RU2571528C2 - Method for rehabilitation of patients with infantile cerebral paralysis in form of spastic displegia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention is applicable for rehabilitation of patients with infantile cerebral paralysis (ICP) in the form of spastic displegia. A heat therapy, general and differentiated massage are followed by placing a child into a training apparatus which represents a system of flexible rods with an underarm support, and performing a three-staged combined exercises including: 4-6-minute introductory exercises, 17-20-minute basic exercises and 3-5-minute final exercises. The procedure involves doing combined passive and active exercises including breathing exercises, coordination exercises, relaxation technique, exercises to normalise posture and position of head and extremities, exercises to develop flexion and extension of upper and lower extremities in accordance with the patent claim.

EFFECT: method provides the deepest possible exposure covering the whole child's locomotor system, ensures the stable rehabilitation effect with using no complex accessory equipment, reduces a risk of complications, enables the rehabilitation even if the patient stays wheelchaired and lying, and has no age limits.

1 dwg, 2 ex, 4 tbl

Description

The invention relates to medicine, rehabilitation and can be used for the rehabilitation of patients with cerebral palsy (CRP) in the form of spastic diplegia.

Cerebral palsy (cerebral palsy) is a fairly common disease that leads to limited life and significantly reduces the quality of life of children [1, 2, 3, 4]. Rehabilitation in children with cerebral palsy in the form of spastic diplegia is complex. For many years, both domestic and foreign researchers have proposed various means of physical rehabilitation of people with disabilities with cerebral palsy, most of which are built on the principle of an ontogenetic sequence of exercises, that is, in a sequence corresponding to the development of the child’s movements from birth to the moment of gaining walking skill [5 , 6, 7]. However, the considered methods of physical rehabilitation of people with disabilities with cerebral palsy only allow temporary correction of motor disorders and often do not lead to the achievement of stable results [8]. One of the most difficult problems is the development of methods for correcting motor activity for patients with cerebral palsy with spastic diplegia, since the methods and means of physical development of children with disabilities are based on the specifics of the disease and the initial state of the patient’s body [10, 11, 12]. It has been established that motor disorders are successfully treated with movement. Therefore, with cerebral palsy, physiotherapy exercises (LFK) with the use of special simulators have proven themselves well. Hydrokinesiotherapy and horse riding have a good effect, but they are unsafe. The physical therapy complexes recommended in the methodological literature for patients with cerebral palsy with spastic forms are performed mainly in the initial position lying or sitting [13, 14]. They are often selected without taking into account the severity of motor and social restrictions, the psycho-emotional mood of children, which significantly increases the rehabilitation time [15, 16]. The lack of ability to maintain the vertical posture of patients with cerebral palsy with spastic diplegia violates the formation of natural statokinetic reflexes and the development of the child’s movements at the very early stages of development [17]. Disorders of the musculoskeletal system are manifested for the most part in a decrease in the performance of the upper limbs, supporting function of the lower extremities, and the limitation of the statokinetic capabilities of the spine, which severely limits the child's everyday abilities and impedes his social adaptation. A particular problem is the difficulty of the targeted development of motor capabilities in patients with musculoskeletal disorders whose natural development is slowed down. Insufficient physical rehabilitation leads to aggravation of perverse attitudes, the occurrence of contractures and deformations. Movement in children is one of the main physiological components, the normal formation and development of the body. A decrease in motor activity leads to a violation of the functions of all organs and systems of the body. Correction of such violations can be carried out by various means.

The most affordable and effective is the method of rehabilitation using a complex of special physical exercises [18].

Analysis of available literature sources showed that rehabilitation is mainly carried out with the help of auxiliary technical means, such as load-bearing (costumes "Adele", "Gravistat", "Cosmonaut"). In practice, the use of these suits proved to be difficult due to the large time interval when putting them on and taking off. On average, it was 30-35 minutes. A child with cerebral palsy was tired, and not having started classes, he developed emotional-volitional disorders, which later did not allow the use of this type of exposure. Therefore, the Gross simulator was used, which is a specialized suit equipped with elastic rods. The instructor placed the child in this suit and conducted the training, adjusting the load experimentally.

The disadvantages of this method were:

1. The impact of the load on the unprepared musculoskeletal system of the child, without taking into account his muscular tension;

2. The predominance of the fragmented nature of the load;

3. The occurrence of pain in places of contact with the suit due to inadequate load and increased muscle hypertonicity;

4. The complexity of using the suit, due to the complexity and duration of donning.

5. The age restrictions of the Gross simulator (up to 8 years of age) make it difficult to use it in children of primary school age (7-12 years) and older school age (12-18 years).

A known method developed by K. Bobat (1967) [19]. The known method has proved to be insufficiently effective in connection with the unsatisfactory state of the muscles of the chest. Optimum synergies between the muscles of the neck were not achieved, which made it possible to keep the head as close to the physiological state as possible. The tone of the pectoralis major muscles was slightly reduced, as a result of which the shoulder breeding was difficult. Decreased tone of the lumbar iliac muscles and rectus femoris. Large gluteal muscles were not trained enough, which in patients with cerebral palsy are hypotonic, hypotrophic (while the main function of the gluteal muscles is the verticalization of the musculoskeletal system). The position used did not sufficiently stimulate the relationship between the central nervous system and the central nervous system. The possibility of finding a child with cerebral palsy in this position to a small extent stimulated the immature vestibular apparatus.

A new technical task is to increase efficiency, due to the possibility of a deeper effect on the entire musculoskeletal system of the child, to obtain a stable rehabilitation effect without the use of complex auxiliary technical means while simplifying the method, and reducing complications.

To solve the problem in a method of rehabilitation of patients with cerebral palsy (CRP) in the form of spastic diplegia, which consists in acting on the musculoskeletal system, after heat treatment and the procedure of general and differential massage, the child is placed in a simulator, which is a system of elastic traction with supporting axillary grip and perform a set of exercises in three stages, including: introductory for 4-6 minutes, the main for 17-20 minutes and the final part for 3-5 minutes, and in the introductory part of the lesson they become inactive in the starting position (I.P.) while sitting, perform head tilts back and forth, 6-8 times, 2-3 sets, the pace is slow, making sure that the child does not jerk his head, all movements should be smooth, then I.P. sitting, they tilt their heads to the right and left, 6-8 times, 2-3 sets, the pace is slow, then they compress and unclench their fingers into fists, 10-12 times, 2-3 sets, the average pace, in I. P. sitting, hands on the hips, then perform clenching-unclenching of the fingers into fists with simultaneous flexion-extension in the elbow joints, 10-12 times, 2-3 sets, the pace is slow, breathing is arbitrary, after breathing in, raise your hands up, expiration - return to I.P., 4-6 times, 2-3 sets, average pace, next I.P. sitting, brushes to the shoulders, carry out circular rotation of the shoulder joints forward, then back, 6-8 times in each direction, 2-3 approaches, the pace is average, making sure that the movement is performed with the maximum possible amplitude, passing to I.P . lying on your back, arms along the body, performing alternate lifting of straight legs, 6-8 times, 2-3 approaches, the pace is slow, making sure that the leg does not bend at the knee, I.P. same, they perform bending of the leg in the knee, sliding alternately on the floor with the heel of each leg, 6-8 times, 2-3 approaches, the pace is slow, making sure that the heel does not come off the floor, then simultaneously slide with both heels, bending legs, 6-8 times, 2-3 sets, the pace is slow, while both heels should not be torn off the floor, then in I.P. place the cuffs in the armpits in the projection of the triceps muscles and hold the belts to prevent cuffs from slipping, the feet are fixed at one point, swinging the pelvis back and forth, 10-15 times, 3-4 approaches in each exercise, while eliminating painful sensations with using bending at the knees, at a slow pace, then swinging the pelvis left to right, 10-15 times, 3-4 approaches in each exercise, then bending in the hip joint with support on the feet with movement of 10-15 times, 3-4 approach in each exercise, while the instructor controls the support on the heel, then bend the legs in the knee and hip joints at the same time - squat, slow pace, 5-15 times, 3-4 approaches in each exercise, after which the right and left legs, bent at the knees, are raised slowly, the pace is slow , 10-15 times, with the reduction of the legs, the instructor insures against injuries the inner surfaces of the legs of the child, then the legs are extended apart, 5-10 times, 3-4 approaches in each exercise, then the pelvis moves in a circular motion, the pace is slow, 3-7 minutes, in the final part of I.P. sitting, hands on the belt inhale-tilt the body forward, exhale - return to I.P. 6-8 times, the pace is slow, make sure that the back is even, further, I.P. the same, inhale - tilt the body to the side, exhale - I.P., then inhale - tilt the other way, exhale - I.P., 6-8 times in each direction, the pace is slow, I.P. the same, on the count of “times” - hands to the shoulders, “two” - arms up, “three” - to the shoulders, “four” - to the waist, breathing arbitrary, 6-8 times, average pace, monitor coordination of movements, I.P. lying on your back, arms along the body, raise your hands up - inhale, lower your arms along the body - exhale, 4-6 times, slow pace, monitor the combination of the phases of respiration and movement of the hands, then I.P. the same, the brushes on the stomach, inhale - inflate the stomach, exhale - retract, repeat 4-6 times, the pace is slow, on the exhale the brushes help the abdominal wall move down, I.P. lying on his stomach, arms along the body.

The method is as follows.

The proposed method is recommended for patients with cerebral palsy with mild, moderate and severe severity from the age of 3 to 12 years. Contraindications for the appointment of a rehabilitation complex with the inclusion of classes on the created and improved simulators are:

- epilepsy, a persistent decrease in the threshold of convulsive activity on the EEG;

- pathology of behavior and emotional-volitional disorders;

- heart defects of various etiologies

- severe hypertension-hydrocephalic syndrome.

A complex of rehabilitation treatment including exercises using a simulator

1. It is advisable to carry out exercise therapy exercises using author's simulators after heat therapy and massage procedures.

2. Training rehabilitation using a simulator A.V. Rogov is carried out in conditions of rehabilitation centers, medical institutions. The method of rehabilitation of children with cerebral palsy in the form of spastic diplegia consists of an introductory part (4-7 minutes), a main part (17-20 minutes), a final part (3-5 minutes). In the introductory part of the lesson, the starting position (I.P.) is sitting, bending the head back and forth, 6-8 times, 2-3 approaches, the pace is slow, making sure that the child does not jerk his head, all movements should be smooth, further, I.P. sitting, they tilt their heads to the right and left, 6-8 times, 2-3 sets, the pace is slow, then at the main stage they compress and unclench their fingers into fists, 10-12 times, 2-3 sets, the average pace is I.P. sitting, hands on the hips, then perform clenching-unclenching of the fingers into fists with simultaneous flexion-extension in the elbow joints, 10-12 times, 2-3 sets, the pace is slow, breathing is arbitrary, after breathing in, raise your hands up, expiration - return to I.P., 4-6 times, 2-3 sets, average pace, next I.P. sitting, brushes to the shoulders, carry out circular rotation of the shoulder joints forward, then back, 6-8 times in each direction, 2-3 approaches, the pace is average, making sure that the movement is performed with the maximum possible amplitude, passing to I.P . lying on your back, arms along the body, performing alternate lifting of straight legs, 6-8 times, 2-3 approaches, the pace is slow, making sure that the leg does not bend at the knee, I.P. same, perform bending of the leg at the knee, sliding alternately on the floor with the heel of each leg, 6-8 times, 2-3 approaches, the pace is slow, making sure that the heel does not come off the floor, then simultaneously slide with both heels, bending legs, 6-8 times, 2-3 sets, the pace is slow, while both heels should not be torn off the floor, then in I.P. we place the cuffs in the armpits in the projection of the triceps muscles and hold the straps to prevent cuffs from slipping, the feet are fixed at one point, swinging the pelvis back and forth, 10-15 times, 3-4 approaches in each exercise, excluding painful sensations using flexion in the knees, at a slow pace, then rocking the pelvis left to right, 10-15 times, 3-4 sets in each exercise, then bending in the hip joint with support on the feet with movement of 10-15 times, 3-4 sets in each exercise , the instructor controls the support on the heel, then bend the legs in the knee and hip joints at the same time (squat), the pace is slow, 5-15 times, 3-4 sets in each exercise, after which we raise the right and left legs bent at the knees, the pace is slow, 10-15 times, when the legs are reduced, the instructor insures against injuries the inner surfaces of the lower legs of the child, then we extend the legs to the sides, 5-10 times, 3-4 approaches in each exercise, then the pelvis moves in a circular motion, the pace is slow, 3 -7 minutes, in the final part of I.P. sitting, hands on the belt, inhale - tilt the body forward, exhale - return to I.P., 6-8 times, the pace is slow, make sure that the back is even, I.P. the same, inhale - tilt the body to the side, exhale - I.P., then inhale - tilt the other way, exhale - I.P., 6-8 times in each direction, the pace is slow, I.P. the same thing, at the expense of times - hands to the shoulders, two - hands up, three - to the shoulders, four - to the belt, breathing arbitrary, 6-8 times, average pace, monitor coordination of movements, I.P. lying on your back, arms along the body, raise your hands up - inhale, lower your arms along the body - exhale, 4-6 times, slow pace, monitor the combination of the phases of respiration and movement of the hands, then I.P. the same, the brushes on the stomach, inhale - inflate the stomach, exhale - retract, repeat 4-6 times, the pace is slow, on the exhale the brushes help the abdominal wall move down, I.P. lying on his stomach, arms along the body.

Rehabilitation of patients with cerebral palsy with spastic diplegia is advisable to carry out continuously. Classes of exercise therapy with the use of simulators of simple design, for example a simulator, it is desirable to carry out between the course rehabilitation at home.

Currently, there are many simulators for the correction of motor disorders for children with cerebral palsy, but none provides the optimal range of motion. After all, children come to a rehabilitation course at different ages, with varying degrees of motor activity, spasticity, and varying degrees of intelligence. Existing rehabilitation methods are mostly local and do not give an effect on the whole organism. The created set of classes on the author's simulator complements existing techniques and allows you to expand the range of therapeutic effects. In each case, a wide range of effects is possible both on the deep and on the superficial muscles of the musculoskeletal system. Most often, spasticity in a child with cerebral palsy occurs due to excessive tone of the deep muscles, which does not contradict the data of Semenova K.A. [21]. Superficial muscles are in pathological connection with the deep. To resolve this pathology, exposure to the deep muscles is required.

The simulator used is an elastic support that verticalizes a child with cerebral palsy. It makes it possible to use cardiovascular equipment (treadmill, exercise bike) to a non-walking child, and develops strength qualities. Classes can be carried out from any position (lying on your back, sitting in a wheelchair, standing with soft support). The absence of hard parts in the supporting elements significantly expands the range of possible exercises for physiotherapy in patients with cerebral palsy in the form of spastic diplegia. Auxiliary technical means, such as, for example, a simulator used to implement the method, can be used for exercise therapy and at home.

The proposed method is based on the analysis of the results of clinical observations. The examination and rehabilitation of patients with cerebral palsy with spastic diplegia was carried out. They were divided into 2 groups: the 1st (main) group - 35 children, received basic therapy in the form of physiotherapy (thermal procedures in the form of paraffin-ozokerite applications at a temperature of 45-48 ° C, on spastic muscles of the lower and upper extremities, exposure time 10-15-20 minutes daily, 10 procedures, general massage with differentiated techniques that take into account muscle tone, daily, up to 10 procedures per course. Patients were added to the basic therapy physical therapy classes with the development of verticalization skills using the created and improved simulator in the form of elastic supports, which allowed changing motor restrictions in patients with cerebral palsy. Classes were held in the gym of physical therapy 5 times a week in the morning, for 15-30 minutes, for a course of up to 20 procedures. 2nd group (comparisons) - 35 children received basic therapy (thermal procedures, massage). Exercise therapy classes were developed with the development of verticalization skills using standard unimproved simulators, which allowed changing motor restrictions in patients with cerebral palsy. Classes were held in the gym of physical therapy 5 times a week in the morning, for 15-30 minutes, for a course of up to 20 procedures.

The complex of exercises for patients with cerebral palsy with spastic diplegia consisted of a warm-up, the main and final parts. It takes 4-6 minutes to warm up, 17-20 minutes to the main part, 3-5 minutes to the final part. In addition, it must be borne in mind that during the warm-up exercises the neuromuscular apparatus is prepared for the main part, where the load is much greater based on the characteristics of the exercises and their dosage (despite their number). The final part is the recovery period after the main load part of the session.

To assess the functionality of the lower extremities, the following tests were used:

- "balance holding" The test was conducted for children with impaired equilibrium on two legs or on one leg. With cerebral palsy there is no differentiated coordinated tonic muscle tension. With an unreduced symmetric cervical-tonic reflex, the foot assumes the position of equino-varus - there is support on the distal part of the foot. With pathological activity of the labyrintho-tonic reflex, triple bending is formed in all joints of the leg. In the causes of impaired equilibrium functions in cerebral palsy, disturbances in the vestibular system also occur. For the test, the child was asked to maintain balance in an upright position on two legs. At the command "ready" the patient let go of the support. The test for maintaining balance on one leg was carried out as follows: the child was asked to maintain balance in an upright position on the right, left leg, alternately. The test subject stood on two legs, then, on a “ready” command, raised his left leg, the time to maintain equilibrium was taken into account, and then, similarly, the right one. The countdown was made by the stopwatch, which ended at the moment of loss of balance, which was expressed in the movement of the legs, descent, touching the support.

ON. Bernstein identifies the general qualitative and geometric characteristics of normal walking: symmetry, rhythm, constant length and step length. By Semenova K.A. (1999) stride length is the distance that the fly leg is extended during the stride. This distance is measured in centimeters from the thumb of the supporting foot to the heel of the fly leg when this foot performs the front push and sets the heel on the support.

- step length (distance from the big toe of the supporting foot to the heel in centimeters).

Given the uneven walking speed in children, especially with a violation of coordination during cerebral palsy, the step length was measured on a lined electric treadmill with a predetermined speed of 0.8 km / h with hands resting on the handrails for 1 minute using the interval method. For the calculation, the last 20 steps were taken, because in the first period, the child adapted to walking on the simulator. A video camera for recording steps was set at a distance of 65 cm from the track. The obtained step length data in children were compared with standard indicators, deviations from them were calculated as a percentage of the data sought. The results of measuring the step length in children in the main and comparison groups before and after the course of exercise therapy.

- “walking speed” The number of steps in one place for 1 minute was recorded. Increased walking speed, i.e. the number of steps in one place in one minute. Increased walking speed, i.e. the number of steps taken over a certain period of time, before and after the applied treatment, gives an idea of its effectiveness.

- "the number of squats (half-squats)." The number of squats per 1 minute was taken into account. A healthy child over 7 years old does 25 deep squats in 1 minute, Table 1.

The positive dynamics of tests for the lower extremities was considered an increase in stride length; balance holding time; number of squats. The proposed series of tests makes it possible to additionally assess the degree and characteristics of motor disorders.

The vestibular function of patients with cerebral palsy and foot support were assessed by the test to maintain equilibrium of Table 1 before and after treatment, Figure 1, table 4.

When evaluating the test results in patients of the main group, an increase in the duration of maintaining equilibrium from 30.4 ± 3.7 to 123.7 ± 8.2 seconds (P <0.05) was revealed. In the control group, there was also a positive dynamics of the functional balance test. The equilibrium retention time increased from 30.2 ± 3.8 to 98.4 ± 7.6 (P <0.05). Estimating the time interval, a significant increase in the indicator in the main group by the last lesson by 25.7% was established with the comparison group.

Measurements of stride length showed the effectiveness of the therapy in the compared groups. The dynamics of the step was determined in patients with a 3rd level of severity of clinical manifestations. Before therapy, the step was significantly shortened in patients with cerebral palsy with spastic diplegia due to equino-varus installation of the foot. Most of the examined children showed oscillatory, swaying body movements, there were no friendly hand movements that helped coordinate the movements of a patient with cerebral palsy with spastic diplegia. The results of changing the length and speed of the step before and after rehabilitation are presented in table 2.

Before rehabilitation, the average step length in patients with cerebral palsy was 14.9 ± 0.3. The increase in stride length gradually increased during the rehabilitation process and reached a maximum by 20 days. In the main group, the result after a course of rehabilitation treatment was 20.6 ± 0.3, in the comparison group 18.1 ± 0.3. Analysis of table 2 showed that the step length increased by 5.9 ± 0.2 in the main group (P <0.05), in the comparison group by 3.0 ± 0.1 (P <0.05). The number of steps one minute before rehabilitation was 27.7 ± 0.4 in the main and comparison groups. After the rehabilitation course, an increase of 9 steps in 1 minute (P <0.05) was recorded in the main group, in the comparison group by 2 steps. After rehabilitation treatment, the number of squats increased in the main group by 2, and in the comparison group by 1. An increase in length and step speed in patients in the main group made it possible to reduce discoordination manifestations. In patients, the gait became more stable, the swinging movements became less.

The effectiveness of the applied method was evaluated by increasing the volume of active and passive movements, after 20 sessions of Table 1. The range of movements in the ankle joints increased in the main group in 42.8% of children, in the comparison group 37.1% of children. Reliance on the full foot was recorded in 11.4% of the main children and in 8.5% of the children of the comparison group. Extension of the lower leg was diagnosed in 20.0% of the children of the main and in 8.5% of the children of the comparison group. Gait improved in the main group in 48.6% of children, in the comparison group in 34.2%. The range of movements in the wrist, elbow joints increased in 11.4% of the children of the main and 8.5% of the comparison group. Fine motor skills improved in 17.2% of the main children and in 14.3% of the comparison group. A month after the treatment, the indicators of the psycho-emotional state of the children of the main group improved to a greater extent. So, before treatment in the main group, 51.4% of children did not come into contact, Table 3.

Note: X ² - Pearson's compliance indicator

P - statistical significance of the indicators in the main group and the comparison group after treatment

Slightly fewer (48.6%) children came into contact in accordance with the age level. More than half of the children (60%) were active, the rest were passive. There were no significant differences in the categories of active and inert, peppy and lethargic. More than half (57.1%) of children worked with pleasure, the rest from subordination. Efficiency was reduced in approximately 37.2% of children, sufficient in 62.8% of children. In the comparison group, 57.2% of children did not come into contact before treatment, in accordance with the age norm - 42.9%. Equally often, children were active and passive, they worked with pleasure and out of submission, their working capacity was reduced and sufficient. Almost 63% of the children remained inert, others remained active. Only 20% of the children were lethargic, and 80% were vigorous (Table 2).

After therapy, the following indicators were recorded: according to the category - the child is inert, the decrease is 2.7 times, the child works from submission - 2.1 times. In the category - the child is active 1.8 times, the performance is reduced - the decrease is 1.6 times. In the comparison group, there was a decrease in indicators in such categories as: the child is sluggish, the child is inert, working capacity is reduced (3.5, 1.7 and 4 times, respectively).

Example 1. Patient A. 5.5 years old, Diagnosis: cerebral palsy, spastic diplegia, impaired posture; sensorineural hearing loss, impaired articulation due to hearing loss (ZPR, OHP - 1 level).

Anamnestic data: a child from 3 pregnancies with a risk of miscarriage in the 2nd half. Mother's age - 22 years old, worked as a conductor. First childbirth, with a period of 39-40 weeks, in the head presentation, with a mass of 2200 g, Apgar score of 7 points, registered asphyxia in childbirth. Applied to the chest for 3 days, did not take the chest. In the neonatal period, tremor of the extremities was noted. Registered at 9 months with a diagnosis of perinatal damage to the central nervous system, spastic diplegia.

Expert opinion:

Psychiatrist - moderate mental retardation;

Psychologist - underdevelopment of the basic mental processes;

Psycho-neurological status: state of damage to the central nervous system of moderate severity. The consciousness is clear, comes into contact, is inhibited, does not fully evaluate its defect, criticism is reduced. He does not show interest in work, does not fulfill tasks, attention is unstable, memory is short-term, he does not reproduce subjects, there is no perception of size, shape, color, size.

The head is of normal shape, the head circumference is 51 cm. From the side of 12 pairs of cranial nerves are dysarthria. The tone in all muscle groups is high in spastic type, D = S. Stiffness in the hip joints, limitation of range of motion in these joints, it is difficult to breed the hips. He manipulates his hands, reaches for toys. Flat valgus installation of feet. Reliance on socks, with cross-legs. Muscle strength is reduced. Tendon reflexes from the arms, from the legs are high, with an expanded reflexogenic zone, D = S. The child walks on his own in a spastic-parietic gait with a strong front-sagittal swing. The girl maintained equilibrium of 46 seconds, stride length 15.3 cm, number of steps per minute 29. On admission: ∠ flexion of the joint with the bent right, left leg 64 °, 66 °, respectively; ∠ flexion of the t / b joint with a straight right, left foot 44 °, 48 °, respectively; ∠ flexion of the knee right, left joint 122 °, 124 °; ∠g / c right, left foot 110 °, 115 °

During the initial assessment of the child’s disability, the 3rd degree of restriction (inability) to self-care, independent movement, learning, and the inability to play activities for orientation and communication was established. She did not control her behavior completely (2 degree of restriction).

Ultrasound of the abdominal cavity - an excess of the gallbladder. EEG - moderate cerebral changes with dysfunction of subcortical structures. The adaptation period in the RC was rather difficult. The child often suffered from colds. Interruption treatment courses were interrupted (exercise therapy, massage, physiotherapy). The rehabilitation course: 1) drug therapy (cortexin, tanakan), 2) exercise therapy individually using exercise equipment by exercise therapy according to the proposed method using the exercise machine (Pat. No. 89402); 4) general massage with a composition based on camelina oil No. 10 (Pat. No. 2302854); 4) physiotherapy (paraffin applications on the lower extremities No. 10, 6) psychological and speech therapy correction with articulatory massage No. 25.

The patient's condition stabilized after the first course of rehabilitation (4 weeks). After two courses of treatment (6 months after the start of therapy), the ability to self-care, to move with the help of assistive devices and other persons (2 degree of restriction) appeared. She began to study in the RC under a special program (1 degree of restriction). Game activity has improved (1 degree of restriction). Disorientation disappeared (2 degree of restriction). The ability to communicate has improved (1 degree of restriction). The girl began to control her behavior (2nd degree of restriction). Before discharge: The girl maintained equilibrium was 97 seconds, step length 19.3 cm, the number of steps per minute 36; ∠ flexion of the t / b joint with the bent right, left leg 76 °, 77 °, respectively; ∠ flexion of the t / b joint with a straight right, left leg 49 °, 52 °, respectively; ∠ flexion of the knee right, left joint 137 °, 139 °; ∠g / c of the right, left leg increased by 14 °, 16 °. There was a continuity in rehabilitation measures. Faster was the effect of the treatment.

After the rehabilitation course, the child began to walk more confidently, his fronto-sagittal sway decreased.

Example 2. To illustrate the effectiveness of therapy, we provide an extract from the medical history. Patient F., 10 years old, Diagnosis: cerebral palsy, spastic diplegia, final residual stage; internal symmetric hydrocephalus; congenital malformation of the kidneys (left-sided hydronephrosis); congenital deformity of the thigh (congenital dislocation of the left thigh, subluxation of the right). Hallux valgus deformity of both feet.

When a child enters the Center, his condition was assessed as moderate to severe due to the severity of stato-dynamic and psycho-emotional disorders. Anamnestic data: boy from 2 pregnancies, mother's age 23 years. During pregnancy, there was gestosis in the 1st half, anemia, nervous stress. The birth is premature, with a period of 32 weeks, the mass at birth is 1450. He was born in the head presentation, screamed right away, obstetric benefits were not applied. The condition of the child was serious, on the 10th day he was transferred to the 2nd stage of nursing, where he stayed for 2 months. Formula of development: 1 year - 2.5 years - 0, i.e. in a year the child began to hold his head, at 2.5 he began to sit and at the time of assessing the condition does not walk. At 2 years old, she was registered with a diagnosis of cerebral palsy, spastic diplegia. I did not receive regular treatment.

Psycho-neurological status: Consciousness is clear, the reaction is not always adequate, it does not always come in contact, there is interest in the classes, productivity is average. The pace of work is average. Steady attention. Long-term memory, accuracy of reproduction is noted. Perception of size, size, shape, color is present. Intelligence intact. Speech development by age, an active vocabulary is sufficient. Speech is normal.

The head is rounded in shape, the head circumference is 51.5 cm. From the side of 12 pairs of cranial nerves, pathology was not detected. There is moderate spastic muscle hypertonicity in the hands D> S, pronounced hypertonicity in the legs D = S. The range of motion is limited in the elbow joint D, in the wrist D, in the hip, knee, ankle joints. There is stiffness in the hip, right elbow, wrist joints, contracture in the knee joints. Tendon reflexes are high, with the expansion of reflexogenic zones from the legs D = S, from the hands - animated D = S. There is hypotrophy of the muscles of the lower extremities along the entire length, more pronounced in the distal sections, D = S. In the Romberg position is not stable, because alone is not worth it, finger-nasal test is satisfactory.

Upon admission: the boy maintained equilibrium was 52 seconds, step length 16.3 cm, the number of steps per minute 31; ∠ flexion of the t / b joint with bent right, left leg 62 °, 61 °, respectively; ∠ flexion of the t / b joint with a straight right, left foot 43 °, 45 ° respectively; ∠ flexion of the knee right, left joint 121 °, 120 °, rear flexion of the right, left leg 125 °, 23 °.

The results of additional research and expert opinion:

Ultrasound of the abdominal organs: reactive changes in the pancreas, 2-sided pyelonephritis.

Optometrist: on the fundus - the veins are dilated, the arteries are significantly convoluted, narrowed.

The initial perception of physiotherapeutic procedures, massage, therapeutic exercises was sharply negative. The period of getting used to treatment and rehabilitation measures was quite long. Motor skills were formed difficult due to severe pain and the presence of contractures that limit his life.

During the visit, the child received a course of treatment:

1) general, differentiated massage;

2) an individual complex of therapeutic exercises according to the claims using a simulator [20].

When conducting therapeutic exercises, the degree of restriction of movements was taken into account, a set of passively active exercises was used. The intensity and duration of the lesson was determined by the individual characteristics of the child. When carrying out the procedures, the identified potential opportunities were taken into account, didactic principles were observed: accessibility, systematicity, from simple to complex, from known to unknown.

To solve the problems was applied, the proposed method according to the claims. Before the therapeutic gymnastics complex, a general and differentiated massage was used with a predominance of relaxing techniques. It was justified by the data of academician I.P. Pavlova: passive reproduction of a certain movement sends an impulse to those kinesthetic cells of the cortex, the irritation of which actively causes this movement [64]. The irritation of certain kinesthetic cells in the cortex corresponds to a certain movement. Rationally performed massage affected the muscle tone of the child, lowering it. Massage was carried out in a room with T = 22 degrees Celsius at the same hours, 60 minutes after a meal. The course consisted of 15 procedures. Massage plan: Starting position - lying on your stomach with a roller under the ankles - massage of the back, paravertebral areas, back of the legs. Starting position - lying on your back with a roller under the knees - massage of the front surface of the legs, abdomen, chest, arms. Massage techniques: superficial and deep stroking, sawing, crossing, squeezing, shearing. Alternating techniques.

After the course of treatment, an improvement in the psycho-emotional sphere of the child is noted. In addition, there was a positive dynamics of motor skills. The boy learned to independently turn and roll over from back to stomach and back. He began to learn to crawl in a plastubsky way. The use of auxiliary technical means - a simulator with elastic traction for verticalization, allowed the child to continue stage physical rehabilitation at a qualitatively new level.

Before discharge: the boy maintained equilibrium was 112 seconds, step length 19.7 cm, the number of steps per minute 35; ∠ flexion of the t / b joint with the bent right, left leg 73 °, 76 °, respectively; ∠ flexion of the t / b joint with a straight right, left foot 50 °, 53 °, respectively; ∠ flexion of the knee right, left joint 137 °, 139 °; Rear flexion of the right, left leg 117 °, 119 °. After 6 months, the state of the dynamics improved. The strength of the muscles increased, muscle tone decreased, the dilution of the hips with bent legs increased by 11 cm, the knees began to straighten, and the manipulative function of the hands improved.

Given the positive dynamics in the child’s health, parents are recommended daily visits to the gym of physical therapy and repeated quarterly comprehensive treatment.

The advantages of the proposed method:

1. Convenience and speed in use, its compactness

2. Security

3. The possibility of application at home (phasing, continuity of rehabilitation)

4. The child spends most of the lesson in an upright posture.

5. Trains the vestibular apparatus

6. Reduces motor restrictions

7. Allows you to work in a wheelchair or in a prone position

8. No age restrictions

9. Facilitates the work of a rehabilitologist.

Combined therapy, using the simulator, can improve the quality of life of patients with cerebral palsy in the form of spastic diplegia. As a result of applying the technique in children with cerebral palsy in the form of spastic diplegia, mobility in the joints increases; pathological muscle tone decreases; upright skills are acquired. The child's motor and social restrictions are reduced, the psycho-emotional status is leveled.

List of sources of information

1 Buklekbaeva Sh.A. Development and evaluation of the effectiveness of rehabilitation measures for various forms of cerebral palsy: author. dis ... doctor honey. sciences / Sh.A. Buklekbaeva. - Republic of Kazakhstan, Almaty, 2010, - 39 p.

2. Bruykov A.A. The effect of fixation massage with ontogenetic gymnastics on the functional reserves of the body of children with cerebral palsy: author. dis ... cand. honey. sciences / A.A. Bruykov. - M., 2012 .-- 24 p.

3. Shteregerts A.E. Physiotherapy exercises and massage for diseases and injuries of the nervous system in children. - K .: Health, 1989 .-- 187 p.

4. Gifford R., August P. and G., Cunningham. Working Group Report on High Blood Pressure in Pregnancy. 2000.

5. Modern methods of physical rehabilitation of children with impaired musculoskeletal system functions / edited by N. A. Gross - M .: Owls. Sport, 2005 .-- 235 p. Ill .: (Physical culture and sports of disabled people and persons with disabilities in health status).

6. Bortfeld S.A. Therapeutic physical culture and massage with cerebral palsy / S.A. Bortfeld, E.N. Rogacheva. L .: Medicine, Leningrad. Department, 1986. - 162 p.

7. Ganzina N.V. Mobile and sports games as a means of recreation and social adaptation of disabled people with cerebral palsy / N.V. Ganzina, T.I. Gubareva // Sport, spiritual values, culture. - M., 1997 .-- issue 8. - S.175-186.

8. Gross N.A. Optimization of physical activity, taking into account the functional state during motor rehabilitation of children with a violation of the musculoskeletal system: abstract. dis ... cand. ped Sciences / Gross N.A., M., 1999 .-- 24 p.

9. Gross Yu.A. The use of training devices in the process of rehabilitation physical exercises of children with disorders of the musculoskeletal system: abstract. dis ... cand. ped Sciences / Gross Yu.A., M., 1998 .-- 24 p.

10. Dotsenko V.I. Functional programmable muscle electrical stimulation - its role in modern neurorehabilitation of children and adults // Physiotherapist. - M., 2008. - No. 2. - S.8-10.

11. Puzikov A.M. A method for the treatment of spastic diplegia // exercise therapy and massage. - M., 2006. - No. 7 (31). - S.51

12. Rugol L.V. Medical and demographic aspects of healthcare reforming / L.V. Rugol // Health of the Russian Federation, 2010. No. 6. - S.7-11.

13. Dremova, G.V. The complex use of hippotherapy and the Spartan program for the social rehabilitation of disabled people with cerebral palsy / G.V. Dremova, L. Sokolov, V.I. Stolyarov // Sport, spiritual values, culture. - M., 1997 .-- Issue 8. - S. 130-174.

14. www.cerebral-palsy.ru

15. Bondarenko E.S., Sheritorova D.Ch., Tanyukhina E.I. and others. Comprehensive rehabilitation of children with disabilities due to diseases of the nervous system: method. recommended. - Moscow-St. Petersburg, 1998 .-- 536 p.

16. Laisheva O.A. Remodeling of the motor act - a way of the system of regulation of movements / O.A. Laysheva [et al.] // LFK and massage. - 2007. - No. 2. - S.8-13.

17. Kakhidze A.S. Social needs in methods using training simulators for recovery from cerebral palsy, paresis, after strokes, / Kakhidze A.S. // Open World: Scientific Pract. adapt workshop dvigat. activity. - M., 1998, b. g. - S. 42-44.

18. Modern methods of physical rehabilitation of children with impaired musculoskeletal system functions / edited by N. A. Gross - M .: Owls. Sport, 2005 .-- 235 p. Ill .: (Physical culture and sports of disabled people and persons with disabilities in health status).

19. Bobath B., Bobath K. The problem of spastically in the treatment of patients with lesions of the upper motor neuron / B. Bobath, K. Bobath. Cerebral Palsy Center, London, 1969. P. 459-464.

20. Pat. 89402 Russian Federation, IPC A63B 23/035. Rogov simulator / A.V. Rogov, A.Yu. Vlasov. - No. 22009130204/22; declared 08/05/2009; publ. 12/10/2009, 27, bull. Number 34.

21. Semenova K.A. Reconstructive treatment of children with perinatal damage to the nervous system and cerebral palsy - M .: Law and Order, 2007.

application

Table 1. An increase in the volume of active and passive movements in patients with cerebral palsy with spastic diplegia

Table 2. Indicators of stride length, walking speed and squats in patients with cerebral palsy with spastic diplegia

* (P <0.05) - significant difference in the groups

- the differences are significant compared to the value in the main group W> 1.96 according to the Mann-Whitney Wilcoxon test

Table 3. Psycho-emotional state of patients with cerebral palsy with spastic diplegia

Note: X ² - Pearson's compliance indicator

P - statistical significance of the indicators in the main group and the comparison group after treatment

Table 4. Dynamics of maintaining equilibrium in patients with cerebral palsy before and after rehabilitation (in seconds)

Note:

* The difference is significant compared with the initial value (P <0.05);

# - differences are significant compared to the value in the main group W> 1.96 according to the Mann-Whitney Wilcoxon test

FIG. 1 - Graph for assessing the test to maintain equilibrium of Table 1 before and after treatment.

Table 1 Acquired skills The main group (N = 35) Comparison Group (N = 35) P≥ n % n % Increased range of motion in the hip joints 13 37.1 12 34.2 0,9999 Increased range of motion in the ankle joints fifteen 42.8 13 37.1 0.8073 Full foot support four 11,4 3 8.5 0,9999 Leg extension 7 twenty 3 8.5 0.3055 Gait improvement 17 48.6 12 34.2 0.5772 Reduction of tension in the adductor muscles of the thigh 10 28.6 7 20,0 0,9999 Increased range of motion in the wrist, elbow joints four 11,4 3 8.5 0,9999 Improving fine motor skills 6 17,2 5 14.3 0,9999

table 2 Parameter The main group before rehabilitation n = 30, M ± m The main group after rehabilitation n = 30, M ± m Coef. confidence p * Comparison group before rehabilitation n = 30, M ± m Comparison group after rehabilitation n = 30, M ± m Coef. confidence p * Stride length, cm 14.7 ± 0.3 20.6 ± 0.3 <0.05 15.1 ± 0.5 18.1 ± 0.5 <0.05 Steps per minute 28.1 ± 0.4 37.7 ± 0.4 <0.05 27.4 ± 0.5 29.2 ± 0.5 <0.05 Squats in 1 minute 6.3 ± 0.2 8.2 ± 0.2 <0.05 6.2 ± 0.3 7.1 ± 0.3 <0.05

Table 3 indicators The main group n = 35 Comparison Group n = 35 X ² P before treatment after treatment before treatment after treatment Contact: a) does not enter eighteen fourteen twenty 17 33.69 <0.05 b) in accordance with the age norm 17 21 fifteen eighteen 38.90 <0.05 Child: a) active 21 26 eighteen 19 37.80 <0.05 b) passive fourteen 9 17 16 29.49 <0.05 Child: a) active 16 28 13 22 45.63 <0.05 b) inert 19 7 22 13 36.09 <0.05 Child: a) peppy 17 21 28 33 77.04 <0.05 B) sluggish eighteen fourteen 7 2 13.59 <0.01 The child works: a) with pleasure twenty 28 eighteen 23 49.49 <0.05 b) from submission fifteen 7 17 12 23.3 <0.05 Operability a) reduced 13 8 17 12 19.83 <0.05 b) sufficient 22 27 eighteen 23 58.03 <0.05

Claims (1)

A method for the rehabilitation of patients with cerebral palsy (CRP) in the form of spastic diplegia, which consists in acting on the musculoskeletal system, characterized in that after heat treatment, general and differential massage of the child is placed in a simulator, which represents a system of elastic traction with supporting axillary grip, and perform a set of exercises in three stages, including: introductory for 4-6 minutes, the main for 17-20 minutes and the final for 3-5 minutes, and at the opening stage, in the initial position (I.P.) I, perform head tilts back and forth, 6-8 times, for 2-3 approaches, at a slow pace, all movements are performed smoothly, then, in the initial position, sitting, tilt the head left and right, 6-8 times, for 2-3 approaches, at a slow pace, at the main stage, then perform clenching and unclenching of the fingers into fists, 10-12 times, 2-3 approaches, the average pace, then, in the initial position sitting, hands on the hips, perform clenching - unclenching fingers into fists with simultaneous flexion-extension in the elbow joints, 10-12 times, 2-3 sets, slow pace, random khana, then when inhaling - they raise their hands up, when exhaling - they return to I.P., 4-6 times, 2-3 approaches, the rate is average, then, in I.P. sitting, raise the brushes to the shoulders and carry out circular rotation of the shoulder joints forward, then back, 6-8 times in each direction, 2-3 approaches, the pace is average, moreover, the movement is performed with the maximum possible amplitude, then in I.P. lying on your back, arms along the body, perform alternate lifting of straight legs, 6-8 times, for 2-3 sets, the pace is slow, and the leg should not bend at the knee, then, in the same IP, bend the legs in the knee, sliding on the floor alternately with the heel of each leg, 6-8 times, 2-3 approaches, the pace is slow, while making sure that the heel is not torn off the floor, then simultaneously slide with both heels, bending the legs, 6-8 times , 2-3 approaches, the pace is slow, while both heels do not tear off the floor, then in I.P. they place the cuffs of the simulator in the armpits in the projection of the triceps and hold the straps with the hands, the feet are fixed at one point and the pelvis is rocked back and forth, 10-15 times, for 3-4 approaches, while bending the legs at the knees, at a slow pace, then they carry out pelvic sway left-right, 10-15 times, 3-4 approaches, then bend in the hip joint with support on the feet with a movement of 10-15 times, 3-4 approaches, in each exercise the instructor controls the support on the heel, then bend their legs in the knee and hip su tavah at the same time, squatting, slow pace, 5-15 times, 3-4 sets in each exercise, then raise the right and left legs bent at the knees, slow pace, 10-15 times, while reducing the legs the instructor insures against internal injuries the legs of the child, then perform the legs to the side, 5-10 times, 3-4 approaches in each exercise, then perform a circular motion of the pelvis, the pace is slow, 3-7 minutes, then, in the final part in the initial position, sitting, hands on belt, perform on inhalation - tilt the body forward, on the exhale - cart rotate in I.P., 6-8 times, the pace is slow, make sure that the back is even, then, in the same I.P., they perform inspiration - tilt the body to the side, while exhaling - I.P. , then on the inhale - tilt to the other side, on the exhale - I.P., 6-8 times in each direction, the pace is slow, further, I.P. the same, on the “time” account - the hands to the shoulders, on the “two” account - hands up, the “three” account - to the shoulders, the “four” account - on the belt, voluntary breathing, 6-8 times, average pace, follow for coordination of movements, further, I.P. lying on the back, hands along the body, raise their hands to inhale - up, lower along the body - exhale, 4-6 times, the pace is slow, monitor the combination of the phases of respiration and movement of the hands, then, in the same IP, the hands on on the stomach, on inhalation - inflate the stomach, on exhalation - retract, repeat 4-6 times, the pace is slow, on the exhalation of the brush, the abdominal wall helps to move down, I.P. lying on his stomach, arms along the body.

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