50% of patients can walk on their own, 30% move, relying on special devices, such as crutches, the rest move in a wheelchair.
When you try to put the patient in an upright position, the so-called scissors symptom appears - legs extended and crossed.
Incorrect position and curvature of the feet. Support on toes, the child walks on toes, the feet are curved inward or outward.
Limited movement in the joints of the arms and legs, the so-called contracture.
Violation of speech, pronunciation.
70% of children with cerebral palsy have various vision problems.

Hemiparetic form

This form accounts for 15 - 18% of all cases of cerebral palsy.

Birth trauma is a common cause of development. The hemiparetic form often develops in full-term and post-term babies.

The main manifestations of hemiparetic cerebral palsy are given below.

Unevenly dilated lateral ventricles, atrophy of cells of the cerebral hemispheres.
Spastic hemiparesis. Muscle tone and tendon reflexes are enhanced on one side only.
The hand suffers more than the leg.
The arm and leg on the affected side are shorter and thinner (thinner) than healthy ones.
Violation of gait, in which the leg on the side of the lesion, when moving one step, seems to describe a semicircle, at this time the sore arm is bent at the elbow and pressed to the body. This gait is called the hemiparetic or Wernicke-Mann gait.
Curvature of the feet and contractures on the affected side.
Epilepsy (convulsive seizures) develops in 35% of patients due to brain damage.

Hyperkinetic form

This form often develops as a result of brain damage with excess bilirubin, which is often formed during the Rh-conflict of the blood of the mother and the fetus (the mother has a negative Rh, and the fetus has a positive). In full-term, the brain is affected when the level of bilirubin in the blood reaches 428 μmol / L and higher, in premature infants - 171 μmol / L and higher.

Also, the cause of the development of this form can be hypoxia (prolonged lack of oxygen in the fetus) as a result of ischemia (impaired blood circulation in the brain).

The main manifestations of the hyperkinetic form of cerebral palsy are as follows.

Hyperkinesis or involuntary movements and body positions. Muscle tone disorders: increased or decreased tone in all muscles, or dystonia (different tone in different muscle groups).
At first, hyperkinesis occurs in the tongue at the age of 2 - 3 months, then appear on the face at 6 - 8 months, and after two years they are already well expressed. Such children have chorea (it seems that the child is grimacing and making faces) and athetosis or slow convulsions. All these manifestations intensify when the child is worried, and disappear during sleep.
The presence of pathological and high tendon reflexes.
Violation of the vegetative system, which is manifested by vegetative crises (incomprehensible, unreasonable attacks of panic and fear), fever.
Speech is impaired in 90% of patients. She is indistinct, unintelligible, expressionless.
Hearing problems in the form of sensorineural hearing loss are observed in 30 - 80% of patients.

Atonic-astatic form

At an early age it is 10 - 12%, in the older it occurs in 0.5 - 2%.

With this form, the frontal lobes, the cerebellum are affected.

The main manifestations of the atonic-astatic form of cerebral palsy are expressed in the symptoms indicated below.

Decreased muscle tone. Common muscular hypotonia is characteristic from birth.
Impaired coordination of movements (ataxia), inability to determine the range of motion (hypermetria), tremors or tremors.
Out of balance.
Paresis.
The range of motion in the joints is increased, hyperextension is characteristic.
Tendon reflexes are increased.
Speech impairment occurs in 65 - 70% of patients.

Double hemiplegia

This form is the most severe variant of cerebral palsy with a poor prognosis. With her, brain changes are pronounced, as are the main manifestations.

Severe tetraparesis: both arms and legs are affected, and the arms are more affected.
Severe, gross movement disorders. The child is unable to hold his head, fix his gaze, roll over, sit, hands and feet practically do not move.
Tendon and tonic reflexes are sharply strengthened, there is no protective reflex. The connection of the brain with the muscles of the pharynx, tongue, soft palate and vocal cords is disrupted, which is manifested by impaired speech, swallowing and voice. All these are manifestations of the so-called bulbar pseudosyndrome. Also, patients are worried about constant salivation.
Mental development and intelligence suffers. Children have moderate or severe mental retardation.
Speech is absent or significantly underdeveloped.

With cerebral palsy, in addition to motor disorders, complications associated with disruption of the work of other organs and systems often develop.

Complications of cerebral palsy

1) Orthopedic and surgical complications. These include disorders of the hip joints, curvature of the feet, forearms and knee joints.

2) Epileptic syndrome, manifested by attacks of various seizures, is especially often observed in hemiparetic form.

An urgent problem for children with cerebral palsy is the presence of epilepsy (convulsive seizures), which significantly complicate their already difficult life. Convulsions aggravate the course of cerebral palsy, there are certain difficulties with rehabilitation and, in addition, pose a danger to life. Among patients with cerebral palsy, there are various forms of epilepsy, both extremely severe and benign with a favorable prognosis.

3) Cognitive impairment. These include impaired memory, attention, intelligence and speech.

The main speech disorders in cerebral palsy are a violation of pronunciation or dysarthria, stuttering, lack of speech with preserved hearing and intelligence (alalia), delayed speech development. Motor and speech disorders are interrelated, therefore each form of the disease is characterized by specific speech disorders.

4) Visual and hearing impairment.

Treatment and rehabilitation of the consequences of infantile cerebral palsy

Cerebral palsy is difficult to treat and the later the diagnosis is made, the less chances of recovery and correction of the disorders. The most favorable range for complex treatment and correction is considered to be the age period from one month to three years, and it is very important to diagnose and begin treatment in this period.

Cerebral palsy treatment is a long process. The method of treatment is made by a group of doctors working together. The group includes a pediatric neurologist, physical therapy doctor, orthopedist, speech therapist-defectologist, educator and psychologist. When compiling a methodology, the child's age, form and severity of the disease are taken into account. Each child with cerebral palsy needs an individual approach.

The main complex of rehabilitation treatment for cerebral palsy consists of three components.

Medical rehabilitation, which includes the prescription of drugs, physiotherapy exercises and massage, the use of special therapeutic and stress suits and pneumosuits, physiotherapy, orthopedic and surgical treatment, treatment using orthoses - devices that help to make correct movements in the joints.
Adaptation in the social environment. Teaches children to navigate, adapt and behave adequately in society.
Psychological, pedagogical and speech therapy correction, which consists of classes with a psychologist, teacher, speech therapist, occupational therapy, teaching the simplest skills and classes with the family.

Of the methods of medical rehabilitation, kinesiotherapy or motion therapy, drugs and physiotherapy are most often used.

Kinesiotherapy

This is a method of correcting movement disorders and reducing or eliminating the consequences of a sedentary lifestyle.

Types of exercises used in kinesiotherapy.

Gymnastic. These are exercises that help develop muscle strength, restore joint mobility, and develop coordination of movements. They are classified as active and passive; static and dynamic.
Sports and applied. This type of exercise is used to restore complex motor skills.
Physiotherapy. It teaches voluntarily and dosed to strain and relax muscles, maintain balance, normalize muscle tone and help get rid of synkinesis, increase muscle strength and restore motor skills.
Mechanotherapy. Various exercises using simulators and specially designed devices.

Massage

The massage normalizes body functions, improves blood and lymph circulation, and optimizes the oxidation and recovery processes in the muscles. In patients with cerebral palsy, various massage techniques are used. The best effect is observed after classical therapeutic massage, segmental massage and massage of the cervical-collar zone, circular trophic and acupressure massage, sedative and tonic massage, as well as massage performed according to the Monakov system.

Dynamic proprioceptive correction (DPC)

The method is based on the use of a modified "penguin" space suit for the treatment of patients with cerebral palsy over the age of three. For treatment, Adele, Regent and Spiral therapeutic-load suits are used. The duration of the course is 10 - 20 days, the duration of one lesson is 1.5 hours a day. In general, it is necessary to carry out 3-4 courses per year.

The KDP method eliminates pathological (abnormal) posture, improves upright posture support and motor function. Duodenum is contraindicated for up to three years in diseases of the spine, hip joints and during exacerbation of diseases.

Drug therapy

It is a necessary component of the rehabilitation treatment of cerebral palsy.

Several groups of drugs are used for treatment.

Neurotrophic and nootropic drugs (Cortexin, Pantogam, Phenibut, Picamilon).
Drugs that improve blood circulation and microcirculation of the brain (Actovegin, Trental).
Drugs that improve the metabolism in the nervous tissue, have a resorption effect and restore damaged cells (Lidaza).
Drugs that reduce intracranial pressure (Diacarb).
Anticonvulsants (Depakine).
Drugs that normalize muscle tone (Mydocalm, Neurin).
B vitamins and Aevit.

Since 2004, botulinum toxin A has been successfully used in Russia for the treatment of spastic and distal forms of cerebral palsy, which relieves spasticity and stiffness of muscles, increases movement in joints and improves mobility of the child, and also eliminates pain. In general, the use of botulinum toxin improves the patient's quality of life, facilitates his care.

The effect of botulinum toxin treatment is more pronounced at an early start. The most optimal age for botulinum therapy is considered to be from 2 to 7 years.

Physiotherapy

The purpose of physiotherapy is to increase the efficiency of the cells of the nervous and muscular systems not destroyed by damaging factors, to reduce pain and edema.

Types of physiotherapy used for cerebral palsy:

electrotherapy;

Electrophoresis with various drugs that decrease or increase muscle tone, depending on the situation.
Electrical stimulation of muscle groups. A relaxing or stimulating technique is used.
Magnetic fields.

Electrotherapy is not prescribed for patients who have seizures.

thermal, warming procedures (applications of paraffin and ozokerite);
mud therapy (wraps and mud baths);
hydrotherapy (pools, pearl baths, water massage);
acupuncture;
treatment with natural factors. This is a spa treatment prescribed for children over three years of age, subject to 2 conditions: the absence of seizures and increased intracranial pressure.

Surgical treatment in patients with cerebral palsy is often used to eliminate contractures, curvature of the feet and upper limbs.

Neurosurgical treatment is usually used to correct spasticity or high tone in cerebral palsy.

Orthosis therapy

This is a treatment with the use of special devices - orthoses, designed to give the correct position of the musculoskeletal system and correct disorders and curvatures. Splints and corsets are examples of orthoses.

An important component of the complex of rehabilitation of the consequences of cerebral palsy is psychological and pedagogical correction.

Basic principles of psychological and pedagogical correction.

Complex character, simultaneous correction of speech, psyche and movement disorders.
Early start of correction.
Logically consistent principle of corrective work.
An individual approach to the personality of the child.
Observation and control of the dynamics of psychoverbal development.
Joint work and unity of the correction carried out with the child and his immediate environment, that is, with the family.

Sensory education, which develops a full-fledged perception of the surrounding reality by the child, is of great importance in correctional work. It develops all types of perception (visual, auditory, tactile-motor), forming in the child a complete understanding of the properties of the things and objects around him.

The main tasks of speech therapists in working with children with cerebral palsy

Development of verbal communication and improvement of the intelligibility of spoken words.
Restoration of normal tone and movement of the speech apparatus.
Development of voice and speech breathing.
Synchronization of breath, voice and speech.
Correction of incorrect pronunciation.

Early diagnosis of cerebral palsy, adequate and timely medical and social rehabilitation and psychological and pedagogical correction significantly increase the effectiveness of the complex of rehabilitation therapy. The result is a decrease in disability, successful social adaptation and an improvement in the life of patients with cerebral palsy.