New Technologies in Comprehensive Physical Rehabilitation of Patients with Cerebral Palsy in the Late Residual Stage

The dissertation is dedicated to the development and implementation of new technologies for comprehensive physical rehabilitation of children and adolescents with various forms of cerebral palsy (spastic diplegia, hemiparetic, and atactic forms) in the late residual stage. The research substantiates the necessity of an individual approach to the construction of restorative treatment programs, taking into account the diversity of clinical manifestations of motor disorders, and is aimed at optimizing posture and gait stereotypes, improving the quality of life, and social adaptation of patients. Original methods of dynamic muscle stretching, training of coordinated movements of the upper extremities during gait, and pathogenetically justified complexes using phase-electrical muscle stimulation have been created in the work.

Relevance of the Problem. In recent years, the Russian Federation has observed a steady increase in the number of disabled persons, with the peak prevalence of disability falling on children and adolescents aged 10-14. Among the causes of childhood disability determined by the underlying disease, the first place belongs to diseases of the nervous system and sense organs; in this same group falls cerebral palsy (CP), the prevalence of which is 19.4 per 10,000 children. This determines the scale of the problem from both a medical and social standpoint and the relevance of research in this area (D.I. Zelinская, L.S. Baleva, 2001).

The insufficient efficacy of traditional means of physical rehabilitation of patients in the late residual stage of CP, and the slowing of the rate of formation of a positive response to treatment (S.A. Bortfel'd, 1986, B. Yeish, 1995, K.A. Semenova, 1999), determine the necessity of creating new and optimizing existing methods of physical therapy (PT), utilizing modern achievements in the field of artificial control of movements to limit the manifestations of the disease, expand the opportunities for vital activity of patients, and improve the conditions of their professional and social adaptation (A.S. Vitenzon et al., 1999).

The diversity of clinical manifestations and the varying degree of severity of motor disorders in patients with different forms of CP require a strictly individual approach in the development of their physical rehabilitation programs. This determines the necessity of creating a unified system for assessing the state of the musculoskeletal system of the patient and a modern list of basic and auxiliary means of PT to increase the efficacy of rehabilitation measures.

One of the important tasks in the process of correcting the pathological stereotype of gait in patients with CP is the cultivation of physiological synkineses of the upper extremities. However, to date, essentially, no staged cultivation of an optimal gait stereotype with coordinated involvement of the upper extremities in patients with CP has been developed, which could be based on the biomechanical regularities of the gait cycle in norm and pathology (N.A. Bernstein, 1947, A.S. Vitenzon, 1998, D. Winter, 1991, J. Perry, 1992, D. Sutherland et al., 1996).

The relevance of the research is also determined by the fact that the minimization of the manifestations of posture and gait defects in children and adolescents simultaneously eliminates their negative influence as a psychotraumatic factor, which substantially affects personality formation, becoming the subject of acute experiences of patients, the cause of anomalies in their behavior and learning (E.S. Kalazhnyuk, 1987, K.A. Semenova, 1999).

The Aim of the Study:

To increase the efficacy of physical rehabilitation of patients with cerebral palsy in the late residual stage in order to improve their quality of life and social adaptation.

Tasks of the Research:

1. To develop a method of dynamic muscle stretches in patients with spastic forms of cerebral palsy and to evaluate the efficacy of its use.

2. To create a method for training coordinated movements of the upper extremities and to substantiate the advisability of its application in patients with cerebral palsy in the late residual stage.

3. To develop a pathogenetically justified complex of physical rehabilitation for patients with tibial syndrome in spastic diplegia.

4. To develop an algorithm for the combined comprehensive application of methods of dynamic muscle stretching, training of coordinated movements of the upper extremities, and functional electrical muscle stimulation in patients with spastic forms of cerebral palsy.

5. To determine the efficacy of modern means of physical rehabilitation for patients with atactic syndrome in spastic diplegia.

6. To assess the influence of comprehensive physical rehabilitation aimed at improving the mechanisms of maintaining vertical posture and the structure of gait in patients with the hemiparetic form of cerebral palsy.

Scientific Novelty:

A system of comprehensive physical rehabilitation of patients with spastic forms of cerebral palsy using modern means and methods of restorative treatment has been developed.

A higher efficacy of comprehensive physical rehabilitation of children with spastic forms of cerebral palsy compared to traditional methods of physical therapy has been demonstrated.

The efficacy of the use of artificial gait correction in the comprehensive rehabilitation of patients in the late residual stage of cerebral palsy has been proven for the first time.

Original methods of physical therapy have been developed and introduced for the first time — the creation of a stereotype of coordinated movements of the upper extremities during gait and dynamic muscle stretches, providing comprehensive correction of posture and gait disorders in spastic forms of cerebral palsy in the late residual stage.

An effective pathogenetically justified complex of exercises and training devices for the physical rehabilitation of patients with mild and moderate manifestations of tibial syndrome in spastic diplegia has been developed.

It has been proven that the application of the developed methods in comprehensive physical rehabilitation of patients with cerebral palsy contributes to the optimization of the stereotype of maintaining vertical posture and the improvement of temporal and spatial characteristics of gait.

It has been shown for the first time that the use of phase-electrical muscle stimulation in comprehensive physical rehabilitation provides effective correction of posture and gait disorders in patients with the therapeutically resistant hemiparetic form of cerebral palsy.

It has been proven that the complex use of original methods of physical therapy and artificial gait correction improves locomotor function in patients with spastic diplegia and atactic syndrome.

Practical Significance:

It has been established that the efficacy of comprehensive physical rehabilitation of patients with cerebral palsy in the late residual stage is substantially increased when using original methods of physical therapy and artificial gait correction.

A modern system for assessing the state of the musculoskeletal system of patients with cerebral palsy has been proposed and introduced, and effective means of physical correction of motor disorders in these patients have been recommended, providing an individual approach in the development of their physical rehabilitation programs.

Methods of dynamic muscle stretching in spastic forms of cerebral palsy and training of coordinated movements of the upper extremities during gait have been created and introduced, which increase the efficacy of restorative measures for improving posture and gait in patients with CP in the late residual stage.

An algorithm for comprehensive physical rehabilitation using modern means and original methods of physical therapy for the optimization of motor capabilities of patients with cerebral palsy has been developed, which improves the quality of life and social adaptation of children and adolescents.

The efficacy of comprehensive physical rehabilitation of patients with the hemiparetic form of cerebral palsy through normalization of posture and optimization of the gait stereotype has been demonstrated.

The efficacy of restorative therapy for patients with atactic syndrome in spastic diplegia in the late residual stage indicates the necessity of combined application of PT methods and the method of artificial gait correction in these patients.

Normalization of the range of motion in joints, elimination of pathological settings and spastic contractures by means of the method of dynamic stretches ensures the optimization of the stereotype of maintaining vertical posture and the improvement of the biomechanical structure of gait in patients with cerebral palsy in the late residual stage.

Comprehensive physical rehabilitation of patients with CP using the developed method of staged cultivation of an optimal stereotype of movements of the upper extremities during gait contributes to the destruction of the pathological pattern of gait, the development of a normalized gait stereotype with the leveling of unaesthetic postures and movements, which are psychotraumatic moments for patients, especially in adolescence.

The implementation of measures of the developed system of comprehensive physical rehabilitation in patients with spastic forms of cerebral palsy ensures the normalization of pathological stereotypes of posture and gait maintenance, reduces the severity of disability, improves the quality of life, and the possibilities of their social adaptation.

Implementation of the Obtained Results in Practice. The results of the conducted comprehensive research and the developed system of medical-social rehabilitation of children and adolescents have been introduced in the work of the Children's Psychoneurological Hospital No. 18 of the Department of Healthcare of Moscow, the Scientific Center for Children's Health of the RAMN (Research Institute of Pediatrics), Moscow, as well as in specialized pediatric departments and Rehabilitation Centers for Children with Disabilities of the Tyumen Oblast, the cities of Magnitogorsk and Syktyvkar.

The Dissertation Materials are Used in the educational process of the Russian Academy of Postgraduate Education of the Ministry of Healthcare of the Russian Federation and Siberian State Medical University at the Department of Restorative Treatment and Work Capacity Expert Examination of the Faculty of Advanced Training of the Russian State Medical University and are recommended for introduction in profile departments of scientific-research institutes, city, regional, and republican psychoneurological centers.

A method for the normalization of muscle tone in children with spastic forms of cerebral palsy is proposed (priority patent certificate No. 2005127092 (030414) dated 08/29/2005).

Validation of the Work. The main provisions of the dissertation were presented and discussed at the All-Union Scientific-Practical Conference «Medical-Technical Problems in Rehabilitation of Children and Adolescents with Lesions of the Musculoskeletal System and Nervous System» (Moscow, 2000), the Scientific-Practical Conference «Problems of Rehabilitation of Children with Neurological-Orthopedic Pathology» (Moscow, 2003); the Seminar-Council «Rehabilitation of Persons with Disabilities» (Salekhard, 2003); the joint outgoing meeting of the Russian and Moscow Associations of Sports Medicine and Rehabilitation of Patients and Disabled Persons (Moscow, 2004); the International Congress «Restorative Medicine and Rehabilitation» (Moscow, 2004), the VI City Scientific-Practical Conference «Medical Rehabilitation of Patients with Diseases and Injuries of the Musculoskeletal and Nervous Systems» (Moscow, 2004), the X Congress of Pediatricians of Russia «Ways to Increase the Efficiency of Medical Care for Children» (Moscow, 2005).

Volume and Structure of the Dissertation. The dissertation is presented on 315 pages and consists of an introduction, 7 chapters of original research, a conclusion, conclusions, and practical recommendations. The list of literature includes 149 domestic and 137 foreign sources. The work is illustrated by 27 tables and 68 figures.