Spastic Forms Of Cerebral Palsy Research Articles

Assessment of spasticity-related pain in cerebral palsy and the efficacy of its treatment with incobotulinumtoxin A (literature review)

Pain in cerebral palsy (CP) occurs in 30–60% of cases. Pain associated with spasticity (PAS) is one of the most common causes of pain syndrome in cerebral palsy, which is often associated with impairment of the child’s daily life. Recently, more studies have been published on the use of botulinum toxin type A preparations to control PAS. The review article presents the results of a special pooled analysis of data on the analgesic effect of the drug Xeomin (incobotulinumtoxin A) in the treatment of PAS based on data from three phase III multicentre prospective comparative studies in children and adolescents with spastic forms of cerebral palsy. To evaluate PAS and the effect of incobotulinumtoxin A on it, a special questionnaire (Questionnaire on Pain caused by Spasticity, QPS) was used in these studies. The QPS reflects the child's pain associated with spasticity, which can be observed at rest and during various activities of the child.It was found that the children included in these studies reported the presence of PAS in more than 80% of cases with lower limb spasticity and in almost 70% of cases with upper limb spasticity. Parents or caregivers of these children observed an even higher prevalence of PAS. The use of incobotulinumtoxin A showed not only a pronounced antispastic effect, but also a significant reduction in the frequency and intensity of PAS in children and adolescents with cerebral palsy during normal daily activities, and during strenuous activities such as physical exercise and rehabilitation treatment. With repeated injection cycles of incobotulinumtoxin A, PAS continued to decrease, ensuring a reduction in pain even when physical activity became more difficult. Nowadays, injections with incobotulinumtoxin A can be considered as a routine therapeutic approach for the treatment of spasticity and increased muscle tone, but it is certainly an innovative method for effective pain reduction in cerebral palsy patients with lower and upper limb spasticity accompanied by PAS.

The use of postural balance restoration tools in the complex treatment of children with cerebral palsy

Physical rehabilitation of children with cerebral palsy (CP) requires long-term, systematic, individual and step-by-step use of a complex of tools to restore lost motor functions.
 All forms of cerebral palsy cause a violation of the body's balance control system, which is manifested by unsteady walking, unexpected falls, swaying, and impaired coordination of movements.
 The purpose of the study is to increase the effectiveness of comprehensive rehabilitation of patients with cerebral palsy in the late residual stage by using means of restoring postural balance.
 Research methods: analysis of special scientific and methodical literature; analysis of medical histories; assessment of the level of motor disorders (gross motor function classification system (GMFCS); assessment of the degree of change in muscle tone (modified Ashworth scale); assessment of balance function (Berg balance scale); methods of mathematical statistics.
 To achieve the goal, an examination of 20 children with cerebral palsy from 6 to 12 years of age with mainly spastic forms of cerebral palsy was carried out. Patients of the main group received standard rehabilitation treatment and classes on the balance beam and in the rehabilitation system "Spider" in combination with therapeutic gymnastics. The control group of patients received the standard rehabilitation treatment used in this rehabilitation facility. The standard rehabilitation program included therapeutic gymnastics, segmental-reflex massage, mechanotherapy.
 The impact of means of postural balance restoration in combination with existing methods of physical rehabilitation in children with cerebral palsy on coordination and movement disorders was studied.
 It has been established that complex therapy with the use of means for restoring postural balance can improve the rehabilitation of children with cerebral palsy, both in the older and younger age groups. According to all the conducted tests, positive dynamics were obtained.

Motor Nerve Blocks as a Predictor of Efficacy of Selective Dorsal Rhizotomy and Botulinum Neurotoxin Type A Injection in Children With a Spastic Form of Cerebral Palsy

Motor Nerve Blocks as a Predictor of Efficacy of Selective Dorsal Rhizotomy and Botulinum Neurotoxin Type A Injection in Children With a Spastic Form of Cerebral Palsy

СОВРЕМЕННЫЕ ВОЗМОЖНОСТИ ЛЕЧЕБНОГО ПИТАНИЯ ПАЦИЕНТОВ С ДЕТСКИМ ЦЕРЕБРАЛЬНЫМ ПАРАЛИЧОМ ПРИ НАРУШЕНИЯХ НУТРИТИВНОГО СТАТУСА

With the purpose of successful rehabilitation, reduction of concomitant diseases, improvement of nutritional status and the quality of life of patients with cerebral palsy (CP) it is necessary to develop therapeutic nutrition technology, which would include methods for nutritional status assessment, choosing of enteral nutrition formulas, methods of their delivery and the duration of nutritional support. The purpose of this research was to substantiate the nutritional support for patients with CP. Materials and methods used: 98 children aged 2 to 16 years and 9 months old (Me 5.7 y/o) with a spastic form of CP that had been admitted for examination, treatment and rehabilitation at the National Medical Research Center for Children’s Health (Moscow, Russia) were examined. Depending on the level of motor activity calculated with GMFCS, the participants were divided into two groups: G1 of 51 (52%) with severe motor impairment (GMFCS IV to V) and G2 of 47 (48%) with mild and moderate motor impairment (GMFCS I to III). Clinical and anamnestic data, information about the severity and the course of the disease, concomitant pathology were analyzed as well as the anthropometric data (Z-scores: weight/age, height/age, BMI/age) using the WHO AnthroPlus application (2009 revision). EDACS survey had also been carried out. Results: Patients with severe motor impairments were significantly more likely to have problems associated with food intake, such as: prolonged feeding (over 30 minutes), predominance of semi-liquid and pureed food in the diet as well as frequent choking, vomiting, wheezing and coughing during the feeding process. All patients in this group needed external assistance in feeding. 75% had respiratory and 72% had gastrointestinal complications. Severe impairments (EDACS IV to V) characterized by significant restrictions on food safety were identified in 24 (23%) children, that met statistically significantly (p<0.001) more often in patients from G1 than from G2 (41% vs. 4%, respectively). Dietary analysis children with CP had showed that the quality and quantity of food consumed were monotonous and deficient. Consumption of pasta, cereals, and baking was 1.5 times higher than recommended whilst vegetables, fruits and healthy dairy products were reduced by 3 and 1.8 times, respectively, on the contrary. The WHO recommendations for children on the mandatory daily intake of 3 to 4 servings of various vegetables and fruits were not followed: in the majority (80%) of cases they’ve only had it once per day, and they even were completely absent in some cases. Nutritional assessment revealed that patients with severe movement disorders, regardless of the gender and nutritional status, had significant deficiencies in energy and protein intake. All studied anthropometric indicators in G1 patients were significantly (p<0.005) lower compared to G2 children. Prevalence of undernutrition was 72% and 32% (p<0.001), respectively. Individual nutritional program was developed for each and every studied patient with identified malnutrition and oropharyngeal dysphagia, followed by its clinical effectiveness assessment. Conclusion: enteral nutritional support with specialized formulas based on both whole and hydrolyzed proteins using the sipping/gastrostomy method, as well as with the use of a food and liquids thickeners, proved to be highly effective in the treatment and rehabilitation of CP children. Indicators characterizing food intake (time taken for feeding, frequency of choking records during meals, episodes of vomiting and regurgitation) have improved as well as the anthropometric indicators improved accordingly.

Prognostic efficiency of diagnostic blockade as a method of modeling the result of selective neurotomy of the motor branches of the musculocutaneous nerve in patients with cerebral palsy

BACKGROUND: A combination of movement disorders with contractures in the joints is a feature of upper limb lesions in patients with spastic forms of cerebral palsy. As part of the spastic hand syndrome, contractures are differentiated into primary and secondary. Primary contractures are caused by muscle spasticity, whereas secondary contractures are caused by the structural shortening of the muscle motor segment in relation to the bone, which can subsequently lead to deformities of articular surfaces. In theory, the use of diagnostic blockade as a mandatory procedure in patient examination before selective neurotomy of the peripheral nerves on the upper limb makes it possible to optimize the result of tone-lowering treatment because of the accurate selection and exact category of patients in whom neurosurgical treatment can be effective.
 AIM: To assess the prognostic effectiveness of diagnostic blockade for modeling the result of selective neurotomy of the motor branches of the musculocutaneous nerve in patients with cerebral palsy.
 MATERIALS AND METHODS: This longitudinal prospective study included an examination of 31 patients aged 517 years with spastic forms of cerebral palsy. Before neurosurgical treatment, each patient underwent a diagnostic blockade of the n. musculocutaneus under ultrasonography and neurostimulation. Before and after the diagnostic blockade and after the neurosurgical treatment, each patient was examined for the amplitude of passive and active joint movements, muscle tone, hand functionality, and dynamometry.
 RESULTS: Results of the data analysis showed a significant relationship between the state of the elbow joint during the simulation of surgical treatment and after neurosurgical treatment.
 CONCLUSIONS: The study showed the high prognostic effectiveness of diagnostic blockades when deciding on the techniques of treating tonic flexion contractures of the elbow joint as part of the spastic arm syndrome. The diagnostic blockade of the musculocutaneous nerve during the planning of surgical treatment makes it possible to create a reliable temporal model of selective neurotomy of the motor nerve branches.

Criterion-based assessment of masticatory muscle hypertonia severity in children with cerebral palsy

Relevance. In children, muscle hypertonia, including sustained stiffness of the chewing muscles, accompanies the spastic form of cerebral palsy. Considering hypertonia severity is necessary to develop treatment tactics and schemes. This paper proposes a reasonable criterion-based assessment of the above pathology severity based on clinical and functional examination data.Material and methods. To develop grading of muscle hypertonia severity, we examined 30 children with spastic cerebral palsy and 30 healthy children of the same age to obtain normalized parameters. Based on the questionnaire data, the study analyzed the functions of chewing, swallowing, and speech formation, assessed the condition of the hard dental tissues by clinical examination, and obtained active and passive mouth-opening data. Electromyography calculated the average amplitude of the right and left temporal and masticatory muscles and the total biopotential.Results. Clinical and functional evaluation data showed a direct correlation. The more complex the situation in the oral cavity was, the higher the amplitude of the chewing muscles was.Conclusion. The correlation allowed the development of the criterion-based assessment of moderate and significant masticatory muscle hypertonia severity, which management of this patient type should consider.

The use of IncobotulinumtoxinA in spastic forms of cerebral palsy: a review of randomized clinical trials

Botulinum therapy has been used to treat increased muscle tone and spasticity in cerebral palsy (CP) over almost 30 years. Despite this, every year a large number of published scientific articles present new clinical studies devoted to various aspects of the use of botulinum toxin type A (BTA) products in children. The article discusses in detail the results of three major international randomized clinical trials concerning determination the efficacy and safety of the product Xeomin (IncobotulinumtoxinA) in spastic forms of cerebral palsy. All these studies were performed in accordance with the criteria of evidence-based medicine - randomized, prospective, multicenter, comparative, and longitudinal with a large number of patients, clear inclusion and exclusion criteria. The TIM (Treatment with incobotulinumtoxinA in Movement) study demonstrated the effectiveness of the treatment of spasticity of the lower extremities muscles when using different doses of IncobotulinumtoxinA (8, 6 and 2 units/kg of body weight to correct one pathological pattern) in a double-blind study. The TIMO (Treatment with IncobotulinumtoxinA in Movement Open Label) study showed the efficacy and safety of high doses of IncobotulinumtoxinA (total doses of 16-20 units/kg of body weight) in the treatment of spasticity of the lower and upper extremities with prolonged use. The XARA study (IncobotulinumtoxinA in Arm Treatment in Cerebral Palsy) presented data on the high efficacy of IncobotulinumtoxinA when using a multi-level approach for the treatment of lower and upper limb spasticity in CP children and adolescents, which reflects the real clinical needs of a large number of patients. In each of these studies, the safety of the use of IncobotulinumtoxinA was also evaluated. Good tolerability of therapy was demonstrated (84.1% of patients completed all visits in total according to three studies - TIM, TIMO and XARA) and its safety (the frequency of adverse events associated with therapy was observed in less than 2% of cases). Treatment with IncobotulinumtoxinA was characterized by the lack of an immunologic response - Xeomin as a starting therapy provides a stable effect without fading associated with the development of neutralizing antibodies.

Influence of initial nutritional status on rehabilitation potential and motor abilities of children with cerebral palsy after orthopedic single-event multilevel surgery

Introduction. Protein-energy malnutrition in patients with cerebral palsy is an urgent problem. Given the high frequency of cerebral palsy orthopedic complications requiring surgical treatment, it is necessary to determine the impact of the initial nutritional status on the effectiveness of treatment. Purpose of the study: to analyze the impact of the initial nutritional status on the rehabilitation potential and motor abilities of children with cerebral palsy after orthopedic single-event multilevel surgeries. Materials and methods. The inclusion criteria were the age less than 18 years at the time of examination, spastic form of cerebral palsy, and a single-event multilevel surgical intervention due to orthopedic complications of cerebral palsy in medical history. Results. Lower indices of motor abilities after single-event multilevel surgeries were registered in patients with protein-energy malnutrition according to the FMS (5,50, and 500 meters) and the Gillette scale (p = 0.020, p = 0.026, p = 0.048, p = 0.008, respectively). Conclusion. The initial normal nutritional status before surgery has a positive effect on the rehabilitation potential and motor abilities of children with cerebral palsy after orthopedic single-event multilevel surgeries. Further research on this issue is needed.

The role of neurotrophic factors in the rehabilitation of children with cerebral palsy

Improving the function of the upper limb in children with cerebral palsy (CP) is one of the main tasks of rehabilitation treatment and socialization of the patient. Objective : to determine the dynamics of the concentration of neurotrophic factors (NTFs) in the peripheral blood of children with CP during rehabilitation treatment using the non-invasive interface “brain – computer – exoskeleton of the hand” (“NIMK – exoskeleton of the hand”). Patients and methods . 151 patients aged 12 to 18 years with spastic forms of CP were examined. The complex of rehabilitation treatment included training on the hardware and software complex “NIMK – Exokist-2”. The dynamics of the spasticity level, muscle strength in the paretic limbs, the level of household skills, the concentration of NTFs (brain growth factor – BDNF; neurotrophins 3 and 4/5 – NT-3, NT-4/5; fibroblast growth factors – FGF-1 and FGF-2) in peripheral blood were determined. Results and discussion . A positive result was obtained from the use of the combined technique “NIMK – exoskeleton of the hand” in the rehabilitation of children with CP due to an increase in the upper limbs muscle strength, an increase in working capacity, an improvement in everyday skills and stability of attention. At the same time, a significant decrease in the concentration of a number of NTFs was noted: BDNF, NT-3 and NT4/5, FGF-1 and FGF-2 – on the 10th day after the completion of rehabilitation treatment. Conclusion . The results of clinical and laboratory studies show that during the use of the “NIMK – exoskeleton of the hand” technique the improvement in the upper limbs motor functions in children with spastic forms of CP is associated with a decrease in the concentration of NTFs in the peripheral blood, which may indicate their active involvement in this process.

The nutritional support in children with spastic forms of cerebral palsy

Background. The approaches to the managing of nutrition for healthy children are not always applicable to patients with neurological disorders, since their body composition, muscle tone, level of physical activity, and energy requirements significantly differ from healthy children and, therefore, must be personalized with the mandatory involvement of a nutritionist/dietitian. The purpose is to assess nutrition in children with cerebral palsy (CP) depending on Gross Motor Function Classification System (GMFCS) level. Materials and methods. Eighty-eight 2 to 16 years nine months CP children rehabilitated at the National Medical Research Center for Children’s Health from 2019 to 2021 were included in this study. Participants were divided into two groups. The main group was patients with GMFCS levels IV-V (48 children) and the comparison group - GMFCS levels I-III (40 children). The medical and dietary history of participants was analyzed. Anthropometric parameters using the WHO AnthroPlus (2009) software were assessed in all participants, the ability to eat and drink was determined by questioning the EDACS scale (Eating and Drinking Ability Classification System). Results. The mean values of weight/age, height/age, BMI/age Z-scores were significantly below 0 (p = 0.01) in all patients (88): WAZ -1.54 ± 1.9, HAZ -1.03 ± 1.48, BAZ -1.5 [-3.11; -0.35]. Children of the main group had significantly lower Z-scores. As a result of the survey, patients of the main group were revealed to have indicators characterizing eating disorders significantly more often (p < 0.001) than the comparison group. EDACS survey revealed that children of the main group were significantly more likely (58% and 10%, respectively; p < 0.001) to have disorders corresponding to levels IV-V, characterized by significant safety restrictions. We have developed a nutritional assessment and management algorithm for children with cerebral palsy, admitted for rehabilitation at the neurological department. Conclusion. Children with cerebral palsy need regular nutritional assessment and management for timely and adequate nutritional support, including enteral nutrition.

Selective Dorsal Rhizotomy in Treatment of Spasticity in Patients with Cerebral Palsy

Selective dorsal rhizotomy (SDR) is effective and safe neurosurgical method for the treatment of patients with spastic forms of cerebral palsy (CP). The aim of the review is to introduce the opportunities of SDR in CP patients, to present indications, contraindications, and current inclusion criteria for the surgery for the broad audience of specialists. Authors have given recommendations on SDR implementation in complex rehabilitation of CP patients and have defined its effective combination with other methods of spasticity treatment according to the international experience of SDR, and its short-term and long-term results. The particular attention was paid to the application of SDR in cases of secondary orthopaedic deformities due to CP. The understanding of opportunities and limitations of SDR will allow us to give the patients relevant help and use the advantages of this method.

The Effectiveness and Safety of Adaptive Climbing in the Rehabilitation of Patients with Cerebral Palsy

The use of adaptive physical culture in the system of complex rehabilitation of patients with cerebral palsy (CP) is becoming more popular. Adaptive climbing (AC) is one of these types of physical culture and sports activities. Currently, there are not many data in the domestic and world literature devoted to the study of the AC use in the complex rehabilitation of patients with CP. Aim. Evaluation of the effectiveness and safety of AC in the rehabilitation of children and adolescents with spastic forms of CP in addition to conventional medical rehabilitation. Material and methods. The study included 30 patients aged from 5 to 18 years with spastic forms of CP who were allocated into one of two groups: the 1st group, the study group (n=15) — patients who underwent standard medical rehabilitation and AC classes; the 2nd group, the control group (n=15) — participants who received only medical rehabilitation. A comprehensive assessment of the rehabilitation measures effectiveness and safety was performed before the start of AC classes and after 3 months using clinical neurological and instrumental examinations, including biomechanical examination (electropodography, video analysis of walking and stabilography). Results. Group 1 patients showed a statistically significant improvement in general motor functions on the GMFM-88 scale (p=0,0001), a decrease in the level of spasticity on the мodified Ashworth scale (p=0,0051) and an improvement in manual abilities on the MACS scale (p=0,0431) 3 months after inclusion in the study. Positive dynamics in the form of an increase in the symmetry of step time (p=0,0063), step length (p=0,0083) and step velocity (p=0,0409) were noted according to the electropodographic study in the 1st group. A statistically significant increase in the range of motion in the hip (p=0,0038) and knee joints (p=0,0076) was detected in the 1st group according to video analysis of walking. There was no significant change in the indicators in the 2nd group, except for the severity of spasticity on the modified Ashworth scale (p=0,0180). A positive correlation was found between the indicators “step length” and “ step velocity” (r=0,605, p=0,0168). A negative correlation was found between the “step velocity “ indicator and the GMFCS score (r= – 0.832, p=0,0372). Only 2 adverse events were registered in the study group: acute respiratory viral infection and wrist injury during AC. Conclusion. AC, in addition to traditional methods of medical rehabilitation, leads to a decrease in spasticity, increased joint mobility and control of voluntary movements, improved maintenance of the body position, walking and precise hand movements, and also has a favorable safety profile. AC is an effective and safe motivating method of physical culture that can change the patient’s view on traditional therapy.

Лікування спастичних форм дитячого церебрального паралічу в дітей на етапах оперативного втручання

Проведено аналіз лікування 320 дітей віком від 3 до 18 років зі спастичними формами дитячого церебрального паралічу. Дітям було проведено оперативне лікування. До операціїї діти отримували препарат сирдалуд, після операції — сирдалуд, масаж, лікувальну фізкультуру. Препарат зменшує спастичний стан м'язів, чинить знеболювальну дію.

Comprehensive rehabilitation of patients with movement disorders with spastic forms of cerebral palsy

Until now, there is no radical method of treating children with cerebral palsy, which allows us to consider scientific research in this direction reasonable and promising.The aim of the research: to study the effect of exercises on the mini-simulator “Kinesioplatform-swing” with biofeedback on the indicators of motor skills in children with spastic cerebral palsy.Materials and methods. We conducted an open, non-randomized, prospective, comparative, controlled study in pairs (each participant in the main group corresponds to a participant in the control group). The study involved 53 patients aged 4–12 years with cerebral palsy: the intervention group (group 1: n = 27 (13 boys, 14 girls)) and the control group (group 2: n = 26 (11 boys, 15 girls)), comparable in terms of gender, age and severity of movement disorders. Characteristics of the medical intervention: group 1 – botulinum toxin type A (BTA, for exercising against the background of relative muscular normotonus) + exercise therapy + exercises on the mini-simulator “Kinesioplatform-swing” with biofeedback (BFB); group 2 – BTA + exercise therapy. Duration of the study: 2019–2020. The difference between groups in terms of motor skills on the day of hospitalization and after completion of the training program (10 sessions each) was determined. Motor skills were assessed according to the GMFM-66/88 (Gross Motor Function Measure) table using the “Scales for measuring global motor functions”.Results. The inclusion of additional exercises on the mini-simulator “Kinesioplatformswing” with biofeedback in the rehabilitation of patients with movement disorders with spastic cerebral palsy (BTA + exercise therapy) in comparison with the control group. However, the question of the long-term effects of such training remains open and requires further study.

Cost analysis of botulinum therapy of spastic forms of cerebral palsy in Ukraine

Cerebral palsy (CP) represents a group of disorders of the mechanisms of movement and body position, causing limitations of activity, which are caused by non-progressive damage to the developing brain, fetus or child. About 80% of cases are spastic forms of cerebral palsy. Along with motor rehabilitation, the use of botulinum toxin type A (BoNT-A) is considered one of the main methods of treatment of choice for focal spastic and dystonic syndromes, regardless of their etiology. At present, there are no studies in Ukraine on the analysis of the costs of using drugs based on BoNT-A, taking into account the recommended dose and frequency of administration.
 The aim of the work. Carrying out an analysis of minimizing the cost of botulinum therapy for spastic forms of cerebral palsy in patients aged two years and older.
 The annual dosage and frequency of administration of abobotulotoxin and onabotolutoxin for the treatment of dynamic equinus deformity of the foot caused by focal spasticity due to cerebral palsy in children over two years of age were obtained from the instructions for use. The cost of abobotulotoxin and onabotolutoxin was obtained from the Register of Wholesale Prices of the Ministry of Health of Ukraine.
 Cost analysis for a model cohort of children in different weight categories showed that abobotulotoxin 500 U will be the least expensive treatment technology in the weight category of 21–33 kg at a dosage of 15 U/kg in the treatment of diplegia. Abobotulotoxin 300 U is most rationally used in weight categories 10–20 kg and 34–40 kg with a dosage of 15 U/kg in the treatment of hemiplegia and in the weight category 17–20 kg with a dosage of 30 U/kg in the treatment of diplegia. Weight categories were identified in which the costs of using abobotulotoxin 300 U and abobotulotoxin 500 U were equal to and less than the costs of onabotolutoxin treatment.
 The study was the first to analyze the cost of botulinum therapy, which identified the benefits of abobotulotoxin in the symptomatic treatment of hemiplegia and diplegia in cerebral palsy in the focus of different weight groups of children. Possible variability in the dosage and frequency of administration of onabotolutoxin per year indicates the relevance of collecting additional information on the application in real clinical practice and further pharmacoeconomic studies.

Comparative analysis of the effect trunk-hip-knee-ankle foot orthosis and ankle-foot orthosis on the gait biomechanical parameters in children with cerebral palsy (case report)

BACKGROUND: In children with spastic forms of cerebral palsy often prescribed difference type of trunk-hip-knee-ankle foot orthosis (THKAFO). At the same time, we have not found any significant reports in the world literature dedicated to the study of the influence of these orthosis on the gait biomechanical parameters.
 AIM: To demonstrate the results of a comparative analysis of the effect of trunk-hip-knee-ankle-foot orthosis and ankle-foot orthosis on the gait biomechanical parameters in children with cerebral palsy.
 MATERIALS AND METHODS: The study involved two 13-and 15-year-old children with a diagnosis of cerebral palsy, spastic diplegia, GMFCS 3, MACS 23, Ashworth Scale 23. Six studies were conducted ― three tests for each child (barefoot, in AFO and THKAFO) using the 3D video analysis system Qualisys (Sweden). The spatio-temporal and kinematic indicators of gait, as well as the gait index, were evaluated.
 RESULTS: Analysis of the results in patient D. demonstrated that using the THKAFO in comparison with AFO led to a slight improvement in spatio-temporal gait indicators (from 4.012.5%), but to a deterioration in hip kinematics and a deterioration in the gait index (2.528.1%). Whereas in patient A., it was noted that the use of the THKAFO in comparison with AFO had a negative effect on the spatio-temporal parameters of gait (4.097.6%), on the kinematics of the knee and ankle joints, and on the improvement of the hip kinematics in the sagittal plane, but the effect on the gait index was not unambiguous. According to the totality of the analyzed data, patient D. was recommended to wear AFO instead of the THKAFO. Patient A. was also recommended to wear an AFO instead of a THKAFO, even despite the ambiguous results of the biomechanical research, since the final decision on the choice of the orthosis design took into account not only accurate changes in biomechanical parameters, but also a number of other factors, in particular social and household ones.
 CONCLUSION: In patients with level GMFCS 3, for improve the biomechanical parameters of gait, it is advisable to give preference to shorter and functional orthoses before prescribing orthoses that capture two or more body segments.

Нейрофизиологические особенности спастического синдрома у детей с детским церебральным параличом в зависимости от выраженности моторных нарушений

Актуальность. Детский церебральный паралич (ДЦП) — собирательный термин, объединяющий многочисленные тяжелые заболевания нервной системы. 80 % детей с ДЦП страдают спастическими формами, основным симптомом которых является повышение мышечного тонуса — спастичность. Объективизацию состояния мышечного тонуса и контроль за динамикой спастичности можно проводить с помощью методов биомеханики и электронейромиографического (ЭНМГ) исследования, что дает возможность качественно и количественно изучить состояние нервно-мышечной системы. Цель: установить клинико-нейрофизиологические особенности спастического синдрома у детей с ДЦП в зависимости от выраженности моторных нарушений. Материалы и методы. Обследовано 122 ребенка с ДЦП (средний возраст 8,8 ± 3,7 года), которые были распределены на группы согласно шкале больших моторных функций, расширенной и дополненной (Gross Motor Function Classification (GMFCS E&R)). Всем пациентам проведено тщательное неврологическое обследование и осуществлялось ЭНМГ-исследование. Для оценки надсегментарного (верхнего мотонейрона) и сегментарных (α-мотонейронов спинного мозга и периферических нервов) уровней поражения анализировали параметры Н-рефлекса и F-волны. Результаты. У большинства обследованных детей были диагностированы спастические формы ДЦП: у 40 (32,8 %) детей — спастическая диплегия, у 25 (20,5 %) — гемипаретическая форма, у 6 (4,9 %) — спастический трипарез, у 34 (27,9 %) — спастический тетрапарез. У детей с ДЦП с выраженными моторными нарушениями значительно чаще наблюдалась ортопедическая патология, а именно эквиновальгусная установка и плосковальгусные деформации стоп. По данным ЭНМГ у больных с ДЦП регистрировались нарушения надсегментарных влияний, проявлявшиеся повышением амплитуды М-ответа, особенно при тестировании большеберцового нерва, увеличением соотношения Нмах/Ммах, повышением амплитуды Н-рефлекса и F-волны. Выводы. С увеличением выраженности двигательных нарушений по шкале больших моторных функций (GMFCS E&R) у детей с детским церебральным параличом достоверно усугублялись нейрофизиологические изменения.

Biomechanical Study of Walking and Vertical Posture in 4-6-year-old Children with Spastic Forms of Cerebral Palsy

Rehabilitation of children with cerebral palsy (CP) requires a systematic approach and dynamic assessment of the results achieved. The development of methods for assessing the dynamics of motor disorders during medical rehabilitation is of great importance for modern medical rehabilitation. In recent years, there are more and more scientific papers devoted to the study of biomechanical disorders of locomotion in patients with CP. Aim. To assess the features of walking biomechanical characteristics and vertical pose stability in of children 4-6 years old with spastic forms of CP for further formation of rehabilitation groups, taking into account the identified functional disorders. Material and methods. The study included 20 patients (5.4±0.67 years) with spastic forms of CP. A comparative analysis of walking parameters and stabilography of children with spastic diplegia and hepiplegic CP among themselves and with a group of conditionally healthy children (norm group) (n=12) was performed. Results. A statistically significant decrease in the following indicators was found in children with hemi-and paraparesis: walking speed, double step length, and hip flexion/extension angle. Deviations of indicators are more pronounced in spastic diplegia, but are not always equivalent for both limbs; there is a violation step cycle proportions. the decrease in the length of the double step is more pronounced on the affected limb; there is a decrease in the angle of flexion/extension in the knee joint, more pronounced on a healthy limb in patients with hemiplegic CP. A wide range of stabilographic indicators values is observed in both study groups. However, only the average position of the pressure center relative to the frontal plane statistically significantly differs from the norm in the group of children with hemiparesis. In paraparesis, such differences from the norm are much more common: the area of the statokinesiogram, the maximum amplitude of fluctuations in the center of pressure and the energy of the frequency spectrum. The range of values for most indicators in paraparesis is wider. Conclusion. The revealed biomechanical features of walking and stability of the vertical posture of children with spastic forms of CP can serve as a basis for the development of rehabilitation programs. Clinical and rehabilitation groups of children with CP should be formed taking into account the severity of static-dynamic disorders present in patients. This approach will make it possible to plan further rehabilitation treatment of such patients and adequately assess the results obtained.

Orthotics lower limbs in children with spastic forms of cerebral palsy: (literature review)

Background. Cerebral palsy (CP) is an important medical and social problem due to the high frequency of childhood disability and a significant prevalence of the disease. One of the features of cerebral palsy is the formation of secondary orthopedic complications, for the correction of which, along with surgery and botulinum therapy, technical rehabilitation devices and orthoses in particular are used.
 Aim: To analyze world experience in orthotics in children with cerebral palsy. World literature review in open electronic databases PubMed and Elibrary for the last 30 years. The most of publications focuses on ankle-foot orthoses as the most commonly used in foreign clinical practice. A minimal number of papers cover the problem of orthopedic footwear, despite on its prevalence in Russia. There are no works analyzing the frequency characteristics of orthoses used, including the likelihood of their reuse and rejection. There is no unified, generally accepted terminology and classification of orthoses. We found no articles covering the effectiveness of combined use of several types of orthoses. To date, no clinical guidelines for orthotics in children with cerebral palsy have been developed; therefore, in many cases, orthoses are prescribed empirically.
 Conclusion. Thus, further research of the role of orthotics in the medical rehabilitation of children with cerebral palsy appears to be an urgent task.

Physical therapy of spasticity for correction of spatiotemporal impairments of gait in children with cerebral palsy

The aim of the work is to increase the effectiveness of physical therapy of motor impairments in children with spastic form of cerebral palsy by applying a program of therapeutic training on the device developed for rehabilitation of people with musculoskeletal disorders.
 Materials and methods. 30 children aged 6 to 11 years with cerebral palsy-associated spastic diplegia were included in the study. Patients were divided into 2 groups. In addition to the standard rehabilitation program, all patients were prescribed therapeutic gait training using a device for rehabilitation of people with musculoskeletal disorders: group I (n = 14) – according to the dynamic method; group II (n = 16) – by static method.
 The spatiotemporal characteristics of gait, activity daily indicators, the level of spasticity of lower extremity muscles, functional characteristics of gait, and the methods of mathematical statistics were studied.
 Results. The implementation of the elaborated program of therapeutic exercises using a device for rehabilitation of people with musculoskeletal disorders had a positive effect on the level of muscle spasticity of the lower extremity, stride length, walking speed, general endurance. It also improved balance and reduced the risk of falling in children with cerebral palsy.
 Conclusions. The application of the elaborated therapeutic program had a positive effect on the spatiotemporal characteristics of walking, balance and functional condition of children with cerebral palsy, as well as reduced the level of spasticity. The increase in the stride length occurs during the first 4 weeks of training, and functional condition indicators showed the greatest dynamics only after 6 weeks of training. The elaboration of the rehabilitation device with the ability to move and apply the technique of exercising with partially unstable pelvic support by the abductor-lift moving along the vertical axis, positively affected the balance and reduced the risk of falling.