Movement disorders in neurological disorders. Syndrome of motor disorders: causes, symptoms, diagnosis, treatment, prognosis Graph of the structure of motor and sensory disorders

One of the pathologies of motor activity is the syndrome of motor disorders in children. Basically, the disease manifests itself in infants. The risk group includes children who have undergone oxygen starvation (hypoxia), as well as those who have received a skull injury.

Types of SDS

The disease can progress, therefore, the sooner it is identified, the greater the chance of a positive outcome. With adequate treatment, the baby can be cured. Doctors distinguish these types of syndrome:

• Muscular hypotension. The main symptom is a decrease in muscle tone. This type of movement disorder syndrome is mainly found in children under one year old, but sometimes it is detected at an older age.
• Muscular hypertonicity. Significantly increased tone is noted. The baby is not capable of maintaining balance for a long time. Parents may notice problems in the development of grasping ability.

Syndrome of movement disorders in children

• Cerebellar Syndrome. With this pathology, there is a violation of the functioning of the cerebellum. A patient with this syndrome has a gait that resembles a person in a state of intoxication.
• Tonic labyrinth reflex. The baby is unable to sit or roll over to the other side.
• Cerebral palsy.

When determining the type of disorders in a patient, the most common disease is cerebral palsy.

Symptoms of the disease

A distinctive feature of the disease - the syndrome of movement disorders does not have specific symptoms found only in this pathology. Basically, these are signs that even healthy children can have. Parents should be very careful. Of course, you don’t need to take your child to the doctor because of any little thing. However, it is also not worth ignoring the signs of a possible pathology, otherwise everything can be very deplorable.
The main symptoms of movement disorder syndrome in children are:

• poverty of facial expressions;
• crying for no reason, most often monotonous;
• the child constantly picks up toys, but does not seem to know what to do next with them;

Crying for no reason is one of the symptoms of the disease

• the expression of emotions is delayed, for example, the first attempts to smile at three to four months;
• slow reactions to external stimuli;
• labored breathing;
• speech problems, as a result of which the child begins to speak late.

If, nevertheless, you notice several symptoms in the baby, carefully observe him. If you suspect a syndrome of impaired motor activity of infants, you should contact a specialist.

Causes of the syndrome of movement disorders

In some cases, the risk of acquiring SOS increases. For example, if a pregnant woman or the newborn itself suffered from hypoxia, there is a high probability of getting abnormalities in muscle function and coordination. Also in the womb there may be an incorrectly formulated musculoskeletal system.

Another reason is CNS infection. A pregnant woman can infect the fetus through the placenta. However, sometimes movement disorder syndrome occurs after complications during childbirth, including when non-professional obstetricians try to push the baby out with force, causing injury to him. After this, the child runs the risk of getting a syndrome of movement disorders.

A pregnant woman can infect the fetus through the placenta

After childbirth, parents are required to closely monitor the baby. At two to four months, it is already possible to diagnose SDN, but for this you need to carefully monitor your child. Parents should not be afraid to contact a specialist and hear the diagnosis. SDN cannot be called a sentence, because with proper treatment, the baby will be absolutely healthy.

Treatment

A sick child should undergo a course of treatment under the supervision of a neurologist. The most effective methods are massage and exercise therapy. Treatment of the syndrome of movement disorders in children is complex and multi-stage. Before making an appointment, the doctor must determine the specific abnormalities in the child (problems with gait, sitting or crawling).

Relaxing massage gives results and is considered the most effective method of treatment. But this is provided that it is carried out by professionals. This method will not tolerate amateur performance, otherwise the syndrome may even worsen. It is recommended to spend 15 massage sessions. If the syndrome was diagnosed before the year, then the child needs 4 courses. It is desirable that each consists of 20 massage sessions.

You can learn more about the number of trips to a massage therapist from a doctor who will recommend the optimal number of sessions, depending on the type of SOS. Also, a certain ointment must be used during the procedure. Which one is right for your child, the specialist will tell you.

Relaxing massage gives results and is considered the most effective method of treatment.

Therapeutic exercise is somewhat inferior in effectiveness to massage, but it is an integral element of successful treatment. When doing exercise therapy, special attention should be paid to the lower extremities. Before starting the exercises, it is recommended to put woolen socks on the baby's legs. It will not be superfluous to make paraffin boots after the end of physical education. They can be replaced with trays of boiled oats.

Another method of treatment is physiotherapy. These include:

• electrophoresis,
• ultraviolet irradiation,
• phonophoresis.

These procedures will help in a speedy recovery, but you should not count on them alone.

Also, medication is sometimes prescribed for the child. However, despite the high efficiency, parents prefer to abandon it.

Traditional medicine in SDN has not shown itself on the good side, it does not give results. But this does not prevent some parents from forgetting about doctor's appointments and looking for more and more new recipes on the Internet or in old books, notebooks of mothers and grandmothers. Thus, they miss the time and opportunity to help their child.

The most effective treatment for CNS developmental delay is reflexology.

Prevention

It is much easier to prevent a disease than to treat it later. First of all, a pregnant woman needs to do everything so that the child in the womb does not need oxygen and nutrients. You need to take seriously the choice of an obstetrician-gynecologist.

When the child is already able to sit and crawl, give him the opportunity to explore the objects around. Give him as many toys, colorful pictures as possible. But do not forget about the precautions, exclude the possibility of the child getting to the sockets, climbing onto the windowsill or swallowing small things. Also, do not forget about gymnastics. Play finger games with your child and, if possible, give him a separate room.

Disturbances in motor functions are largely associated with damage to the central nervous system, i.e. certain parts of the brain and spinal cord, as well as peripheral nerves. Disorder of movements is more often caused by organic damage to the nerve pathways and centers that carry out motor acts. There are also so-called functional motor disorders, for example, in neuroses (hysterical paralysis). Less often, the cause of movement disorders is anomalies in the development of the musculoskeletal organs (malformations), as well as anatomical damage to bones and joints (fractures, dislocations). In some cases, motor insufficiency is based on a disease of the muscular system, for example, in certain muscle diseases (myopathy, etc.). A number of departments of the nervous system take part in the reproduction of a motor act, sending impulses to the mechanisms that directly perform the movement, i.e. to the muscles.

The leading link of the motor system is the motor analyzer in the cortex of the frontal lobe. This analyzer is connected by special pathways with the underlying parts of the brain - subcortical formations, the midbrain, the cerebellum, the inclusion of which gives the movement the necessary smoothness, accuracy, plasticity, as well as with the spinal cord. The motor analyzer closely interacts with afferent systems, i.e. with systems conducting sensitivity. Through these pathways, impulses from proprioreceptors enter the cortex, i.e. sensitive mechanisms located in the motor systems - joints, ligaments, muscles. Visual and auditory analyzers exert a controlling influence on the reproduction of motor acts, especially during complex labor processes.

Movements are divided into voluntary, the formation of which in humans and animals is associated with the participation of the motor sections of the cortex, and involuntary, which are based on automatisms of stem formations and the spinal cord.

The most common form of movement disorders in both adults and children are paralysis and paresis. Paralysis means the complete absence of movement in the corresponding organ, in particular in the arms or legs (Fig. 58). Paresis includes such disorders in which the motor function is only weakened, but not completely turned off.

The causes of paralysis are infectious, traumatic or metabolic (sclerosis) lesions that directly cause damage to the nerve pathways and centers or upset the vascular system, as a result of which the normal supply of these areas with blood stops, for example, in strokes.

Paralysis varies depending on the localization of the lesion - central and peripheral. There are also paralysis of individual nerves (radial, ulnar, sciatic, etc.).

It matters which motor neuron is affected - central or peripheral. Depending on this, there are a number of features in the clinical picture of paralysis, taking into account which the specialist doctor can determine the localization of the lesion. With central paralysis, increased muscle tone (hypertension), increased tendon and periosteal reflexes (hyperreflexia), often the presence of pathological reflexes of Babinsky (Fig. 59), Rossolimo, etc. are characteristic. There is no weight loss of the muscles of the arms or legs, and even a paralyzed limb may be somewhat swollen due to circulatory disorders and inactivity. On the contrary, with peripheral paralysis, there is a decrease or absence of tendon reflexes (hypo- or areflexia), a drop in muscle tone

(atony or hypotension), a sharp weight loss of muscles (atrophy). The most typical form of paralysis in which a peripheral neuron suffers is cases of infantile paralysis - poliomyelitis. It should not be thought that all spinal lesions are characterized only by flaccid paralysis. If there is an isolated lesion of the central neuron, in particular the pyramidal pathway, which, as you know, having begun in the cortex, also passes in the spinal cord, then the paralysis will have all the signs of a central one. This symptomatology, expressed in a milder form, is referred to as "paresis". The word "paralysis" in medical terminology is defined as "plegia". In this regard, there are: monoplegia (monoparesis) with the defeat of one limb (arm or leg); paraplegia (paraparesis) with damage to both limbs; hemiplegia (hemiparesis) with damage to one half of the body (arm and leg on one side suffer); tetraplegia (tetraparesis), in which both arms and legs are affected.

Paralysis resulting from an organic lesion of the central nervous system is not completely restored, but under the influence of treatment can be weakened. Traces of the lesion can be detected at different age periods in varying degrees of severity.

The so-called functional paralysis or paresis basically does not have structural disorders of the nervous tissue, but develops as a result of the formation of congestive foci of inhibition in the region of the motor zone. More often they are caused by acute reactive neuroses, especially hysteria. In most cases, they have a good outcome.

In addition to paralysis, movement disorders can be expressed in other forms. So, for example, violent inappropriate, superfluous movements may occur, which are combined under the general name of hyperkinesis. To them

These include such forms as convulsions, i.e. involuntary muscle contractions. There are clonic convulsions, in which contractions or muscle relaxations rapidly following each other, acquiring a peculiar rhythm, are observed. Tonic convulsions are characterized by prolonged contraction of muscle groups. Sometimes there are intermittent twitches of individual small muscles. This is the so-called myoclonus. Hyperkinesis can manifest itself in the form of peculiar violent movements, more often in the fingers and toes, resembling, as it were, the movements of a worm. Such peculiar manifestations of seizures are called athetosis. Tremor is a violent rhythmic vibration of the muscles, acquiring the character of trembling. There is a tremor of the head, arms or legs, or even the whole body. In school practice, hand tremor is reflected in the writing of students, which acquires an irregular character in the form of rhythmic zigzags. Tics - they usually mean stereotypically repetitive twitches in certain muscles. If a tick is observed in the muscles of the face, then there are peculiar grimaces. There is a tick of the head, eyelids, cheeks, etc. Some types of hyperkinesis are more often associated with lesions of the subcortical nodes (striatum) and are observed with chorea or in the residual stage of encephalitis. Certain forms of violent movements (tics, tremors) may be functional in nature and accompany neuroses.

Disorders of movements are expressed not only in violation of their strength and volume, but also in violation of their accuracy, proportionality, friendliness. All these qualities determine the coordination of movements. Proper coordination of movements depends on the interaction of a number of systems - the posterior columns of the spinal cord, trunk, vestibular apparatus, cerebellum. The lack of coordination is called ataxia. The clinic distinguishes between various forms of ataxia. Ataxia is expressed in the disproportion of movements, their inaccuracy, as a result of which complex motor acts cannot be correctly performed. One of the functions resulting from the coordinated actions of a number of systems is walking (the nature of the gait). Depending on which systems are especially disturbed, the nature of the gait changes dramatically. When the pyramidal tract is damaged due to the resulting hemiplegia or hemiparesis, a hemiplegic gait develops: the patient pulls up the paralyzed leg, the entire paralyzed side

The torso, when moving, seems to lag behind a healthy one. Ataxic gait is more often observed with damage to the spinal cord (posterior columns), when the paths that carry deep sensitivity are affected. Such a patient walks, spreading his legs wide to the sides, and strongly hits the floor with his heel, as if he puts his foot on a grand scale. This is observed with dorsal dryness, polyneuritis. The cerebellar gait is characterized by particular instability: the patient walks balancing from side to side, which creates a resemblance to the walking of a very intoxicated person (drunk gait). In some forms of neuromuscular atrophy, for example, in Charcot-Marie's disease, the gait acquires a peculiar type: the patient seems to act, raising his legs high ("circus horse gait").

Features of movement disorders in abnormal children. Children who have lost their hearing or sight (blind, deaf), as well as those suffering from underdevelopment of the intellect (oligophrenic), in most cases are characterized by the originality of the motor sphere. Thus, pedagogical practice has long noted that the majority of deaf children have a general lack of coordination of movements: when walking, they shuffle their soles, their movements are jerky and abrupt, and uncertainty is noted. A number of authors in the past (Kreidel, Brook, Bezold) carried out various experiments aimed at studying both the dynamics and the statics of the deaf and dumb. They checked the gait of deaf-mutes on the plane and when lifting, the presence of dizziness during rotation, the ability to jump on one leg with closed and open eyes, etc. Their opinions were rather contradictory, but all authors noted the motor retardation of deaf children compared to hearing students.

Prof. F.F. Zasedatelev carried out the following experiment. He forced normal schoolchildren and deaf-mutes to stand on one leg. It turned out that hearing schoolchildren can stand with their eyes open and closed on one leg for up to 30 s, deaf children of the same age could stand in this position for no more than 24 s, and with their eyes closed, the time sharply decreased to 10 s.

Thus, it has been established that the deaf from the side of the motor sphere lag behind the hearing both in dynamics and statics. The unstable balance of the deaf was attributed by some to the insufficiency of the vestibular apparatus of the inner ear, while others attributed it to disorders of the cortical centers and the cerebellum. Some observations made by O.D. Kudryasheva, S.S. Lyapidevsky showed that, with the exception of a small

Groups - deaf with a pronounced lesion of the motor sphere, in most of them motor insufficiency is transient. After systematically conducted classes in physical education and rhythm, the movements of the deaf acquire quite satisfactory stability, speed and smoothness. Thus, the motor retardation of the deaf often has a functional character and can be overcome with appropriate exercises. Physiotherapy exercises, dosed occupational therapy, sports are a powerful stimulus in the development of the motor sphere of the deaf.

The same can be said about blind children. It is quite natural that the lack of vision reduces the volume of motor abilities, especially in a wide space. Many blind people, writes Prof. F. Workshop, indecisive and timid in their movements. They stretch their arms forward so as not to stumble, drag their feet, feeling the ground, and walk bent over. Their movements are angular and awkward, there is no flexibility in them when bending, during a conversation they do not know where to put their hands, they grab onto tables and chairs. However, the same author points out that as a result of proper education, a number of shortcomings in the motor sphere of the blind can be eliminated.

Studies of the motor sphere of the blind, which we conducted at the Moscow Institute of the Blind in 1933-1937, showed that severe motor insufficiency occurs only in the first years of education, with the exception of a small group of children who have had severe brain diseases (meningoencephalitis, the consequences of a remote tumor of the cerebellum and etc.). In the future, conducting special classes in physical education perfectly developed the motor skills of the blind. Blind children could play football, volleyball1, jump over obstacles, and perform complex gymnastic exercises. The sports olympiads for blind children organized every year (Moscow school) once again confirm what successes can be achieved with children deprived of sight by means of special pedagogy. However, this is not easy and involves a lot of work for both the blind child and the teacher. The development of compensatory adaptations based on the plasticity of the nervous system

1 With blind children, football and volleyball games are played with a sounding ball.

We also concern the motor sphere, which, under the influence of special corrective measures, noticeably improves. Of great importance is the time of onset of blindness and the conditions in which the blind person was. It is known that people who have lost their sight at a later age do not compensate well for their motor sphere. Early blind as a result of appropriate training from a young age, better control their movements, and some freely orient themselves in a wide space. However, the conditions of upbringing also matter here. If an early blind child, while in the family, was under the vigilant supervision of his mother, grew pampered, did not encounter difficulties, did not train in orientation in a wide space, then his motor skills will also be limited. It is in this group of children that the above-mentioned fear of a wide space is observed, sometimes acquiring the character of a special fear (phobia). The study of the anamnesis of such children shows that their early development took place in conditions of constant "holding the mother's hand."

We encounter more severe changes in the motor-motor sphere in children with an intellectual disorder (oligophrenic). This is determined primarily by the fact that dementia is always the result of underdevelopment of the brain in the prenatal period due to certain diseases or its damage during childbirth or after birth. Thus, the child's mental inferiority arises on the basis of structural changes in the cerebral cortex caused by a neuroinfection (meningoencephalitis) or under the influence of craniocerebral trauma. Naturally, inflammatory, toxic, or traumatic lesions of the cortex often have a diffuse localization and affect, to one degree or another, the motor areas of the brain. Deep forms of oligophrenia are more often accompanied by severe disorders of motor functions. In these cases, paralysis and paresis are observed, and more often spastic hemiparesis or various forms of hyperkinesis. In milder cases of oligophrenia, local motor disturbances are rare, but there is a general insufficiency of the motor sphere, which is expressed in some lethargy, clumsy, awkward movements. At the heart of such insufficiency, apparently, most likely lie neurodynamic disorders - a kind of inertia of nervous processes. In these cases, a significant correction of the backwardness of the motor sphere is possible by carrying out special corrective measures (physiotherapy exercises, rhythm, manual labor).

Apraxia is a form of movement disorder. In this case, paralysis is absent, but the patient cannot perform a complex motor act. The essence of such disorders is that such a patient loses the sequence of movements necessary to perform a complex motor act. So, for example, a child loses the ability to make habitual movements, straighten, fasten clothes, lace up shoes, tie a knot, thread a needle, sew on a button, etc. Such patients also fail to perform imaginary actions on orders, for example, to show how they eat soup with a spoon, how they repair a pencil, how they drink water from a glass, etc. The pathophysiological mechanism of apraxia is very complex. Here there is a disintegration, due to the action of certain harmful agents, motor stereotypes, i.e. well-coordinated systems of conditioned reflex connections. Apraxia often occurs when the supra-marginal or angular gyrus of the parietal lobe is affected. Writing disorders in children (dysgraphia) is one of the types of apraxic disorders.

The role of the motor analyzer is exceptionally great in our nervous activity. It is not limited only to the regulation of voluntary or involuntary movements that are part of ordinary motor acts. The motor analyzer also takes part in such complex functions as hearing, sight, and touch. For example, full vision is impossible without the movement of the eyeball. Speech and thinking are based on movement, since the motor analyzer moves all speech reflexes formed in other analyzers * "The beginning of our thought," wrote I.M. Sechenov, "is muscle movement."

Treatment of movement disorders such as paralysis, paresis, hyperkinesis was considered ineffective for a long time. Scientists relied on previously created ideas about the nature of the pathogenesis of these disorders, which are based on irreversible phenomena, such as the death of nerve cells in cortical centers, atrophy of nerve conductors, etc.

However, a deeper study of pathological mechanisms in violations of motor acts shows that the previous ideas about the nature of motor defects were far from complete. An analysis of these mechanisms in the light of modern neurophysiology and clinical practice shows that a movement disorder is a complex complex, the components of which are not only local (often irreversible) defects, but also a number of functional changes caused by neurodynamic disorders that enhance the clinical picture of a movement defect. These violations, as studies by M.B. Eidinova and E.N. Pravdina-Vinarskaya (1959), with the systematic implementation of therapeutic and pedagogical measures (the use of special biochemical stimulants that activate the activity of synapses, as well as special exercises in physical therapy, in conjunction with a number of educational and pedagogical measures aimed at educating the child's will, purposeful activity to overcome the defect) in a significant number of cases remove these pathological layers. This, in turn, leads to the restoration or improvement of impaired motor function.

Visual disorders

Causes and forms of visual disturbances. Severe visual disturbances are not an obligatory result of a primary lesion of the nerve devices of vision - the retina, optic nerves and cortical visual centers. Visual disturbances can also occur as a result of diseases of the peripheral parts of the eye - the cornea, lens, refractive media, etc. In these cases, the transmission of light stimuli to receptor nerve devices may completely stop (complete blindness) or have a limited character (poor vision).

The causes of severe visual impairment are various infections - local and general, including neuroinfections, metabolic disorders, traumatic eye lesions, and anomalies in the development of the eyeball.

Among visual disorders, first of all, there are such forms in which visual acuity suffers, up to complete blindness. Visual acuity can be impaired if the eye apparatus itself is damaged: the cornea, lens, retina.

The retina is the inner membrane of the eyeball that lines the fundus of the eye. In the central part of the fundus

There is an optic disc from which the optic nerve originates. A feature of the optic nerve is its structure. It consists of two parts that carry irritation from the outer and inner parts of the retina. First, the optic nerve departs from the eyeball as a whole, enters the cranial cavity and goes along the base of the brain, then the fibers that carry irritation from the outer parts of the retina (central vision) go posteriorly on their side, and the fibers that carry irritation from the inner parts of the retina (lateral vision), completely intersect. After the decussation, the right and left visual tracts are formed, which contain fibers both on their side and on the opposite side. Both visual tracts go to the geniculate bodies (subcortical visual centers), from which the Graziole bundle begins, carrying irritation to the cortical fields of the occipital lobe of the brain.

When the optic nerve is damaged, blindness in one eye occurs - amaurosis. Damage to the optic chiasm is manifested by a narrowing of the visual fields. When the function of the optic tract is impaired, half of the vision is lost (hemianopsia). Visual disturbances with damage to the cerebral cortex in the occipital region are manifested by partial loss of vision (scotoma) or visual agnosia (the patient does not recognize familiar objects). A common case of this disorder is alexia (reading disorder), when a child loses the signal meaning of alphabetic images in memory. Visual disturbances also include loss of color perception: the patient does not distinguish some colors or sees everything in gray.

In special pedagogical practice, two groups of children are distinguished who require education in special schools - the blind and the visually impaired.

Blind children. Usually, blind people are those with such a loss of vision in which there is no light perception, which is rare. More often these people have a weak light perception, distinguish between light and darkness, and, finally, some of them have slight remnants of vision. Usually the upper limit of such a minimum vision is considered to be 0.03-0.04!. These remnants of vision may somewhat facilitate the orientation of the blind in the external environment, but are of no practical importance in teaching.

Normal vision is taken as one.

Chenia and labor, which therefore have to be carried out on the basis of tactile and auditory analyzers.

On the part of the neuropsychic sphere, blind children have all the qualities that are characteristic of a sighted child of the same age. However, the absence of vision causes a number of special properties in the blind person in his nervous activity, aimed at adapting to the external environment, which will be discussed below.

Blind children study in special schools, training is carried out mainly on the basis of skin and auditory analyzers by specialist tiflopedagogues.

visually impaired children. This group includes children who have preserved some remnants of vision. It is generally accepted to consider visually impaired children whose visual acuity after correction with glasses ranges from 0.04 to 0.2 (according to the accepted scale). Such residual vision in the presence of special conditions (special lighting, use of a magnifying glass, etc.) makes it possible to teach them on a visual basis in classes and schools for the visually impaired.

Features of nervous activity. Severe visual disturbances always cause changes in the general nervous activity. The age at which the loss of vision occurred (congenital or acquired blindness), the localization of the lesion in the region of the visual analyzer (peripheral or central blindness) matters. Finally, the nature of the disease processes that caused severe visual impairment should be taken into account. In this case, it is especially important to single out those forms that are caused by previous brain lesions (meningitis, encephalitis, brain tumors, etc.). Proceeding from the foregoing, changes in nervous activity will differ in some originality. Thus, in cases of onset of blindness due to causes not related to brain damage, nervous activity in the process of growth and development will be accompanied by the formation of compensatory adaptations that make it easier for such a person to participate in socially useful work. In cases of blindness resulting from a previous brain disease, the described pathway for the development of compensatory adaptations may be complicated by the influence of other consequences that may have occurred after a brain injury. We are talking about possible violations in the field of other analyzers (except for vision), as well as intellect and emotional-volitional sphere.

In these cases, there may be difficulty in learning, and in the future, disability. Finally, one should keep in mind the influence of the time factor on the nature of nervous activity. Observations show that in those who were born blind or who lost their sight at an early age, its absence often does not cause severe changes in the psyche. Such people have never used sight, and it is easier for them to endure its absence. In those who lost their sight at a later age (school age, adolescence, etc.), the loss of this important function is often accompanied by certain disorders in the neuropsychic sphere in the form of acute asthenic conditions, severe depression, pronounced hysterical reactions. Some blind children have special phobias - fear of large spaces. They can only walk by holding their mother's hand. If such a child is left alone, then he experiences a painful state of uncertainty, he is afraid to take a step forward.

Some originality of nervous activity, in contrast to the blind, is observed in persons belonging to the visually impaired. As mentioned above, such children have vestiges of vision that allow them, under special conditions in a special class, to learn on a visual basis. However, their volume of visual afferentation is insufficient; some have a tendency to progressive visual impairment. This circumstance makes it necessary to acquaint them with the method of teaching the blind. All this can cause a certain overload, especially in persons belonging to a weak type of nervous system, which can result in overstrain and disruption of nervous activity. However, observations show that reactive shifts in nervous activity in the blind and visually impaired are more often observed at the beginning of learning. This is due to the significant difficulties that children experience in general at the beginning of education and adaptation to work. Gradually, as compensatory adaptations are developed and stereotypes are created, their behavior noticeably levels out and balances out. All this is the result of the remarkable properties of our nervous system: plasticity, the ability to compensate to some extent for lost or weakened functions.

Let us briefly describe the main stages in the development of scientific thought on the development of compensatory adaptations in persons with severe visual impairments.

Loss of vision deprives a person of many advantages in the process of adapting to the external environment. However, loss of vision is not a violation in which labor activity is completely impossible. Experience shows that the blind overcome primary helplessness and gradually develop in themselves a number of qualities that allow them to study, work and actively participate in socially useful work. What is the driving force that helps the blind to overcome his severe defect? This issue has been the subject of controversy for a long time. Various theories arose, trying in different ways to determine the path of adaptation of the blind to the conditions of reality, mastering various forms of labor activity. Hence, the view of the blind has changed. Some believed that the blind, with the exception of some restriction in freedom of movement, have all the qualities of a full-fledged psyche. Others attached great importance to the absence of visual function, which, in their opinion, has a negative effect on the psyche of the blind, up to the violation of intellectual activity. The mechanisms of adaptation of the blind to the external environment were also explained in different ways. There was an opinion that the loss of one of the sense organs causes an increased work of others, which, as it were, make up for the missing function. In this sense, the role of hearing and touch was singled out, considering that in the blind, the activity of hearing and touch increases compensatory, with the help of which the blind person orients himself in the external environment, masters labor skills. Experimental studies were carried out, which tried to prove that the blind have sharpened (compared to the sighted) skin sensitivity, especially in the fingers, and that hearing is exceptionally developed. Using these features, the blind can compensate for the loss of vision. However, this position was disputed by studies of other scientists who did not find that hearing and skin sensitivity in the blind are better developed than in the sighted. In this sense, they completely denied the accepted position that the blind have a highly developed ear for music. Some have come to the conclusion that the musical talent of the blind is no less and no more than that of the sighted. The very problem of the psychology of the blind turned out to be controversial. Is there a special psychology for the blind? A number of scientists, including individual typhlopedagogues, denied the existence of such. Others, in particular Geller, believed that the psychology of the blind should be considered as one of the branches of general psychology. It was believed that the upbringing and education of a blind child, as well as his adaptation to socially useful activities, should be based on taking into account those features of his psychology that arise as a result of loss of sight. Attempts to uncover the mechanisms of compensation rested on the contradictory results of the study of hearing and touch in the blind. Some scientists found a special hyperesthesia (increased skin sensitivity) in the blind, others denied it. Similar conflicting results have been observed in the field of auditory nerve function research in the blind. As a result of these contradictions, attempts arose to explain the compensatory possibilities of the blind by processes of a mental order. In these explanations, the question of the increased work of the peripheral sections of the auditory and skin receptors, supposedly replacing the lost function of vision, the so-called vicariate of the senses, was no longer put forward in the first place, and the main role was assigned to the mental sphere. It was assumed that a special mental superstructure is created in the blind, which arises as a result of his contact with various influences of the external environment and is that special property that allows the blind to overcome a number of difficulties on the path of life, i.e. first of all, to navigate in the external environment, to move without outside help, to bypass obstacles, to study the outside world, to acquire labor skills. However, the very concept of a mental superstructure, undoubtedly considered in an idealistic aspect, was rather vague. The material essence of the processes that took place in such cases was in no way explained by the put forward hypothesis about the role of the psychic superstructure. Only much later by the works of domestic scientists (E.A. Asratyan, P.K. Anokhin, A.R. Luria, M.I. Zemtsova, S. Zimkina, V.C. Sverlov, I.A. Sokolyansky), who based their studies on the teachings of I.P. Pavlov about higher nervous activity, significant progress has been made in resolving this complex problem.

Neurophysiological mechanisms of compensatory processes in the blind. The psyche is a special property of our brain to reflect the external world that exists outside of our consciousness. This reflection is carried out in the brain of people through their sense organs, with the help of which the energy of external irritation is converted into a fact of consciousness. The physiological mechanisms of the function of reflecting the external world in our brain are conditioned reflexes that ensure the highest balance of the body with constantly changing environmental conditions. In the cortex of a sighted person, conditioned reflex activity is due to the influx of stimuli from all analyzers. However, a sighted person does not use sufficiently, and sometimes not at all, those analyzers that are not leading for him in this act. So, for example, while walking, a sighted person primarily focuses on vision; hearing and especially touch are used to a small extent. And only in special conditions, when a sighted person is blindfolded or when moving in the dark (at night), he uses his hearing and touch - he begins to feel the soil with his soles, listen to the surrounding sounds. But such provisions for the sighted are atypical. Hence, the increased formation of conditioned reflex connections with hearing and touch during certain motor acts, for example, when walking, is not a vital necessity for a sighted person. A powerful visual analyzer sufficiently controls the execution of the indicated motor act. We notice something completely different in the sensory experience of the blind. Being deprived of a visual analyzer, the blind rely on other analyzers in the process of orientation in the external environment, in particular on hearing and touch. However, the use of hearing and touch, in particular when walking, is not of an auxiliary nature, as in a sighted person. A peculiar system of nervous connections is actively formed here. This system in the blind is created as a result of prolonged exercises of auditory and cutaneous afferentation, caused by vital necessity. On this basis, a number of other specialized systems of conditional connections are formed that function in certain forms of adaptation to the external environment, in particular, when mastering labor skills. This is the compensatory mechanism that allows the blind to get out of the state of helplessness and engage in socially useful work. It is debatable whether any particular changes occur in the auditory nerve or sensory apparatus in the skin. As is known, studies of peri-

The pheric receptors - hearing and touch - in the blind have given conflicting results. Most researchers do not find local changes in terms of increased auditory or cutaneous peripheral afferentation. Yes, this is no coincidence. The essence of the complex compensatory process in the blind lies elsewhere. It is known that peripheral receptors produce only a very elementary analysis of incoming stimuli. A subtle analysis of stimuli takes place in the cortical ends of the analyzer, where higher analytical-synthetic processes are carried out and sensation turns into a fact of consciousness. Thus, by accumulating and training in the process of daily life experience numerous specialized conditioned connections with the indicated analyzers, the blind person forms in his sensory experience those features of conditioned reflex activity that the sighted person does not need in full measure. Hence, the leading adaptation mechanism is not a special sensitivity of the finger gauge or the cochlea of ​​the inner ear, but the higher part of the nervous system, i.e. the cortex and the conditioned reflex activity proceeding on its basis.

These are the results of many years of disputes about ways to compensate for blindness, which could only be correctly resolved in the aspect of modern brain physiology created by I.P. Pavlov and his school.

Features of the pedagogical process in teaching blind and visually impaired children. The education and upbringing of blind and visually impaired children is a complex process that requires the teacher not only to have special knowledge of typhlopedagogy and typhlotechnics, but also to understand those psychophysiological characteristics that occur in persons who are completely or partially deprived of vision.

It has already been said above that with the exclusion from the sphere of perception of such a powerful receptor as vision, which is part of the first signal system, the cognitive activity of the blind person is carried out on the basis of the remaining analyzers. The leading ones in this case are tactile and auditory reception, reinforced by the increasing activity of some other analyzers. Thus, conditioned reflex activity acquires some peculiar features.

In pedagogical terms, the teacher faces a number of difficult tasks. In addition to purely educational (educational work,

Teaching literacy, etc.) problems of a purely specific order arise, for example, the development of spatial representations in a blind child (orientation in the environment), without which the student is helpless. This also includes the development of motor skills, self-service skills, etc. All these moments related to education, at the same time, are closely related to the educational process. For example, poor orientation in the environment, a kind of motor clumsiness and helplessness will sharply affect the development of literacy skills, the development of which in the blind is sometimes associated with a number of specific difficulties. As for the peculiarities of teaching methods, in particular teaching literacy, the latter is carried out on the basis of touch and hearing.

The leading point here is the use of skin reception. Technically, training is carried out with the help of a special dotted font of the system of the teacher L. Braille, accepted all over the world. The essence of the system is that each letter of the alphabet is represented by a different combination of the arrangement of six convex points. A number of studies conducted in the past have shown that the point is physiologically better perceived by the skin surface of the finger than a linear raised font. Passing the soft surface of the tip of both index fingers over the lines of raised dotted type in a specially printed book, the blind man reads the text. In the physiological aspect, the same thing happens here as when reading with a sighted person, only the skin receptor acts instead of the eyes.

The blind write with the help of special techniques, which consist in the fact that the letters of the dotted alphabet are squeezed out with a metal rod on paper inserted in a special device. On the reverse side of the sheet, these impressions form a convex surface, which makes it possible for another blind person to read the written text. Tactile (skin) reception is also involved in other sections of the educational process, when it is necessary to acquaint a blind child with the shape of various objects, mechanisms, the structure of the body of animals, birds, etc. Feeling these objects with his hand, the blind person gets some impression of their external features. However, these representations are far from accurate. Therefore, an equally strong receptor, hearing, is involved in the educational process to help skin reception, which makes it possible for the teacher to accompany the tactile display (feeling objects) with verbal explanations. The ability of the blind to abstract thinking and speech (which indicates a good development of the second signaling system) helps, on the basis of the teacher's verbal signals, to make a number of adjustments in the cognition of various subjects and clarify their ideas about them. At subsequent stages of development, the hearing and speech of others acquire special significance in the cognitive activity of the blind.

Further development of typhlopedagogy is impossible without taking into account the advances that are taking place in technology. We are talking about the use, for example, of devices that help the blind to orient themselves in space, the creation of devices that allow the blind to use a book with a regular font, and so on. Consequently, the current level of development of special pedagogy (especially in teaching the blind and deaf and dumb) requires finding ways to use the achievements that take place in the field of radio engineering (radar), cybernetics, television, requires the use of semiconductors (transistor hearing devices), etc. In recent years, work has been underway to create devices that facilitate the training of people with visual and hearing impairments.

As for the education of visually impaired children, in these cases the pedagogical process is mainly based on the use of the remnants of vision that the child has. A specific task is to enhance visual gnosis. This is achieved by choosing appropriate glasses, using magnifiers, paying special attention to good classroom lighting, improving desks, etc.

To help visually impaired children, contact lenses, contact orthostatic loupes, special machines for reading the usual type of graphic font have been created. The use of contact lenses proved to be quite effective; they increase the efficiency of a visually impaired student, reduce fatigue. Taking into account that in some forms of low vision, the progression of the disease process occurs, accompanied by a further decrease in vision, children receive the appropriate skills to master the dotted Braille alphabet.

Features of the visual analyzer in deaf children. With the exception of rare cases when deafness is combined with blindness (deaf-blind), the vision of most deaf people does not present any deviations from the norm. On the contrary, the observations of former researchers, who proceeded in solving this problem from the idealistic theory of the vicariate of the senses, showed that the deaf have increased visual acuity due to the loss of hearing, and there were even attempts to explain this by a special hypertrophy of the optic nerve. At present, there is no reason to speak about the special anatomical qualities of the optic nerve of the deaf. The visual adaptation of deaf-mutes basically has the same patterns that were mentioned above - this is the development of compensatory processes in the cerebral cortex, i.e. enhanced formation of specialized conditioned reflex connections, the existence of which is not needed in such a volume by a person with normal hearing and vision.

Features of the visual analyzer in mentally retarded children. Special pedagogical practice has noted for a relatively long time that mentally retarded children do not clearly perceive the features of those objects and phenomena that arise before their eyes. The poor handwriting of some of these children, the slipping of letters behind the lines of the notebook, also gave the impression of reduced visual function. Similar observations were made in relation to auditory functions, which in most cases were considered to be weakened. In this regard, an opinion was created that the basis of mental retardation is an inferior function of the sense organs, which poorly perceive the irritations of the outside world. It was believed that a mentally retarded child sees poorly, hears poorly, feels poorly, and this leads to reduced excitability, sluggish brain function. On this basis, special teaching methods were also created, which were based on the tasks of the selective development of the sense organs in special lessons (the so-called sensorimotor culture). However, such a view of the nature of mental retardation is already a past stage. On the basis of scientific observations, both psychological, pedagogical and medical, it is known that the basis of mental retardation is not selective defectiveness of individual sense organs, but underdevelopment of the central nervous system, in particular the cerebral cortex. Thus, against the background of an inferior structure, insufficient physiological activity develops, characterized by a decrease in higher processes - cortical analysis and synthesis, which is characteristic of the weak-minded. However, taking into account that oligophrenia occurs as a result of previous brain diseases (neuroinfections, traumatic brain injuries), there may be individual cases of damage to both the visual organ itself and the nerve pathways. A special study of the visual organ in oligophrenic children, conducted by L.I. Bryantseva gave the following results:

A) in 54 cases out of 75 no abnormalities were found;

B) in 25 cases, various refractive errors were found (the ability of the eye to refract light rays);

C) in 2 cases, anomalies of a different nature.

Based on these studies, Bryantseva comes to the conclusion that the organ of vision of some students of auxiliary schools differs to some extent from the organ of vision of a normal student. A distinctive feature is a lower percentage of myopia compared to normal schoolchildren and a high percentage of astigmatism - one of the forms of refractive error1.

To this it should be added that in some mentally retarded children as a result of meningoencephalitis, there are cases of progressive weakening of vision due to atrophy of the optic nerve. More often than in normal children, there are cases of congenital or acquired strabismus (strabismus).

Sometimes, with deep forms of oligophrenia, underdevelopment of the eyeball, an irregular pupil structure, running nystagmus (rhythmic twitching of the eyeball) are observed.

It should be noted that teachers of special schools are not attentive enough to the peculiarities of the vision of their students and rarely refer them to ophthalmologists. Often timely selection of glasses and special treatment dramatically improve the child's vision and improve his performance in school.

1 Astigmatism - a lack of vision due to incorrect refraction of rays due to the unequal curvature of the cornea of ​​​​the lens in different directions.

Syndromes of movement disorders

Movement disorders in newborns and infants are fundamentally different from those in older children and adults. Damage to the brain in the early stages of ontogenesis in most cases causes generalized changes, which makes topical diagnosis extremely difficult; more often it is possible to speak only about the primary lesion of those or other parts of the brain.

It is very difficult in this age period to differentiate pyramidal and extrapyramidal disorders. The main characteristics in the diagnosis of motor disorders in the first year of life are muscle tone and reflex activity. Symptoms of changes in muscle tone may look different depending on the age of the child. This is especially true for the first and second age periods (up to 3 months), when the child has pronounced physiological hypertension.

Changes in muscle tone are manifested by muscle hypotension, dystonia and hypertension. The syndrome of muscular hypotension is characterized by a decrease in resistance to passive movements and an increase in their volume. Spontaneous and voluntary motor activity is limited, tendon reflexes may be normal, increased, reduced or absent depending on the level of damage to the nervous system. Muscular hypotension is one of the most frequently detected syndromes in newborns and infants. It can be expressed from birth, as is the case with congenital forms of neuromuscular diseases, asphyxia, intracranial and spinal birth trauma, lesions of the peripheral nervous system, some hereditary metabolic disorders, chromosomal syndromes, in children with congenital or early acquired dementia. At the same time, hypotension may appear or become more pronounced at any age, if the clinical symptoms of the disease begin several months after birth or are of a progressive nature.

Hypotension, expressed from birth, can transform into normotonia, dystonia, hypertension, or remain a leading symptom throughout the first year of life. The severity of clinical manifestations of muscular hypotension varies from a slight decrease in resistance to passive movements to complete atony and the absence of active movements.

If the syndrome of muscular hypotension is not pronounced and is not combined with other neurological disorders, it either does not affect the age development of the child, or causes a delay in motor development, more often in the second half of life. The lag is uneven, more complex motor functions are delayed, requiring the coordinated activity of many muscle groups for their implementation. So, a planted child sits for 9 months, but cannot sit down on its own. Such children later begin to walk, and the period of walking with support is delayed for a long time.

Muscular hypotension may be limited to one limb (obstetric paresis of the arm, traumatic paresis of the leg). In these cases, the delay will be partial.

A pronounced syndrome of muscular hypotension has a significant impact on the delay in motor development. Thus, motor skills in the congenital form of Werdnig-Hoffmann spinal amyotrophy in a child of 9-10 months can correspond to the age of 2-3 months. The delay in motor development, in turn, causes the peculiarities of the formation of mental functions. For example, the lack of the possibility of arbitrary capture of an object leads to underdevelopment of visual-motor coordination, manipulative activity. Since muscle hypotension is often combined with other neurological disorders (convulsions, hydrocephalus, cranial nerve paresis, etc.), the latter can modify the nature of the developmental delay determined by hypotension as such. It should also be noted that the quality of the hypotension syndrome itself and its impact on developmental delay will vary depending on the disease. With convulsions, congenital or early acquired dementia, it is not so much hypotension as delayed mental development that is the cause of the lag in motor development.

The syndrome of movement disorders in children of the first year of life may be accompanied by muscular dystonia (a condition in which muscular hypotension alternates with hypertension). At rest, in these children with passive movements, general muscle hypotonia is expressed. When you try to actively perform any movement, with positive or negative emotional reactions, muscle tone increases sharply, pathological tonic reflexes become pronounced. Such conditions are called "dystonic attacks". Most often, muscular dystonia is observed in children who have had hemolytic disease as a result of Rh or ABO incompatibility. The pronounced syndrome of muscular dystonia practically makes it impossible for the child to develop straightening reflexes of the body and balance reactions due to the constantly changing muscle tone. The syndrome of mild transient muscular dystonia does not significantly affect the age-related motor development of the child.

The syndrome of muscular hypertension is characterized by an increase in resistance to passive movements, limitation of spontaneous and voluntary motor activity, increased tendon reflexes, expansion of their zone, foot clonus. An increase in muscle tone can prevail in the flexor or extensor muscle groups, in the adductor muscles of the thighs, which is expressed in a certain specificity of the clinical picture, but is only a relative criterion for topical diagnosis in young children. Due to the incompleteness of the myelination processes, the symptoms of Babinsky, Oppenheim, Gordon, etc. cannot always be considered pathological. Normally, they are expressed unsharply, inconsistently, and weaken as the child develops, but with an increase in muscle tone they become bright and do not tend to fade.

The severity of the syndrome of muscular hypertension can vary from a slight increase in resistance to passive movements to complete stiffness (posture of decerebrate rigidity), when any movement is almost impossible. In these cases, even muscle relaxants are not able to cause muscle relaxation, and even more so passive movements. If the syndrome of muscular hypertension is not pronounced, is not combined with pathological tonic reflexes and other neurological disorders, its effect on the development of static and locomotor functions may manifest itself in their slight delay at various stages of the first year of life. Depending on which muscle groups are more toned, differentiation and final consolidation of certain motor skills will be delayed. So, with an increase in muscle tone in the hands, a delay in the development of the direction of the hands to the object, the capture of a toy, the manipulation of objects, etc. is noted. The development of the grasping ability of the hands is especially disturbed. Along with the fact that the child later begins to take the toy, he retains the ulnar grip, or grip with the whole hand, for a long time. The finger grip (tweezer grip) develops slowly and sometimes requires additional stimulation. The development of the protective function of the hands may be delayed, then the balance reactions in the position on the stomach, sitting, standing and walking are delayed, respectively.

With an increase in muscle tone in the legs, the formation of the support reaction of the legs and independent standing is delayed. Children are reluctant to stand up, prefer to crawl, stand on their toes on a support.

Cerebellar disorders in children of the first year of life may be the result of underdevelopment of the cerebellum, damage to it as a result of asphyxia and birth trauma, in rare cases - as a result of hereditary degeneration. They are characterized by a decrease in muscle tone, impaired coordination during hand movements, a disorder of balance reactions when trying to master the skills of sitting, standing, standing and walking. Actually cerebellar symptoms - intentional tremor, impaired coordination, ataxia can be detected only after the development of voluntary motor activity of the child. Disorders of co-ordination can be suspected by observing how the child reaches out to the toy, grabs it, brings it to the mouth, sits, stands, walks.

Infants with impaired coordination, when trying to grab a toy, make a lot of unnecessary movements, this becomes especially pronounced in the sitting position. Skills of independent sitting develop late, by 10-11 months. Sometimes even at this age it is difficult for children to maintain balance, they lose it when they try to turn to the side, take an object. Because of the fear of falling, the child does not manipulate objects with both hands for a long time; Walking begins after a year, often falls. Some children with balance disorders prefer to crawl when they should already be able to walk on their own. Less commonly, with cerebellar syndrome in children of the first year of life, horizontal nystagmus and speech disorders can be observed as an early sign of cerebellar dysarthria. The presence of nystagmus and the frequent combination of cerebellar syndrome with other disorders of craniocerebral innervation can give certain specifics to developmental delay in the form of a more pronounced delay in the function of fixing the gaze and tracking, hand-eye coordination, and spatial orientation disorders. Dysarthria disorders especially affect the development of expressive speech skills.

The most common form of movement disorders in children of the first year of life is the syndrome of cerebral palsy (ICP). The clinical manifestations of this syndrome depend on the severity of muscle tone, the increase of which to one degree or another is observed in any form of cerebral palsy. In some cases, a high muscle tone prevails in a child from birth. However, more often muscle hypertension develops after the stages of hypotension and dystonia. In such children, after birth, muscle tone is low, spontaneous movements are poor, and unconditioned reflexes are depressed. By the end of the second month of life, when the child in the position on the stomach and vertically makes attempts to hold the head, the dystonic stage appears. The child periodically becomes restless, his muscle tone increases, his arms are extended with internal rotation of the shoulders, the forearms and hands are pronated, the fingers are clenched into fists; legs are extended, adducted and often crossed. Dystonic attacks last a few seconds, recur throughout the day, and can be provoked by external stimuli (loud knocking, crying of another child).

Movement disorders in cerebral palsy are due to the fact that the defeat of the immature brain disrupts the sequence of stages of its maturation. Higher integrative centers do not have an inhibitory effect on primitive stem reflex mechanisms. The reduction of unconditioned reflexes is delayed, and pathological tonic neck and labyrinth reflexes are released. Combined with an increase in muscle tone, they prevent the consistent formation of the reactions of straightening and balance, which are the basis for the development of static and locomotor functions in children of the first year of life (holding the head, grasping a toy, sitting, standing, walking).

To understand the features of psychomotor development disorders in children with cerebral palsy, it is necessary to consider the influence of tonic reflexes on the formation of voluntary motor activity, as well as speech and mental functions.

Tonic labyrinth reflex. Children with a pronounced tonic labyrinth reflex in the supine position cannot tilt their heads, stretch their arms forward to bring them to their mouth, grab an object, and later grab, pull themselves up and sit down. They lack the prerequisites for the development of fixation and free tracking of an object in all directions, an optical rectifying reflex to the head does not develop, head movements cannot freely follow the movement of the eyes. Violated the development of visual-motor coordination. In such children, it is difficult to turn from the back to the side, and then to the stomach. In severe cases, even by the end of the first year of life, the turn from back to stomach is carried out only in a "block", i.e., there is no torsion between the pelvis and upper body. If the child cannot tilt his head in the supine position, turn on his stomach with torsion, he has no prerequisites for the development of the sitting function. The severity of the tonic labyrinth reflex is directly dependent on the degree of increase in muscle tone.

With the severity of the tonic labyrinth reflex in the position on the stomach, as a result of an increase in flexor tone, the head and neck are bent, the shoulders are pushed forward and down, the arms bent in all joints are under the chest, the hands are clenched into fists, the pelvis is raised. In this position, the child cannot raise his head, turn it to the sides, release his arms from under the chest and lean on them to support the upper body, bend his legs and kneel. Difficulty turning from stomach to back for sitting down. Gradually bent back leads to the development of kyphosis in the thoracic spine. This posture prevents the development of chain rectifying reflexes in the prone position and the acquisition of a vertical position by the child, and also excludes the possibility of sensory-motor development and vocal reactions.

The influence of the tonic labyrinth reflex to a certain extent depends on the initial type of spasticity. In some cases, extensor spasticity is so strong that it can also be expressed in the prone position. Therefore, children lying on their stomachs, instead of bending, unbend their heads, throw them back, and raise their upper torso. Despite the extensor position of the head, the muscle tone in the flexors of the arms remains elevated, the arms do not provide support for the body, and the child falls on his back.

Asymmetric cervical tonic reflex (ASTR) is one of the most pronounced reflexes in cerebral palsy. The severity of ASTR depends on the degree of increase in muscle tone in the arms. In severe damage to the hands, the reflex appears almost simultaneously with turning the head to the side. If the arms are only slightly affected, as is the case with mild spastic diplegia, ASTD occurs intermittently and requires a longer latent period to appear. ASTR is more pronounced in the supine position, although it can also be observed in the sitting position.

ASTR, combined with the tonic labyrinth reflex, prevents the capture of a toy and the development of hand-eye coordination. The child cannot bring his arms forward to bring his hands closer to the midline, and accordingly hold the object he is looking at with both hands. The child cannot bring the toy put into the hand to the mouth, eyes, because when trying to bend the hand, the head turns in the opposite direction. Due to the extension of the arm, many children cannot suck their fingers, as most healthy children do. ASTR is usually more pronounced on the right side, so many children with cerebral palsy prefer to use their left hand. With a pronounced ASTR, the child's head and eyes are often fixed to one side, so it is difficult for him to follow the object on the opposite side; as a result, a syndrome of unilateral spatial agnosia develops, spastic torticollis is formed. scoliosis of the spine.

Combined with the tonic labyrinth reflex, ASTR makes it difficult to turn on the side and on the stomach. When the child turns his head to the side, the resulting ASTR prevents the movement of the body following the head, and the child cannot release his arm from under the body. Difficulty turning on its side prevents the child from developing the ability to transfer the center of gravity from one hand to the other when moving the body forward, which is necessary for the development of reciprocal crawling.

ASTR disturbs the balance in the sitting position, since the distribution of muscle tone on one side (its increase mainly in the extensors) is opposite to its distribution on the other (the predominant increase in the flexors). The child loses balance and falls to the side and back. In order not to fall forward, the child must tilt his head and torso. The impact of ASTR on the "occipital" leg can eventually lead to subluxation of the hip joint due to a combination of flexion, internal rotation and adduction of the hip.

Symmetric neck tonic reflex. With a pronounced symmetrical neck tonic reflex, a child with increased flexor tone in the arms and torso, kneeling, will not be able to straighten his arms and lean on them to support his body weight. In this position, the head tilts, the shoulders are drawn in, the arms are brought forward, bent at the elbow joints, the hands are clenched into fists. As a result of the influence of a symmetrical cervical tonic reflex in the position on the stomach, the child has a sharp increase in muscle tone in the extensors of the legs, so that it is difficult to bend them at the hip and knee joints and put him on his knees. This position can be eliminated if you passively raise the child's head, taking him by the chin.

With the severity of a symmetrical cervical tonic reflex, it is difficult for a child to maintain head control, and, accordingly, to stay in a sitting position. Raising the head in a sitting position increases the extensor tone in the arms, and the child falls back; lowering the head increases the flexion tone in the arms and the child falls forward. The isolated effect of symmetrical neck tonic reflexes on muscle tone is rarely revealed, since in most cases they are combined with ASTR.

Along with tonic neck and labyrinth reflexes, a positive supporting reaction and friendly movements (synkinesias) play an important role in the pathogenesis of motor disorders in children with cerebral palsy.

Positive supportive response. The influence of a positive supportive reaction to movements is manifested in an increase in extensor tone in the legs when the legs come into contact with the support. Since children with cerebral palsy always touch the ball of their feet first when standing and walking, this reaction is constantly maintained and stimulated. There is a fixation of all joints of the legs. Rigid limbs can support the weight of the child's body, but they greatly complicate the development of balance reactions, which require joint mobility and fine regulation of the constantly reciprocally changing static state of the muscles.

Concomitant reactions (synkinesias). The effect of synkinesis on the child's motor activity is to increase muscle tone in various parts of the body during an active attempt to overcome the resistance of spastic muscles in any limb (i.e., perform movements such as grabbing a toy, extending an arm, taking a step, etc. ). So, if a child with hemiparesis strongly squeezes the ball with his healthy hand, muscle tone may increase on the paretic side. Trying to straighten the spastic arm can cause increased extensor tone in the homolateral leg. Strong flexion of the affected leg in a child with hemplegia causes friendly reactions in the affected arm, which are expressed in increased flexion in the elbow and wrist joints and fingers. Strenuous movement of one leg in a patient with double hemiplegia may increase spasticity throughout the body. The emergence of friendly reactions prevents the development of purposeful movements and is one of the reasons for the formation of contractures. With cerebral palsy, synkinesis most often manifests itself in the oral muscles (when trying to grab a toy, the child opens his mouth wide). With voluntary motor activity, all tonic reflex reactions act simultaneously, combined with each other, therefore it is difficult to identify them in isolation, although in each individual case one can note the predominance of one or another tonic reflex. The degree of their severity depends on the state of muscle tone. If muscle tone is sharply increased and extensor spasticity predominates, tonic reflexes are pronounced. With double hemiplegia, when the arms and legs are equally affected, or the arms are more affected than the legs, the tonic reflexes are pronounced, are observed simultaneously and do not tend to slow down. They are less pronounced and constant in spastic diplegia and hemiparetic form of cerebral palsy. In spastic diplegia, when the hands are relatively intact, the development of movements is prevented mainly by a positive supporting reaction.

In children who have had hemolytic disease of the newborn, tonic reflexes appear suddenly, leading to an increase in muscle tone - a dystonic attack. With the hyperkinetic form of cerebral palsy, the development of voluntary motor skills, along with the indicated mechanisms, is difficult due to the presence of involuntary, violent movements - hyperkinesis. However, it should be noted that in children of the first year of life, hyperkinesis is slightly expressed. They become more noticeable in the second year of life. In the atonic-astatic form of cerebral palsy, balance reactions, coordination and static functions suffer more. Tonic reflexes can be observed only occasionally.

Tendon and periosteal reflexes in cerebral palsy are high, but due to muscle hypertension, they are often difficult to elicit.

Motor pathology in combination with sensory deficiency also leads to impaired speech and mental development [Mastyukova E. M., 1973, 1975]. Tonic reflexes affect the muscle tone of the articulatory apparatus. The labyrinth tonic reflex increases muscle tone at the root of the tongue, which makes it difficult to form arbitrary vocal reactions. With pronounced ASTR, the tone in the articulatory muscles increases asymmetrically, more on the side of the "occipital limbs". The position of the tongue in the oral cavity is also often asymmetrical, which disrupts the pronunciation of sounds. The severity of the symmetrical cervical tonic reflex creates unfavorable conditions for breathing, voluntary opening of the mouth, and forward movement of the tongue. This reflex causes an increase in tone in the back of the tongue, the tip of the tongue is fixed, ill-defined and often boat-shaped.

Disorders of the articulatory apparatus make it difficult to form voice activity and the sound-producing side of speech. The cry of such children is quiet, slightly modulated, often with a nasal tone or in the form of separate sobs that the child produces at the moment of inspiration. The disorder of the reflex activity of the articulatory muscles is the cause of the late appearance of cooing, babbling, the first words. Cooing and babbling are characterized by fragmentation, low vocal activity, and poor sound complexes. In severe cases, a true drawn-out cooing and babbling may be absent.

In the second half of the year, when there is an active development of combined hand-mouth reactions, oral synkinesis may appear - involuntary opening of the mouth during hand movements. At the same time, the child opens his mouth very wide, a violent smile appears. Oral synkinesis and excessive expression of the unconditioned sucking reflex also prevent the development of voluntary activity of the mimic and articulatory muscles.

Thus, speech disorders in young children suffering from cerebral palsy are manifested by a delay in the formation of motor speech in combination with various forms of dysarthria (pseudobulbar, cerebellar, extrapyramidal). The severity of speech disorders depends on the time of brain damage in the process of ontogenesis and the predominant localization of the pathological process. Mental disorders in cerebral palsy are caused by both primary brain damage and secondary delay in its development as a result of underdevelopment of motor speech and sensory functions. Paresis of the oculomotor nerves, a delay in the formation of static and locomotor functions contribute to the limitation of visual fields, which impoverishes the process of perception of the surrounding world and leads to a lack of voluntary attention, spatial perception and cognitive processes. The normal mental development of the child is facilitated by activities that result in the accumulation of knowledge about the environment and the formation of a generalizing function of the brain. Paresis and paralysis limit the manipulation of objects, make it difficult to perceive them by touch. In combination with the underdevelopment of visual-motor coordination, the absence of objective actions hinders the formation of objective perception and cognitive activity. In violation of cognitive activity, speech disorders also play an important role, which impede the development of contact with others.

Lack of practical experience may be one of the causes of disorders of higher cortical functions at an older age, especially the unformed spatial representations. Violation of communication ties with the environment, the impossibility of full-fledged gaming activity, pedagogical neglect also contribute to mental retardation. Muscular hypertension, tonic reflexes, speech and mental disorders in cerebral palsy can be expressed to varying degrees. In severe cases, muscular hypertension develops in the first months of life and, combined with tonic reflexes, contributes to the formation of various pathological postures. As the child develops, the delay in age-related psychomotor development becomes more pronounced.

In cases of moderate and light severity, neurological symptoms and a delay in the formation of age-related psychomotor skills are not so pronounced. The child gradually develops valuable symmetrical reflexes. Motor skills, despite their late development and inferiority, still enable the child to adapt to his defect, especially if the hands are easily affected. Such children develop head control, the function of grasping an object, hand-eye coordination, and body turns. It is somewhat more difficult and longer for children to master the skills to sit, stand and walk independently, maintaining their balance. The range of motor, speech and mental disorders in children of the first year of life with cerebral palsy can vary widely. It can concern both all functional systems that make up the core of cerebral palsy, and its individual elements. The syndrome of cerebral palsy is usually combined with other neurological syndromes: lesions of the cranial nerves, hypertensive-hydrocephalic, cerebrasthenic, convulsive, autonomic-visceral dysfunctions.

Movement disorders are a group of diseases and syndromes that affect the ability to make and control body movements.

Movement disorders: description

It seems simple and easy, but normal movement requires a surprisingly complex control system. Violation of any part of this system can cause movement disorders in a person. Unwanted movements may also occur at rest.

Abnormal movements are symptoms underlying movement disorders. In some cases, abnormalities are the only symptoms. Disorders or conditions that can lead to movement problems include:

• cerebral paralysis,
• choreoathetosis,
• encephalopathy,
• essential tremor,
• hereditary ataxias (Friedreich's ataxia, Machado-Joseph's disease and spinocerebellar ataxia),
• parkinsonism and Parkinson's disease,
• poisoning with carbon monoxide, cyanide, methanol or manganese,
• psychogenic disorders
• restless leg syndrome,
• muscle spasticity,
• stroke,
• Tourette syndrome and other tic disorders,
• Wilson's disease.

Causes of movement disorders

The movements of our body are produced and coordinated by several interacting brain centers, including the cortex, the cerebellum, and a group of structures in the inner parts of the brain called the basal ganglia. Sensory information ensures the accuracy of the current position and speed of parts of the body and spine, nerve cells (neurons) help prevent contractions of antagonist muscle groups at the same time.

To understand how movement disorders arise, it is helpful to consider any normal movement, such as touching an object with the index finger of the right hand. To achieve the desired movement, the hand must be raised and extended with the participation of the forearm, and the index finger must be extended while the other fingers of the hand remain bent.

Motor start commands originate in the cortex, located on the outer surface of the brain. Movement of the right hand begins with the activity of the left motor cortex, which generates signals for the muscles involved. These electrical signals travel along the upper motor neurons through the midbrain to the spinal cord. Electrical stimulation of the muscles causes contraction, and the force of contraction causes movement of the hand and finger.

Damage or death to any of the neurons along the way causes weakness or paralysis of the affected muscles.

Antagonistic muscle pairs

The previous description of a simple movement, however, is too primitive. One important clarification to it is the consideration of the role of opposite, or antagonistic, pairs of muscles. Contraction of the biceps muscle located on the upper arm affects the forearm to flex the elbow and arm. Contraction of the triceps located on the opposite side engages the elbow and straightens the arm. These muscles, as a rule, work in such a way that the contraction of one group is automatically accompanied by the blocking of the other. In other words, the command to the bicep provokes another command to prevent the contraction of the triceps. Thus, the antagonist muscles are kept from resisting each other.

Spinal cord injuries or traumatic brain injury can lead to damage to the control system and cause involuntary simultaneous contraction and spasticity, and an increase in resistance to movement during muscle work.

Cerebellum

Once the hand movement is initiated, sensory information guides the finger to its precise destination. In addition to the appearance of an object, the most important source of information about an object is its "semantic position", represented by the many sensory neurons located in the limbs (proprioception). Proprioception is what allows a person to touch his nose with his finger even with his eyes closed. The balance organs in the ears provide important information about the position of an object. Proprioceptive information is processed by a structure at the back of the brain called the cerebellum. The cerebellum sends electrical signals to change movements as the finger moves, creating a barrage of commands in the form of a tightly controlled, ever-evolving pattern. Cerebellar disorders cause an inability to control strength, precise positioning, and speed of movement (ataxia). Diseases of the cerebellum can also impair the ability to judge the distance to the target, while the person underestimates or overestimates it (dysmetria). Tremor during voluntary movements can also be the result of cerebellar damage.

Basal ganglia

Both the cerebellum and the cerebral cortex send information to a set of structures deep within the brain that help control the involuntary components of movement. The basal ganglia send output messages to the motor cortex, helping to initiate movements, regulate repetitive or complex movements, and control muscle tone.

The circuits within the basal ganglia are very complex. Within this structure, some groups of cells start the action of other components of the basal ganglia, and some groups of cells block their action. These complex feedback patterns are not entirely clear. Disturbances in the circuits of the basal ganglia cause several types of movement disorders. Part of the basal ganglia, the so-called substantia nigra, sends out signals that block their exit from another structure called the hypothalamic nucleus. The hypothalamic nucleus sends signals to the globus pallidus, which in turn blocks the thalamic nucleus. Finally, the thalamic nucleus sends signals to the motor cortex. The black substance then starts the movement of the pale ball and blocks it. This complex pattern can be broken at several points.

Malfunctions in other parts of the basal ganglia are thought to cause tics, tremors, dystonia, and a variety of other movement disorders, although the exact mechanisms by which these disorders occur are not well understood.

Some movement disorders, including Huntington's disease and inherited ataxias, are caused by hereditary genetic defects. Some diseases that cause prolonged muscle contraction are limited to a specific muscle group (focal dystonia), others are caused by trauma. The causes of most cases of Parkinson's disease are unknown.

Symptoms of movement disorders

Subscribe to our YouTube channel !

Movement disorders are classified as hyperkinetic (many movements) and hypokinetic (little movements).

Hyperkinetic movement disorders

Dystonia- sustained muscle contractions, often causing twisting or repetitive movements and incorrect postures. Dystonia may be limited to one area (focal) or may affect the entire body (general). Focal dystonia may affect the neck (cervical dystonia); face (unilateral or hemifacial spasm, narrowing of the eyelid or blepharospasm, contraction of the mouth and jaw, simultaneous spasm of the chin and eyelid); vocal cords (dystonia of the larynx); arms and legs (writer's spasm or occupational cramps). Dystonia can be a painful condition.

Tremor- uncontrolled (involuntary) shaking of a part of the body. Tremors can only occur when the muscles are in a relaxed state or only during activity.

Teak- involuntary, fast, non-rhythmic movements or sounds. Tics can be controlled to a certain extent.

myoclonus- sudden, short, jerky, involuntary muscle contraction. Myoclonic contractions may occur separately or repeatedly. Unlike tics, myoclonus cannot be controlled even for a short time.

spasticity- an abnormal increase in muscle tone. Spasticity may be associated with involuntary muscle spasms, constant muscle contractions, and exaggerated deep tendon reflexes that make movement difficult or uncontrollable.

Chorea- fast, irregular, uncontrolled convulsive movements, most often of the arms and legs. Chorea can affect the arms, legs, trunk, neck, and face. Choreoathetosis is a syndrome of continuous random movements that usually occurs at rest and can manifest itself in various forms.

Convulsive twitches- similar to chorea, but the movements are much larger, more explosive and occur more often in the arms or legs. This condition can affect both sides of the body, or only one (hemiballismus).

Akathisia- Restlessness and a desire to move to reduce discomfort, which may include a feeling of itching or stretching, usually in the legs.

Athetosis- slow, continuous, uncontrolled movements of the arms and legs.

Hypokinetic movement disorders

Bradykinesia- extreme slowness and stiffness of movements.

Freezing- inability to start movement or involuntary cessation of movement before its completion.

Rigidity- an increase in muscle tension when an arm or leg moves under the influence of an external force.

Postural instability is the loss of the ability to maintain an upright position caused by slow recovery or lack of recovery of reflexes.

Diagnosis of movement disorders

Diagnosis of movement disorders requires a thorough medical history and a complete physical and neurological examination.

The medical history helps the doctor evaluate the presence of other conditions or disorders that may be contributing to or causing the disorder. Family history is assessed for muscle or neurological disorders. Genetic testing may also be done for some forms of movement disorders.

Physical and neurological tests may include assessment of the patient's motor reflexes, including muscle tone, mobility, strength, balance, and endurance; work of the heart and lungs; nerve functions; examination of the abdomen, spine, throat and ears. Blood pressure is measured, blood and urine tests are performed.

Brain studies typically involve imaging modalities, including computed tomography (CT), positron emission tomography (PET), or magnetic resonance imaging (MRI). A lumbar puncture may also be needed. Video recording of abnormal movements is often used to analyze their nature and monitor the course of the disease and treatment.

Other tests may include x-rays of the spine and hip, or diagnostic blocks with local anesthetics to provide information about the effectiveness of possible treatments.

In some cases, nerve conduction studies and electromyography are ordered to assess muscle activity and provide a comprehensive assessment of nerve and muscle function.

An electroencephalogram (EEG) is needed to analyze the overall functioning of the brain, and measure the activity of its parts associated with movement or sensations. This test measures the electrical signals in the brain.

Movement Disorders: Treatment

Treatment of movement disorders begins with a correct diagnostic assessment. Treatment options include physical and occupational therapies, medications, surgery, or combinations of these.

The goals of treatment are to increase patient comfort, reduce pain, ease mobility, assist with daily activities, rehabilitation procedures, and prevent or reduce the risk of developing contractures. The type of treatment recommended depends on the severity of the disease, the general health of the patient, the potential benefits, limitations and side effects of therapy, and its impact on the patient's quality of life.

Treatment for movement disorders is provided by a movement disorder specialist, or a specially trained pediatric neurologist in the case of a child, and a multidisciplinary team of specialists that may include a physical therapist, occupational therapist, orthopedic or neurosurgeon, and others.

Denial of responsibility: The information provided in this article on movement disorders is intended to inform the reader only. It cannot be a substitute for the advice of a health professional.

Relevance. Psychogenic movement disorders (PDD) are a fairly common neurological problem, occurring in 2 to 25% of patients seeking neurological care. As a rule, patients bypass many doctors before they are properly diagnosed, and most often a subspecialist in the field of movement disorders comes to the correct conclusion. It is desirable to establish a psychogenic disorder as early as possible in order to avoid unreasonable examinations and prescriptions and to get the best chance for a cure.

Pathophysiology. The use of functional neuroimaging methods showed that in patients with PDR, the amygdala (Amygdala) is in a state of increased functional activity and is more activated to external stimuli. In addition, these patients showed a more active limbic-motor functional connection, especially between the right Amg and the supplementary motor cortex in response to emotional stimuli. Hyperactivated Amg is likely to involve motor structures in the process of emotional arousal, generating subconscious motor phenomena. By analogy with conversion paralysis, potentially key brain regions functionally involved in the pathological process are the limbic-motor connections and the ventromedial prefrontal cortex. It is no coincidence that cases of effective treatment of PDR with the help of transcranial magnetic stimulation () are described in the literature.

Diagnostic criteria for PDR. So far, the criteria for establishing a psychogenic movement disorder have been used by Fahn and Williams (1988). These included sudden onset, inconsistency in manifestations, increased focus on painful manifestations, reduction or disappearance of these manifestations with distraction, false weakness or sensory disturbances, pain, exhaustion, excessive fearfulness, startling from unexpected action, unnatural, bizarre movements, and also accompanying somatizations. The diagnostic criteria of Fahn and Williams initially included identification points for the diagnosis of psychogenic dystonia, later these criteria were extended to other PDDs. These criteria are set out below: [ BUT] Documented EDD: sustained improvement after psychotherapy, suggestion or placebo, no manifestations of movement disorder when no spectators are present. [ AT] Clinically established PDD: inconsistency with the classical manifestations of known movement disorders, false neurological symptoms, multiple somatizations, obvious psychiatric disorders, excessive attention to painful manifestations, simulated slowness. [ FROM] Probable PDR: inconsistency in manifestations or inconsistency with the criteria of organic DR, a decrease in motor manifestations with distraction, multiple somatizations. [ D] Possible EDD: obvious emotional disturbances.

H. Shill, P. Gerber (2006), based on the original criteria of Fahn and Williams, developed and proposed a new version of the criteria for diagnosing PDD. [ 1 ] A clinically compelling DD is if: it is curable with psychotherapy; does not appear when there are no observers; premotor potential is detected on the electroencephalogram (only for myoclonus). [ 2 ] If these features are not characteristic, the following diagnostic criteria are used: [ 2.1 ] primary criteria – inconsistency in manifestations with organic DR * , excessive pain or fatigue exposure to a "model" of disease disorder; [ 2.2 ] secondary criteria – multiple somatizations ** (other than pain and fatigue) and/or obvious mental disorder.

* Multiple somatizations are considered as a spectrum of patient complaints, covering three different systems. Severe pain and fatigue were taken into account as diagnostic criteria if they were the dominant complaints, but did not correspond to objective data.

** Manifestations that conflict with an organic disease: false weakness and sensory disturbances, inconsistent development in time, a clear dependence of manifestations in response to distracting maneuvers of a specialist, sudden onset, the presence of spontaneous remissions, astasia-abasia, selective incapacity, involvement of tremor in repetitive movements, muscle tension accompanying tremor, atypical response to medication, overreaction to external stimuli.

To establish the levels of certainty of the diagnosis, it is proposed to use the following: [ 1 ] clinically defined EDD: if at least three primary criteria and one secondary criterion are met; [ 2 ] clinically probable: two primary criteria and two secondary ones; [ 3 ] clinically possible: one primary and two secondary or two primary and one secondary.

© Laesus De Liro

Dear authors of scientific materials that I use in my messages! If you consider this to be a violation of the “Copyright Law of the Russian Federation” or wish to see the presentation of your material in a different form (or in a different context), then in this case write to me (at the postal address: [email protected]) and I will immediately eliminate all violations and inaccuracies. But since my blog has no commercial purpose (and basis) [for me personally], but has a purely educational purpose (and, as a rule, always has an active link to the author and his scientific work), so I would be grateful to you for the chance make some exceptions for my messages (against existing legal regulations). Sincerely, Laesus De Liro.

Recent Posts from This Journal

• 
  Vagus nerve stimulation in epilepsy

  Despite the significant advances that have been made in epileptology, resistant epilepsies account for [ !!!] approximately 30% of all forms ...

• Aneurysmal bone cyst (of the spine)

  Aneurysmal bone cyst (ACC, English aneurismal bone cyst, ABC, synonym: hemangiomatous bone cyst, giant cell reparative granuloma, ...

• Hernias of the lumbar spine - minimally invasive methods of surgical treatment

  A herniated disc (HMP) is a displacement of the disc tissues (nucleus pulposus and annulus fibrosus) beyond the intervertebral disc ...

• Innervation (sensory) of the knee joint

  Knowledge of the innervation of the knee joint is becoming increasingly important in connection with the recently gaining popularity of treatment methods ...

• Ischemic syndromes in the vertebrobasilar basin

  Often the symptoms of a patient with acute ischemia in the vertebrobasilar basin (hereinafter referred to as VBB) even doctors [!!!] of specialized centers do not ...