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2CEREBRAL PALSY AND FEATURES OF ITS CLINICAL
MANIFESTATIONS
1Sadikova G.K., 2Inoyatova I.Sh.
Tashkent Pediatric Medical Institute https://doi.org/10.5281/zenodo.13168632
Abstract. This article presents data on the impact of various factors on the devlopment of cerebral palsy and its complications based on literature sources, and summarizes the results of recent scientific papers devoted to structural abnormalities occurring in the brain with this pathology. It has been established that the determining factor in the nature of damage and its localization is the period of influence of etiological factors on the developing fetal brain. In addition, the importance of studying neurosensory and cognitive changes in this group of children is indicated.
Keywords: children, brain, cerebral palsy, developmental abnormalities, cognitive impairment, neurosensory changes.
Cerebral palsy (CP) is considered to be a set of stable syndromes with diverse clinical signs that occur as a result of abnormal brain formation or damage during early postnatal development. For many years, CP has remained a pressing global health issue [1]. According to many authors, the leading factors that determine the development of cerebral palsy, taking into account the period of their impact, are divided into three groups. The first group includes harmful agents associated with abnormal pregnancy, developmental defects and intrauterine pathologies of the brain. The second group includes intranatal factors, i.e., processes that negatively affect the central nervous system (CNS) during childbirth, and finally the third group is represented by postnatal external and internal influences that lead to nervous system disorders [2; 3; 4]. According to statistics, the greatest number of CP cases occurs in the pre- and perinatal periods, and only about ten percent are associated with postnatal factors. It is worth noting that more than fifty percent of children with cerebral palsy (CP) are born on time and many do not immediately show risk factors for the development of this pathology [5; 6]. The group of prenatal causes of CP development includes acute or chronic extragenital pathologies of the mother, the effect of various infections on the fetus, the use of therapeutic drugs during pregnancy, etc. [7]. Perinatal causes include premature birth, birth with manual assistance, various complications of childbirth, such as prolonged labor or breech presentation of the fetus, premature rupture of membranes, etc. [8]. Many studies attribute a significant role in the development of CP to the socio-demographic status of the mother, as well as hereditary predisposition and genetic factors [9; 10]. Such polyetiology of cerebral palsy implies problems with a clear definition of the processes of its formation and the development of a unified approach to them, which in turn affects all further therapeutic and rehabilitation measures. At the same time, the versatility of the mechanisms that form the pathogenetic basis of cerebral palsy makes it possible to determine similar structural abnormalities in the brain of children with various clinical variants of cerebral palsy.
In the International Classification of Diseases (ICD-10), the clinical variants of cerebral palsy are as follows: G80.0 - spastic (congenital) cerebral palsy; G80.1 - spastic diplegia ("Tetraparesis with spasticity in the legs" according to Michaelis, i.e. the dominance of motor abnormalities in the lower limbs); G80.2 - childhood hemiplegia or hemiplegic form; G80.3 -
dyskinetic cerebral palsy, or athetoid cerebral palsy (the previously used term "hyperkinetic form" is valid); G80.4 - ataxic cerebral palsy (the previously used term "atonic-astatic form"); G80.8 -another variant of cerebral palsy. Mixed form - a combination of several (usually two) forms described above; G80.9 - cerebral palsy of unspecified etiology [11].
The clinical picture of cerebral palsy is based on motor disorders associated with the formation of statokinetic reflexes, pathological changes in muscle tone, paresis and paralysis. In addition, secondary to the patient's life, pathological processes occur in the nerve and muscle fibers, joints, ligaments, cartilage. Deteriorations arising from the orthopedic side (foot deformities, damage to large joints, the occurrence of joint-muscle contractures, etc.) at the stages of growth and development of a sick child are determined as a consequence of the pathogenic effect of statodynamic overloads in the process of defective formation and implementation of the program of voluntary movements. Many researchers of primary importance in the genesis of violations of the motor program from the development of cerebral palsy is attributed not to the structure of damaging factors, but to the time of their influence on the process of neuroontogenesis [12;13].
In addition to the characteristic motor deficit in children with cerebral palsy, a wide range of cognitive deviations is formed, which include decreased attention and memory, various speech disorders, purposeful actions, gnosis, changes in the emotional-volitional sphere. According to the results of numerous studies, the frequency of cognitive dysfunctions in patients with cerebral palsy on average is: decreased memory - 65%; concentration - 87%; verbal disorders - 82%; disorders of constructive activity - 60%; changes in spatial perception - 81% and body scheme - 75% of patients. By the nature of the cognitive deficit, each variant of cerebral palsy has its own characteristics, for example, with the spastic form, deviations in spatial gnosis and praxis dominate, while satisfactory formation of verbal thinking, abstraction and generalization skills are revealed, and, for example, the hyperkinetic form is characterized by deviations in verbal thinking, since with this variant of cerebral palsy, frequent auditory and auditory-speech disorders are determined, playing an important role in the pathogenetic processes of the above changes [14; 15].
Just as with the formation of motor function disorders, the process of changes in the development of cognitive activity in cerebral palsy is complex, has associations with the time, degree and localization of brain damage, and is also caused by the interaction of such factors as encephalopathic, dysontogenetic and the factor of multisensory disintegration, as a result of which the central nervous system receives incorrect information from the impaired visual, auditory and motor-kinesthetic analyzers. Currently, it is believed that one of the most important roles in the pathogenetic processes of cognitive complications belongs to the multisensory disintegration mentioned above. According to some authors, its formation is due to disorders of ontogenesis and slow development of interneuronal connections of both secondary and tertiary cortical analyzers, caused by hypoxia of the brain with a subsequent inflammatory reaction [16].
From literary sources it follows that of all the components of multisensory disintegration, the most important component is considered to be disorders of the auditory analyzer, which directly affect the formation of speech and the optimal functioning of cognitive activity in general. Of the total number of children with cerebral palsy, hearing changes are detected in 7-25% of patients, while the hyperkinetic form accounts for 62% of cases. In the clinical picture of these disorders, there is a deficit of auditory memory and auditory attention, underdevelopment of phonemic hearing. The main causes of hearing loss in CP are considered to be infections of the
intrauterine and neonatal periods, as well as pathological increase in bilirubin (hyperbilirubinemia) and low birth weight of the newborn [17].
To determine cognitive dysfunctions in cerebral palsy, the most commonly used diagnostic neuropsychological test scales are the A.R. Luria method, adapted for childhood, for the analysis of visual-constructive activity - a test for performing drawings, simple geometric figures, to assess concentration - Bourdon's proofreading test, to assess the level of mental development - a children's version of the Wechsler test, a short version of the Raven method, to study performance and fatigue - the Landolt test, to study memory - methods based on the reproduction of objects or numbers (visual memory), words (auditory memory), etc. [3]. In addition, for the integrity of the study of cognitive activity, laboratory and instrumental examination methods are also used.
In the study of the auditory analyzer, the most widespread method is the acoustic brainstem evoked potentials (ABEP). This method has stable reproducibility and a low percentage of individual lability of responses. ABP is a non-invasive study of the constant flow of impulses in the central nervous system from extero and interoception (afferentation). There are three types of this method: long-latency, medium-latency and short-latency. If the first two recreate information at the cortex level, then the short-latency from the auditory nerve of the brainstem, that is, from the conducting pathways. The so-called ABP curve has five step-by-step negative peaks, where the first two show neuronal excitation of the auditory nerve, the third peak demonstrates excitation of neurons of the medulla oblongata, the fourth peak irritation of neurons of the lateral loop and the fifth peak neuronal induction of the mesencephalic level [18; 19].
The issues of neurological rehabilitation of children with cerebral palsy occupy one of the leading places in the framework of the most important tasks of today's neurology. Neurological rehabilitation measures include a wide range of areas, both for the restoration of motor activity and for the maximum improvement of the child's cognitive functioning, which are extremely necessary for optimal social and intellectual adaptation in modern society.
The processes of rehabilitation of motor acts consist of mandatory therapeutic and gymnastic exercises, physiotherapy and massage procedures, the use of so-called posture supporting devices, specific walking suits. At the same time, special attention is paid to the issues of rehabilitation of motor coordination and proprioceptive control [20]. Over the past two decades, new methods of physical therapeutic intervention have been developed and implemented using modern technological means of robotics, simulators based on computer programs and virtual reality methods. Unfortunately, despite all this, most of them have not confirmed their significant effectiveness in the therapeutic process of patients with cerebral palsy. The reason for this, according to many authors, is the instability and short-term nature of the effects obtained, which almost always return to their original position [21; 22].
Almost 50% of children with CP have cognitive deficits of varying degrees of severity. The system of integrative rehabilitation measures for cognitive dysfunctions in CP consists of medical, psychological, pedagogical and social rehabilitation aimed at developing higher cortical functions and skills that enable those suffering from cerebral palsy to master and perform various social tasks and adapt to society. The main principle of cognitive rehabilitation is psychological, medical and pedagogical correction of this contingent of patients, which helps prevent the occurrence of subsequent changes and helps improve existing deviations, while significantly reducing the degree of disability. With the change in the concept of the essence of the earliest
intervention programs aimed at the formation of motor activity, an analysis of promising areas for changing and improving the cognitive activity of children with CP has also begun [23].
According to Nemkova S.A. (2018), the main corrective measures for patients with cerebral palsy should be on sensory education, that is, aimed at developing the child's optimal comprehension of the surrounding world (visual, acoustic, tactile-motor, etc.). It is on this basis that clear ideas about the external characteristic features of objects arise, which in turn contributes to the formation of the child's thinking, with the ability to think.
The main areas of sensory education are:
- development of all types of interoception;
- development of sensory standards of shape, size, temporal-spatial standards and muscular-articular sense;
- development of a clear idea of the surrounding reality;
- development of higher cortical activity and therapy for their deviations;
- development of speech skills, replenishment of the child's vocabulary [24]. Many authors, depending on the type of cerebral palsy and the structure of cognitive dysfunction, define the following correctional and pedagogical measures [25]:
1) in the spastic-diplegic variant of cerebral palsy: first of all, improving visual-motor coordination, spatial orientation, learning to calculate, developing self-service abilities;
2) in the hemiparetic variant of cerebral palsy: correction of writing, speech delay, development of manipulations of the paretic limb, associated manipulations, correction of attention to the left or right side of objects and images;
3) in the hyperkinetic variant of cerebral palsy: primary correction of auditory deviations, speech development, development of verbal thinking.
The extreme need for the earliest correctional measures in CP is also based on the characteristic features of the child's brain, namely its plasticity properties and versatile ability to compensate for impaired functions.
Conclusions. Thus, patients with cerebral palsy are characterized by a "dissociated" type of cognitive deficit. In addition to motor disorders, the formation of cognitive dysfunctions is also based on sensory pathologies, which very often accompany children with cerebral palsy. Sensory pathology plays a significant role in the pathogenesis of intellectual development disorders, as evidenced by previously conducted research. It should also be noted that, despite the available data on the diversity of scientific papers devoted to deviations in ASVP indicators in demyelinating pathologies of the central nervous system, the number of research papers aimed at analyzing ASVP specifically in cerebral palsy is extremely insignificant. The disorders identified during the analysis will help to objectify the ideas of sensory disintegration and potentially contribute to the early detection of these dysfunctions at the preclinical stage of the pathology. In conclusion, we note that timely and adequate diagnostics of cognitive and neurosensory deficits in children with cerebral palsy is one of the most significant and urgent tasks, since it determines the nature and prognosis of both medical and social rehabilitation measures. The results of the assessment of literary data demonstrate the undeniable need for the development and implementation of modern technological methods for the rehabilitation of children with cerebral palsy, which will be aimed not only at compensating for dysfunctions and adapting to life in society, but will also favor the cognitive and personal development of these children.
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