Page 8 of 10
Differential diagnosis of acute flaccid paralysisIn the paralytic and early recovery stages, poliomyelitis can be mixed with various diseases occurring with paralysis, especially of a flaccid nature, as well as with pseudo-paralysis due to damage to the structures, muscles and bones.
Of great importance is the differential diagnosis between poliomyelitis and polyradiculoneuropathy of various etiologies. The clinical picture of this syndrome (it is often called Guillain-Barré syndrome or Landry's ascending paralysis) consists of motor disorders, changes in the reflex, sensory and vegetative spheres. The disease develops at any time of the year 1-2 weeks after any rise in body temperature, catarrhal phenomena, intestinal disorders or hypothermia.
The disease begins with the patient's complaints of pain in the legs, less often in the hands. Small children refuse to get on their feet, looking for a gentle position. Objectively, there are symptoms of tension, sensitivity disorders such as "stocking" and "gloves".
Paresis and paralysis in polyradiculoneuropathy, as well as in poliomyelitis, are sluggish, but they are usually symmetrical, diffuse, more often expressed in the distal extremities, the type of distribution of paresis is predominantly ascending; their intensity is mostly expressed moderately. Tendon reflexes decrease or disappear, abdominal reflexes are not caused only with widespread paralysis of the muscles of the trunk and limbs, urination may be occasionally disturbed, which does not happen with poliomyelitis. Occasionally, mild, transient, pyramidal symptoms may appear, but cranial nerve damage is common. The most typical is a symmetrical lesion of the facial muscles, then, according to the frequency of involvement in the pathological process, there are IX, X, then III, IV, VI pairs, less often VII and XII.
Table 5
Diagram of types of respiratory disorders
|
Type of upset breath |
What is affected |
The nature of the breath |
Type of breath |
Airway condition |
Development features | ||||
|
amplitude | |||||||||
|
Paralysis of the respiratory muscles (diaphragm, intercostal) |
Right |
Paradoxical breathing, often shallow. |
free |
gradual increase |
Continuous |
||||
|
geal |
Paralysis of the muscles of the pharynx, larynx and tongue (impaired swallowing, phonation, speech) |
Wrong- |
figurative |
increased |
bubbling, |
filled |
sudden appearance |
Suction of mucus, "drainage position", intubation. Apparatus artificial respiration is contraindicated in case of obstruction of the airways. |
|
|
bulbar |
The defeat of the bulbar centers of respiration |
Mess- |
figurative |
Pathological types of breathing (Cheyne-Stokes, Grocco, periodic, etc.) |
free |
sudden appearance |
massive |
||
|
Combined bathroom with bulbar spinal forms |
Paralysis of the respiratory muscles. Paralysis of the muscles of the pharynx, larynx and tongue, respiratory and vasomotor center |
More often wrong |
More often small |
Various combinations of spinal and pharyngeal |
More often filled with mucus, saliva, etc. - |
More often |
First, it is necessary to provide free access of air to the respiratory tract, and then artificial respiration |
||
With bulbar syndrome, as with deep paralysis of the respiratory muscles, life-threatening respiratory disorders occur.
Autonomic disorders occur in a number of patients in the form of cyanosis, soft tissue edema, sweating, cold extremities. There is also a mild diffuse muscle atrophy, mainly in the distal extremities. From the first days of the disease, more often in the second week, protein-cell dissociation is detected in the cerebrospinal fluid, mainly due to a significant increase in the protein content.
The disease has a favorable course, with almost complete restoration of lost functions due to paralysis.
Bulbar forms of poliomyelitis can be mistaken for diphtheria neuritis, polyneuritis, diphtheria croup and vice versa. For differential diagnosis, the fact that in diphtheria there is often a selective lesion of the fibers of the glossopharyngeal nerve, sometimes a violation of accommodation, which is not typical for: poliomyelitis. Neuritis in diphtheria is often accompanied by toxic myocarditis. The diagnosis of diphtheria is confirmed by a high titer of diphtheria antitoxins in the patient's blood serum.
The presence of muscle weakness, hypotension, decreased reflexes is observed in myopathies that develop without connection with the infectious process, without pain. With myopathy, the disease progresses for a long time: a “duck gait”, atrophy of the muscles of the trunk, shoulder and pelvic girdle appear, muscle tone and strength decrease, masking of the face, pseudohypertrophy of the muscles of the legs.
For myasthenia gravis, fatigue, weakness, "flickering" of paresis are typical - weakening of symptoms during the day with their subsequent intensification after fatigue. A positive prozerin test can serve as a confirmation of the diagnosis: after the introduction of prozerin, muscle weakness decreases or disappears.
In exceptionally rare cases, flaccid paralysis can occur in children vaccinated with live polio vaccine. Approximate risk - I case of paralytic disease per 2-3 million doses of the vaccine. The disease can develop not only in vaccine recipients, but also in persons who have had close contact with the vaccinated. The greatest risk of paralysis occurs after the first dose of oral polio vaccine.
WHO introduced the concept of vaccine-associated poliomyelitis. According to WHO recommendations, vaccine-associated poliomyelitis includes cases when:
1) the disease begins within the period from the 5th to the 30th day after taking the live oral polio vaccine (for those who had contact with the vaccinated, the period is extended to 60 days);
2) the development of flaccid paralysis or paresis without impaired sensitivity persists for more than 2 months;
3) there is no progression of the disease;
4) a vaccinal strain of the poliomyelitis virus is isolated from the patient and in the dynamics of the disease, antibody titers to it increase by at least 4 times.
If these conditions do not occur, then the disease resulting from oral polio vaccine is recorded as a vaccine reaction. The course of vaccine-associated poliomyelitis is favorable.
Kharkov - 1993
The textbook was compiled by: candidate of medical sciences, associate professor K.K. Makarenko (Head of the Department of Children's Infectious Diseases of KhIUV), Ph.D. V.A. Mishchenko (Associate Professor of the Department of Children's Infectious Diseases;: KhIUV, I.D. Osadchaya (children's neuropathologist, consultant of the Kharkiv Regional Children's Infectious Clinical Hospital).
This is a neurological syndrome that develops when a peripheral neuron is damaged, and is characterized by the loss of both voluntary and involuntary, or reflex, innervation.
flaccid syndrome is characterized by the following features [Duus P., 1995]:
- lack or decrease in muscle strength;
- decreased muscle tone;
- hyporeflexia or areflexia;
or muscle atrophy.
Hypotension and areflexia develop in connection with the interruption of the arc of the monosynaptic stretch reflex and the breakdown of the mechanism of tonic and phasic stretch reflexes. the muscle is caused by a violation of the trophic influence from the anterior horn on the muscle fibers, develops several weeks after the denervation of the muscle fibers and can be so pronounced that after a few months or years only the connective tissue remains intact in the muscle.
Flaccid paralysis (paresis) develops when a peripheral (lower) neuron is damaged in any area: anterior horn, root, plexus, peripheral nerve.
For treatment appoint:
Restorative measures in the development of flaccid paresis or paralysis are aimed, firstly, at restoring (if possible) the function of a peripheral neuron, and secondly, at preventing the development of muscle tissue atrophy and prevention.
Improving the function of the nervous tissue is achieved by prescribing neutrotrophic and vasoactive drugs:
* nootropil/piracetam (in capsules/tablets of 0.4 g-0.8 g three times a day or 20% solution of 5-10 ml intramuscularly or intravenously);
* Cerebrolysin (3-5 ml intramuscularly or intravenously);
* actovegin (5-10 ml intramuscularly or intravenously once or twice a day; 1 ml contains 40 mg of the active substance);
* trental (in a dragee, 0.1 g three times a day, or intravenously, 5 ml once a day; 1 ml contains 0.02 g of the active substance);
* vitamin B1 (solution of thiamine chloride 2.5% or 5% or thiamine bromide 3% or 6%, 1 ml intramuscularly daily 1 time per day);
* Vitamin B12 (400 mcg intramuscularly once every 2 days, you can simultaneously with vitamin B1, but not in the same syringe).
In violation of the anatomical integrity of the peripheral nerves, neurosurgical intervention may be indicated.
Development warning. It is a very important task, since the degeneration of denervated muscle fibers develops very quickly and is often irreversible. By the time the innervation is restored (by natural reinnervation or with the help of neurosurgical intervention), atrophy can reach such a pronounced degree that it is no longer possible to restore muscle function. Therefore, measures to prevent the development of muscle atrophy with impaired innervation should be started as early as possible. To do this, prescribe massage (classical, acupressure, segmental), therapeutic exercises, electrical stimulation of nerves and muscles.
Massage. It is aimed at stimulating muscles, therefore, among the techniques used are quite intense rubbing, deep kneading, and impact on segmental zones. However, the massage of the paretic muscles should not be done with great force. Massage should be moderate and short-lived, but carried out for many months (short breaks are made between courses). Rough painful techniques can cause an increase in muscle weakness. They also use acupressure according to a tonic technique. The tonic method of acupressure is carried out by applying with a fingertip vibrating, short, quick irritations successively to a series of points that stimulate the desired movement.
The picture of flaccid paraplegia usually occurs when the spinal cord is damaged in the region of the lumbar vertebrae, i.e., the "horse tail" (caudae equinae). In case of injuries of the lower thoracic spine, in the area of thickening of the spinal cord and conus terminalis, spastic paralysis (paresis) of the legs is often accompanied by flaccid paralysis, which apparently developed as a result of extra- or intradural hemorrhage in the caudae equinae area. The picture of the simultaneous existence of symptoms of flaccid and spastic lower paraplegia may also depend on damage to the very substance of the lower part of the spinal cord.
Unlike spastic forms, flaccid paralysis is characterized by deeper functional disorders of the motor apparatus and muscle trophism. So, with lower flaccid paraplegia, the patient cannot move independently and he has to be on bed rest. It changes its position due to the compensatory tension of the muscles of the upper limbs and the shoulder girdle. Some of these patients move around with crutches. The tone of the muscles of the paretic limb is sharply reduced, they are flabby, atrophic. Because of this, the foot is in the position of pes equinus eguinovalgus.
The clinic "Vremena Goda" has developed special complexes of kinesitherapy - including the use of physical exercises as a natural biological stimulator of physiological processes, various methods of magnetic, electrical, ultrasonic and other types of stimulation of atrophic muscles and nerves, a wide range of other methods of influencing the neuromuscular apparatus with the purpose of restoring metabolic processes and restoring lost functions.
Unlike spastic forms in flaccid paralysis, passive movements are performed without muscle tension in the patient's limbs. During passive movements, the instructor-methodist makes efforts to overcome the heaviness of the limb itself. Movements in the joints are often free, and in some cases there is looseness.
Active movements with flaccid paresis are difficult to carry out, their amplitude is usually limited due to severe muscle weakness. When performing exercises, the direction of movement is often disturbed due to the fact that the strength of the muscular system is insufficient to hold the limb. Any exercise associated with overcoming the severity of the paretic limb itself is difficult, and sometimes completely inaccessible to the patient. There is a sharp violation of the support function, patients cannot stand and walk, and if they move with the help of medical personnel or with the help of crutches, then with great physical exertion.
In connection with prolonged bed rest, general weakness develops, in the presence of which a large effort expended on movement creates the prerequisites for increased reactivity of cardio-vascular system.
With flaccid paralysis and paresis, a deeper violation of trophism is observed than with spastic forms. Therefore, therapeutic agents should not only stimulate the neuromuscular impulse, but also significantly affect the improvement of nutrition of the tissues of the paretic limb.
Passive movements in flaccid paralysis are combined with massage or with active restorative movements, and in paresis they are combined with active movements for paretic limbs. When limiting movements in the joints due to the formation of secondary changes in the ligaments, joint capsule and muscles, it is necessary to assign passive movements within the physiological norms of mobility. Passive movements should bring the points of attachment of the paretic muscle groups closer together in order to gradually strengthen and shorten them. Contributing to the preservation of the normal length of the muscles, passive movements protect the joints from the deformity of the subluxations and dislocations observed in flaccid paralysis. Passive exercises in flaccid forms of paralysis, as well as massage, contribute to the restoration of active movements. This property of passive exercises is especially valuable in cases where there are no voluntary movements.
The most important practical value for restoring the function of movement and support are active exercises. Preliminary application of massage, physiotherapy stimulation and passive exercises is a preparatory measure for revealing the active impulse to movements. When the latter appears, it is necessary to pay all attention to the conditions conducive to its detection, and in every possible way strive to systematically evoke it, gradually increasing the motor reaction. For this purpose, sending impulses to the reduction of paretic muscle groups is used.
In the presence of a motor reaction, the most elementary exercises should be prescribed in optimal initial positions that facilitate the implementation of movements. For this purpose, exercises with the help are widely used. One of the conditions contributing to the identification of limited motor function is the exclusion of friction and the gravity of the paretic limb. For this, special simulators and devices are used to facilitate the implementation of active exercises in a lying, sitting or standing position.
When performing active movements, the patient must be strongly required to perform volitional tension, which stimulates the manifestation of a motor reaction in paretic muscle groups.
When exercising the hand and fingers, it is necessary that the entire forearm has a stable support (it is better to sit at the table). In this position, a variety of generally accepted exercises for the hand and fingers are used, using small equipment: ladders, rollers and semi-rollers, balls, supronators, side and table devices, etc.
Highly good results in the complex treatment, occupational therapy classes are given - modeling, fastening, unfastening, grabbing and other various movements for developing fine motor skills of the fingers.
With flaccid mono- and paraplegia of the lower extremities, it is necessary to assign movements that contribute to the development of the support function. Care for the gradual strengthening of the support should be the basis of the method of therapeutic exercises for paresis of the lower extremities. In our Vremena Goda clinic, for this purpose, a large list of special simulators, suspension systems, functional orthoses, and other devices for restoring vertical balance and support function is used.
When applied exercise for patients of this group, it is necessary to take into account disorders of the function of their pelvic organs (urinary incontinence, frequent urge, urinary retention, etc.). When doing therapeutic exercises, it is necessary to include exercises that activate blood and lymph circulation in the pelvic area and strengthen the muscles of the pelvic floor and sphincters. Special exercises include hip movements in different directions with maximum amplitude and exercises with retraction of the anus. In addition, special schemes of drug regulation of function, balneotherapy (mud, hydrotherapy), special types of physiotherapy and more are used.
The gradual forcing of physical tension in the paretic limbs allows the use of exercises with power tension. Exercises are introduced gradually, depending on the motor response of the paretic limb. Weighting with a projectile or movement with resistance must be selected so that the patient can overcome it with the tension of the paretic muscles.
Against the background of special movements for paretic limbs great importance acquires with sluggish forms of restorative gymnastics. It is especially necessary to pay attention to the compensatory development of the upper limbs and shoulder girdle, which bear the main load when the patient moves on crutches.
The process of restoring movements in the limbs with developed flaccid paralysis and paresis is slow, and therefore the persistent exercise during the entire course of treatment several times a day is obligatory element methods.
Sometimes, with the general preservation of the spine, the resulting injury, and often the subsequent surgical intervention (laminectomy), significantly disrupts the musculoskeletal function of the spine. To this should be added the negative effect of prolonged bed rest.
As a result, this leads to limitation of spinal movements along all axes and planes, to weakening of the muscular system that fixes the spine and maintains it in a vertical position, as well as to a decrease in the supporting function of the spine.
All activity of the system of organs of movement (muscles, ligaments, joints, bones) is closely related to the trophic processes occurring in it, which are largely activated by the systematic use of physical exercises. That is why therapeutic exercises for traumatic injuries of the spinal cord and spine, surrounded by " muscle corset' is widely used. In such cases, it is corrective.
Assign exercises to strengthen the muscular-ligamentous "corset" of the spine, mainly for the extensors of the body. Exercises with active muscle tension are performed in the supine position (on the back, on the stomach), sitting, on all fours and standing (if necessary, with the help of medical personnel).
The main thing in the method of therapeutic physical culture is the restoration of the support function, learning to walk. This process is very time-consuming and requires great perseverance and perseverance, both from the patient and from medical workers.
Even when the patient is lying, exercises are prescribed with partial support on the legs in the “half-bridge” position. Later, exercises on all fours play an important role in the development of the support function.
Exercises on all fours are first performed on the spot, and later, after acquiring a stable position, in crawling. Due to the reduction in the length of the lever (thigh) compared to the vertical position (the length of the entire leg), and also due to the increase in the support area, this type of exercise is available to patients at a certain stage in the development of the support function. In the process of developing the support function, exercises on all fours have a large proportion.
The kneeling position is the next stage in the development of support function. To facilitate it, use a horizontal ladder, or low bars, if necessary, a suspension system.
In a standing position, the patient moves from a sitting position on a chair, and getting up is carried out with the help of hands resting in special simulators (walking simulator, mobile bars, etc.). The entire subsequent period of training of the support function is carried out in a standing position. Taking into account the flabbiness of the muscles, twisting and "wobble" of the legs, when learning to walk, they use removable orthoses that fix the knee and ankle joints.
The process of development of the support function, both in spastic and especially in flaccid forms, requires systematic, consistent and persistent training.
When using complex rehabilitation therapy at the Vremena Goda clinic, for the treatment of patients with traumatic spinal cord injury, gymnastics in water is also used - in a warm bath, pool, etc. For a complete list of methods used, see the section of the site "How we treat".
08.05.2013
Introduction. The main difference between flaccid (peripheral) and spastic
sky (central) paralysis is the preservation or destruction
peripheral motor neuron. With its safety, as well as with
earlyness of its axon, paralysis will be in the nature of the central
(spastic), and if the paralysis is destroyed, it will have the character
sluggish or peripheral.
In this lecture, we will consider peripheral (flaccid) paralysis.
on the example of a well-known disease - poliomyelitis.
Poliomyelitis
Poliomyelitis, infantile spinal paralysis, anterior acute polio
myelitis, Heine-Medin's disease - described in 1840.
Poliomyelitis usually affects children 2-3 years of age, but
pain can also occur in older age groups and
in adults.
The causative agent of the disease is a virus. The main gate of infection is
gastrointestinal tract.
The course of poliomyelitis is distinguished by 4 stages: initial or pre-
paralytic (2-5 days), paralytic, recovery, residence
nal or stage of residual phenomena,
Forms of the disease: abortive, neurotic, spinal.
Paralysis appears after 24-48 hours, sometimes later. Restored
the waiting period can last up to 8 years, but, in general, the estimated
the restoration of the functions of the paralyzed groups may be in the coming
1-2 years. In the future, the probability of restoring lost functions
tions is small if there is no pseudo-paralysis due to deformation, resisting
driven by muscle overstretching and disruption of their biomechanics.
Along with general treatment for poliomyelitis, great importance
has a warning of vicious positions of the limbs in order to pro-
lactic overstretching of muscle groups and the development of contractures.
should be pointed out that severe paralytic information after polio
litai of flaccid paralysis of other origin are the result of
underestimation of the orthopedic treatment of these patients in early dates. At
polio vicious situation for several days no longer-
rarely leads to the development of persistent contracture. Thus, or-
topical prevention of contractures should be carried out already from the first
weekends of the paralytic period. The task of the surgeon is the district and
rural district hospital is not only knowledge of prevention
medical measures, but also training them in the staff of the pediatric infectious disease department
Tasks of orthopedic treatment of post-polio patients
Diam of the disease can be formulated as follows:
1. In the acute period at the beginning of the paralytic stage, all measures are
blows to direct the laying of the limbs and their segments in the functional
financially advantageous position for the prevention of contractures.Here
can be used in bed with rollers 6 light
loads on the area of the knee joints, supports for the feet, plaster
and plastic tyres.
2. In the recovery phase, the treatment should be
the following tasks: treatment of contractures that have arisen and prevention of re-
emerging contractures and deformities as a result of loss of function
different muscle groups, creating optimal conditions for the recovery
changes in affected muscle groups.
3. In the residual stage, the main task is to rehabilitate
patient, including sections of physical, labor, social and
household rehabilitation. Those. the patient should be able to
to serve oneself, to get rid of the orthopedic apparatus as much as possible
comrade, find your place in working life and, if possible, approx.
build the appearance of the patient, gait and everyday life to the life of ordinary health
ry man.
the listed tasks should be solved in a complex, because, for example,
measures, with the closure (arthrodesis) of the hip joint with paralysis
gluteal muscles allows a person to return an active gait, but with
multiple lesions of muscle groups, will prevent pain
to him to perform the work of a clerical type, which will become his main
new form of work.
So, in the recovery period, one of the tasks is to treat
contractures and deformities that have already arisen, which is achieved by the following
using methods:
stage plaster casts,
Plaster casts with twists according to Momsen and others,
Various devices such as Volkov - Oganesyan, Ilizarov,
therapeutic gymnastics,
Corrective osteotomies such as Röpke, Kochev, wedge-shaped,
pepper, hinged, etc.,
In some cases, tendon lengthening (it should be remembered that
that with the lengthening of the tendons as the restoration of the lost fun-
a reverse deformation may occur).
The second task of the recovery period is the need
ability to eliminate the risk of recurrence of the existing deformity and development
new, which is achieved by the appointment of orthopedic devices, short
sets, orthopedic shoes with compensation for the existing shortening (for
patients with poliomyelitis there is a lag in the growth of the patient co-
limbs), temporary (for the night) gypsum and plastic splints;
noah gymnastics, etc.
The third task of the recovery period is to create-
the most optimal conditions for the restoration of the function
female muscles. it should be remembered that some muscles are
are in a pseudo-paralytic state due to their overextension
violations of biomechanics (for example, in the case of a pronounced five-
exact foot point of attachment of the Achilles tendon and shin-
top joint can appear almost on one straight line). AT
In this case, the elimination of contractures by conservative methods can
lead to the restoration of muscle function, i.e. and will be optimal.
condition for its restoration.
In addition, to restore the function of the affected muscles, apply
nyut drug treatment(prozerin, dibazol, vitamins B-1, B-6,
B-12), physiotherapy (woolen wrapping, faradization of the affected
muscles, ionogalvanization with potassium iodide, novocaine, general baths),
therapeutic exercises, massage. However, it should be remembered that physiotherapy
fools, massage and gymnastics should begin gradually, with increasing
current strength and duration, otherwise the functional load on
affected muscles can become excessive and lead to aggravation
degenerative-dystrophic process.
In the residual stage, patients with the consequences of poliomyelitis
a full range of orthopedic treatment is carried out. At this stage
all of the listed methods of treating existing con-
contractures. The prevention of new contractures is carried out by such
methods that would rule out or make relapse unlikely
contractures. At this time, tendon-muscular
plastic surgery, i.e. transplantation of muscle groups, arthrosis (surgery
tions aimed at limiting movements in the joints by forming
bony protrusions, changes in the shape of the articular surfaces -
example, when raising the posterior edge of the talus block, a
an obstacle for equinus deformation), arthrodesis - i.e. opera-
tions that immobilize the joint, tenodeses - operations6 limiting movement
zheniya in the joints by suturing the tendons to adjacent segments -
for example, fixing the tendon of the anterior tibial muscle to the lower
third of the tibia; elongation and shortening of the limb
those, reduction of paralytic dislocations, etc.
corrective osteotomies and corrective staged plaster bandages
and twists like Momsen, treatment of contractures with the help of devices ti-
pas Ilizarov, Volkov-Oganesyan and others.
it is important to achieve such a state that the patient as much as possible
freed from orthopedic appliances and orthopedic shoes
the same time was not exposed to the danger of recurrence.
Median pathology in patients with poliomyelitis subordinate
the tor should also know some of the most common de-
formations. Such as deformity of the hip joint (resulting in
shaping, flexion contractures due to the defeat of the gluteal
muscles; paralytic dislocation of the hip), knee joint (flexion
contracture, looseness), feet (drooping foot, equinus deformity)
mation, calcaneal foot, sagging of the first metatarsal bone, paralytic
clubfoot, paralytic flat-valgus foot), shoulder
joint (adductor contracture, laxity due to paralysis
deltoid muscle), scoliosis and some others.
It should be noted that orthopedic treatment is painful
poliomyelitis should proceed from the interests of not only domestic,
but also social rehabilitation. Treatment is usually multi-stage, in
connection with which the patient should be examined in great detail, taking into account
already developed stereotype, the treatment plan should be promising
tive and systematic. Usually orthopedic treatment
start from the "root" of the limb (if the lower limb, then ottazo-
hip joint, gradually descending to the periphery). Wherein
it should be borne in mind that existing deformities can wear concordan-
tny (mutually compensating) and discordant (mutually aggravating)
character.
THE MAIN THING IN THE TREATMENT OF A PATIENT WITH FLEXIBLE PARALYSIS IS PREVENTION
DEFORMATIONS,T.K. DEVELOPED DEFORMATIONS ARE DIFFICULT
NEW ORTHOPEDIC PROBLEM.
LIMB DEFORMATION DUE TO SPASTIC PARALLIES.
Spastic (or central) paralysis occurs in those cases
yah, when the peripheral motor neuron is preserved. These paralysis are often
are the result of cerebral palsy, which is known to
may wear a pyramidal, extrapyramidal or cerebellar pattern
rakter. With the * pyramidal nature of cerebral palsy, developing
spastic paralysis; with an extrapyramidal variant - hy-
perkinesis; with cerebellar - ataxia. That. an orthopedic surgeon, usually
have to deal with patients suffering from a pyramidal form
spastic paralysis.
the largest group of patients with spastic paralysis is
patients with Little's disease.
Spastic paralysis can be divided into prenatal, childbirth
you and postpartum.
The etiology of spastic paralysis is hypoxia of the brain
ha, birth trauma, brain dysplasia, etc.
There are mild, moderate and severe forms of spastic pas-
paresis (paresis).
With a mild degree of spastic paralysis, the intellect in patients
nyh is not violated or is violated slightly, patients are independent
move around and take care of themselves. With an average degree -
often a violation of intelligence, hearing, vision is determined, but some of
these patients can be adapted to work.
Prirezko expressed forms diseases are often disturbed
telno mentality, there is strobism, salivation and other symptoms. Vtya-
In other cases, there is dementia, hyperkinesis, athetosis.
In patients with spastic paralysis, the total muscle strength is reduced
on, impaired reciprocal innervation.
Clinically patients with spastic paralysis have the following
general symptoms: according to the prevalence of the lesion, monopare-
PS, diparesis, paraparesis, hemiparesis, triparesis. Gait in patients with ha-
rakterizuetsya most often walking on half-bent knees, hips
femoral and ankle joints of the legs. At the same time, due to the adductor
leg contractures cross in such a way that traces of the right
legs are located to the left of the traces of the left foot; hands (if they are hit-
us) are bent at the elbow joint and the wrist joint, the fingers are kis-
they are unbent and close, the mouth is half open, there is a grimace on the face -
sa, reminiscent of a smile.
With good consistent treatment in patients with spastic
paralysis, especially with mild and moderate degrees, it is possible to
experience significant improvement. Some of these patients end up
are middle and even higher educational establishments and successful work
functional therapy.
tomy, etc.
culture is the development of the ability to relax various
value.
sanatoriums.
Conclusion.
secondary and higher educational institutions and successfully work-
ut.However, in severe forms, the prognosis may be unfavorable -
nym, which is especially true for patients with severe intellectual impairment.
Treatment of a patient with spastic paralysis should be
lexical with the participation of a neuropathologist, a specialist in therapeutic gymnasium
tick, physiotherapist, orthopedic surgeon, speech therapist, neuropsychiatrist.
Among the listed specialists, the leading one is neuropatho-
log that takes these patients for dispensary registration.
treatment, orthopedic, massage are designed to create conditions for
functional therapy.
To reduce the tone, the following medications are used
paraty: glutamic acid, dibazol, tropacin, vitamins of group B, E.
Among the means of physiotherapeutic effects should be called
such as electrohydrotherapy, ozocerite-paraffin therapy, iono-
galvanization according to the method of the Institute of Children's Orthopedics and Trauma
tology named after G.I. Turner, according to which the electrodes are superimposed on the fingers
end sections of the hands and feet, etc.
Massage for spastic paralysis is carried out using sparing methods -
mi, using only such elements as "stroking", suction
massage and not including the elements of "kneading", "effleurage" and steam.
Acupressure relaxing massage and "shaking" are also used.
Orthopedic treatment is carried out mainly
positive: alcohol-novocaine blockade of motor points, staged correction
plaster bandages and splints, orthopedic devices. One-
to, surgical methods of treatment are also used. But when assigned
the latter should be remembered that by weakening one group, we create
conditions for the predominance of the strength of the opposite group, which can
lead to reverse deformation. In this regard, operational methods
they try to apply the values only if it is impossible to achieve
effect in conservative ways.
Among the operations for spastic paralysis, the following are used:
general: bringing down the spinal muscles, adductor myotomy, osteotomy
bone missions, tendon elongation, transformation of biarticular muscles into
single-articular (transplantation of the gastrocnemius muscle from the region of the supracondyles
hips on the subcondylar region of the tibia and semitendon-
noah, semimembranosus and biceps muscles on the epicondyle of the thigh), neuro-
tomy, etc.
One of the leading methods of treatment of spastic paralysis is
there is a functional therapy, which must be carried out continuously
throughout the childhood and adolescence period of a child's life
in a hospital, at home, in a sanatorium. The main purpose of the medical
culture is the development of the ability to relax various
muscle groups, the implementation of targeted, especially necessary
life, movements; training in the use of clothing, household and work
tools; learning to write and the simplest methods of work
value.
With mild and moderate degrees of the disease, children periodically
are sent for sanatorium treatment to specialized
sanatoriums.
Acute paralytic spinal poliomyelitis and other acute flaccid paralysis (paresis)
POLIO- an acute infectious disease caused by wild (I, II, III serotypes) or vaccine strains of poliomyelitis viruses and proceeding with a characteristic lesion of the gray matter of the spinal cord (mainly cells of the anterior horns of the spinal cord), the development of persistent flaccid paralysis, as well as possible damage to the meninges and nuclei of the cranial nerves.
Classification
According to the classification of M.B. Zucker is distinguished by:
I. Poliomyelitis without CNS involvement:
II. Poliomyelitis with CNS involvement:
Poliomyelitis without damage to the nervous system can be attributed to atypical forms of the disease, with damage - to typical forms.
V.N. Timchenko classifies poliomyelitis by severity (light, medium, heavy forms) and downstream ( smooth, non-smooth).
In addition, by ICD X There are 5 types of poliomyelitis:
I. Acute paralytic poliomyelitis caused by wild poliomyelitis virus (I, II, III) imported or local.
II. Acute paralytic poliomyelitis associated with the vaccine in the recipient (from 4 to 30 days) or in the contact with the recipient (4-60 days).
III. Acute paralytic poliomyelitis of non-polio etiology (for example, enteroviral)
IV. Acute paralytic poliomyelitis of unspecified etiology (with late laboratory examination - later than 14 days of illness)
V. Acute paralytic poliomyelitis of unclear etiology (if the examination was not carried out, but there is a clinic of poliomyelitis and residual effects).
Laboratory diagnostics:
For laboratory diagnosis of poliomyelitis, virological, express and serological methods are used. Material for laboratory diagnostics are faeces and CSF.
The final diagnosis is formulated after receiving the results of virological and serological studies and clinical observation of the reverse dynamics of neurological symptoms.
Scheme for writing a medical history
Complaints. When identifying complaints, pay attention to weakness in the legs, pain, paresthesia, changes in sensitivity in the limbs, lameness, inability to walk and even stand, sit.
Disease history. Indicate the date of onset of the disease, the initial symptoms (there may be temperature, catarrhal phenomena, intestinal dysfunction, it is possible to develop paralysis against the background of complete health), the date of onset of paresis and the presence or absence of intoxication, the duration of the increase in paresis, the severity of pain, changes in sensitivity, the presence pelvic disorders.
Specify the date of application for medical care, initial diagnosis, term of examination by a neurologist, date of filing an emergency notice and where the patient was referred. Ask about a possible traumatic injury to the limbs, the spine, injections in the gluteal region, as well as about the viral and bacterial diseases suffered during the last month. hepatitis neuroinfection child
epidemiological history. Find out contacts with patients with poliomyelitis and visitors from territories unfavorable for poliomyelitis, with people who arrived from the war zone, with the nomadic gypsy population. Find out if the child has traveled to polio-affected areas in the last 1.5 months.
Clarify whether there was a live vaccine 4 to 30 days before the illness, and whether the child was in contact with a live polio vaccine 6 to 60 days before the development of paresis.
Anamnesis of life. Find out the vaccination history against poliomyelitis, at what age the vaccination was started, with what drugs (live, killed vaccine), the timing of vaccination, how many doses of the vaccine received, the date of the last vaccination. Specify previous illnesses.
objective status. Estimate severity of condition the patient in terms of depth, prevalence of paralysis and the presence of bulbar disorders.
When describing skin pay attention to increased humidity and coldness of the affected limbs, to the presence of other disorders of the autonomic nervous system (Trousseau spots).
looking around musculoskeletal system, assess the condition of the joints (deformity, swelling, soreness, hyperemia), the presence of muscle pain.
On palpation lymph nodes determine their size, density, pain.
Describing respiratory system, note the nature of breathing through the nose (free, difficult), the rhythm of breathing, chest excursion, the presence or absence of cough, the nature of sputum. Conduct percussion and auscultation.
From the organs of cardio-vascular system determine the pulse rate, evaluate heart sounds, heart rate, the presence of noise, measure blood pressure.
Inspect digestive organs: muscle soreness and tension abdominal wall on palpation of the abdomen, the size of the liver and spleen, indicate the frequency and nature of the stool. Describe the state of the oropharyngeal mucosa (hyperemia, granularity, vesicular rashes on the arches, hyperemia and tuberosity rear wall pharynx).
Determine if there is any pathology genitourinary system.
Describe in detail neurological status. Assess the patient's consciousness.
Describe the state of the cranial nerves, paying particular attention to possible damage to the facial nerve (smoothness of the nasolabial fold, drooping of the corner of the mouth, asymmetry of the grin, incomplete closure of the palpebral fissure when closing the eyes and in sleep). Possible damage to the glossopharyngeal and vagus nerves (impaired swallowing, phonation, choking, nasal voice, sagging of the soft palate and the absence of a reflex on the side of the lesion, deviation of the uvula, absence or decrease in the palatine and pharyngeal reflexes), hypoglossal nerve (deviation of the tongue, dysarthria).
Assess the motor sphere: gait (paretic, lameness, limb dragging, steppage, cannot walk or stand), the ability to walk on toes (“toe”) and on heels, stand and jump on the left and right legs. Check hand movement.
In case of doubtful paresis, check the gait after physical activity(Phenomena of paresis can be seen more clearly). Assess the muscle tone of each limb in the proximal and distal sections (hypotension, atony, hypertension, dystonia, plastic type). In the supine position of the patient, check the volume of passive and active movements (in the vertical and horizontal plane). Assess the strength of the muscles in the proximal and distal sections on a five-point scale. Determine the presence of atrophy and hypotrophy of muscles. Measure the volume of the right and left limbs at three symmetrical levels (upper 1/3, middle, lower 1/3 limbs). Check tendon reflexes from the arms (with the triceps and biceps muscles of the shoulder, carporadial) and from the legs (knee, Achilles), evaluate their symmetry. Indicate the presence of pathological reflexes (carpal - Rossolimo, Zhukovsky; foot - Babinsky, Rossolimo, Oppenheim and Gordon).
Assess the presence and severity of symptoms of tension (symptoms of Lassegue, Neri), pain along the nerve trunks, along the spine.
Determine skin reflexes: abdominal (upper, middle, lower), cremasteric, plantar.
Check superficial sensitivity: pain, tactile. Perhaps a violation of the neuritic type: a decrease or increase in sensitivity according to the type of "socks", "golf", "stocking", "pantyhose", "short gloves", "long gloves". Check deep sensitivity (muscle-articular feeling). Determine the presence of vegetative disorders (sweating, cold extremities), trophic disorders (pressure sores, ulcers).
Determine the presence of meningeal symptoms.
Note if there are pelvic disorders (urinary and fecal retention or incontinence).
Preliminary diagnosis and its justification.
If a child has signs of flaccid paresis (restriction of movements, hypotension, hyporeflexia) or flaccid paralysis (lack of movement, atony, areflexia), a topical diagnosis (poliomyelitis, Guillain-Barré syndrome, neuropathy, myelitis) is preliminarily set. It is also allowed as a preliminary diagnosis: "Acute flaccid paresis (paralysis)". The topical diagnosis should be confirmed or made 2-3 days after the patient's stay in the hospital after a commission clinical examination (the commission includes an infectious disease specialist, a neuropathologist, a head of the department) and obtaining the results of a study of the cerebrospinal fluid.
For "Acute paralytic poliomyelitis, spinal form" characteristic:
For "Post-infectious polyneuropathy (Guillain-Barré syndrome)" characteristic:
At "Traumatic neuropathy" unlike poliomyelitis:
At "Infectious myelitis":
Examination plan:
Clinical diagnosis and its rationale.
Clinical diagnosis is made after receiving the results of virological (not earlier than 28 days after fecal sampling) and serological studies.
A case of acute flaccid spinal palsy in which wild-type polio virus has been isolated is classified as "Acute paralytic poliomyelitis caused by wild imported poliomyelitis virus (type 1, 2 or 3)" or "Acute paralytic poliomyelitis caused by wild local (endemic) poliomyelitis virus (type 1, 2 or 3)".
A case of acute flaccid spinal palsy occurring not earlier than 4 and not later than 30 days after administration of live polio vaccine, in which vaccine-derived polio virus has been isolated, is classified as "Acute paralytic poliomyelitis associated with a vaccine in a recipient".
A case of acute flaccid spinal paralysis occurring no later than 60 days after exposure to a vaccine-derived poliovirus is classified as "Acute paralytic poliomyelitis associated with a vaccine in a contact".
A case of acute flaccid spinal paralysis, in which the virological examination was carried out correctly (up to the 14th day of illness, twice), but the polio virus was not isolated, is regarded as "Acute paralytic poliomyelitis of other non-polio etiology".
A case of acute flaccid spinal paralysis in which no virological examination was performed or there are defects in the examination (material sampling later than the 14th day of illness, a single examination) and the polio virus is not isolated, is classified as "Acute paralytic poliomyelitis of unspecified etiology".
With established topical diagnoses (post-infectious polyneuropathy, myelitis, traumatic mononeuropathy), the absence of isolation of the polio virus from the patient makes it possible to exclude acute paralytic poliomyelitis.
Examples of clinical diagnoses: "Post-infectious polyneuropathy, severe form","Traumatic neuropathy of the sciatic nerve on the right."
The diagnoses of "Acute paralytic poliomyelitis caused by wild poliomyelitis virus" or "Acute paralytic poliomyelitis associated with the vaccine" are finally confirmed when the patient is examined after 60 days from the onset of paralysis by the preservation of residual paralysis or paresis by this time.
Diary. Before writing the diary, the day of illness, the day of the patient's stay in the hospital is indicated. The date, pulse rate and respiration rate are entered on the fields. The diary should reflect the dynamics of the symptoms of flaccid paresis - muscle tone, tendon reflexes, tension symptoms, pain syndrome, range of motion, muscle strength, limb volume. The presence and dynamics of meningeal symptoms are assessed. The condition of the cranial nerves is noted.
At the end of the diary, a conclusion is written based on the results. laboratory tests substantiate changes in the treatment of the patient.
Stage epicrisis. A stage epicrisis is written once every 10 days according to the generally accepted scheme.
Discharge summary written in the usual way. Recommendations are given for further monitoring and treatment of the patient, for further vaccination against poliomyelitis.
