Central paralysis is a consequence of damage to both the motor zone of the cerebral cortex and any part of the nervous system connecting it with peripheral motor neurons. Along with damage to the cortex motor area of the cerebral hemispheres, the cause of central paralysis may be a dysfunction of the corticonuclear, mono- and polysynaptic corticospinal tracts at the level of the corona radiata, knee and two anterior thirds of the posterior thigh of the internal capsule, cerebral peduncle, brain stem, spinal cord . In most cases, the pathological focus does not damage all structures of the motor zone of the cortex and corticospinal tracts; moreover, some of these tracts do not cross. Therefore, on the side of the body opposite to the pathological focus, all muscles are never affected. More often, the function of the muscles of the hand and shoulder is more impaired, then the lower leg. With central paralysis, peripheral motor neurons are preserved and also disinhibited, so with it, as a rule, tendon reflexes are excessively high, pathological reflexes and synkinesis appear. Thus, central paralysis is the impossibility of voluntary movements while maintaining and even increasing the intensity of elementary reflex motor acts. The following symptoms are characteristic of central, or spastic, paralysis. 1. Increased muscle tone of the contractile type, or muscle spasticity, caused by the cessation of the restraining effects of central neurons on peripheral motor neurons. 2. Increased tendon and periosteal reflexes, also associated with a violation of the restraining influences of central neurons on peripheral motor neurons. 3. The appearance of clonus, which can be considered as a result of pronounced tendon hyperreflexia, while a single stimulation of the reflexogenic zone leads to multiple rhythmic repetition of a stereotypical motor response. 4. Pathological reflexes, many of which are evoked in young children and then disappear. With the disinhibition of peripheral neurons due to the weakening of the restraining influence of cerebral structures, these innate reflexes appear again and are already considered pathological. 5. The appearance of protective reflexes and pathological synkinesis (accompanying movements). 6. Unlike peripheral paralysis with central paralysis there is no reaction of degeneration (or degeneration) of muscles and nerves. Muscle spasticity. Spastic muscle tension, in which muscle tone unevenly increases during movements and jackknife and recoil symptoms are possible, is a characteristic sign of damage to the structures connecting central motor neurons with peripheral ones. At acute defeat spastic tone usually does not develop immediately; paralyzed muscles may be flaccid for some time, but tendon reflexes are increased, and the Babinski foot pathological reflex may appear early. Spastic tone is associated with excessive activity of peripheral motor neurons, freed from the inhibitory effects of the structures of the reticular formation of the brain stem. Mainly in the arms, the tone in the flexor muscles increases, in the legs - in the extensors. Patients with central hemiparesis usually develop Wernicke-Mann posture and gait over time. Clonus. As already noted, for central paresis or paralysis is characterized not only by an increase in tendon myotatic reflexes, which are also evoked normally, but often by the appearance of multiple motor reactions to their induction (clonus). In practice, most often called following forms clonus. Foot clonus is caused as follows: the patient lies on his back, the examiner bends his leg at the knee and hip joints and, holding his lower leg with one hand, sharply extends (dorsiflexes) the foot with the other hand, while it is desirable that the patient slightly sits down. rubbed the plantar surface of the foot against the palm of the examiner. The response is a rhythmic alternation of flexion and extension of the foot throughout the entire period while the examiner stretches the heel (Achilles) tendon. With central paresis, especially in cases of damage to the pyramidal tracts of the spinal cord, foot clonus sometimes occurs spontaneously if the patient rests the front of the foot on the floor or on the headboard (Fig. 4.8a). Patellar clonus is caused by the patient lying on his back with his legs straight. The examiner grabs the upper pole of the patella with his thumb and forefinger and then sharply shifts it towards the lower leg and holds it in this position. The quadriceps femoris muscle is stretched and its rhythmic clonic contraction occurs, which does not stop until the stretching of the muscle tendon stops (Fig. 4.86). Much less frequently than the described forms of clonus, it is possible to detect clonus of the lower jaw, clonus of the hand, and clonus of the gluteal muscle. Pathological reflexes. Depending on the location of invocation and the nature of the motor response, pathological reflexes can be divided into foot and hand reflexes, as well as extension (extensor) and flexion (flexor). Rice. 4.8. Detection of clonus of the foot (a) and patella (b). With all pathological foot extensor reflexes, especially common in central paresis and paralysis, the response is extension of the big toe, sometimes in combination with a fan-shaped divergence of the remaining toes. Extensor pathological reflexes include the following. Babinsky reflex - caused by line irritation of the skin of the outer edge of the plantar surface of the foot, directed from the heels to the toes (Fig. 4.9a, b). It is most constant in central paralysis and paresis, but it must be borne in mind that in children under 2 years of age it is usually caused and is normal. Rice. 4.9. Babinski's pathological reflex (a) and its diagram (b). Rice. 4.10. Oppenheim's pathological reflex. Oppenheim reflex - caused by running the thumb and index finger along the crest of the tibia with some pressure from top to bottom towards the ankle joint (Fig. 4.10). Gordon reflex - caused by compression of the triceps surae muscle (Fig. 4.11). Schaeffer reflex - caused by compression of the heel tendon (Fig. 4.12). With all pathological flexion foot reflexes, the motor response is reduced to rapid nodding plantar flexion of the toes. Pathological foot flexion reflexes include the following. Rossolimo reflex - is caused by short light blows with the fingers of the examiner’s hand on the plantar surface of the terminal phalanges of the II-V toes of the patient’s foot (Fig. 4.13). Rice. 4.11. Gordon's pathological reflex. Rice. 4.12. Pathological reflex of Schaefer. Rice. 4.13. Pathological Rossolimo reflex. Bekhterev-Mendelian reflex - is caused by tapping with a hammer on the back of the foot over the III-IV metatarsal bones. The Zhukovsky-Kornilov reflex is caused by tapping on the central part of the sole (Fig. 4.14). When the pyramidal tracts are damaged above the level of the cervical enlargement of the spinal cord, pathological carpal reflexes can also be caused, which can generally be considered as analogues of the foot reflexes. Rice. 4.14. Pathological reflex Zhukovsky-Kornilov. Protective reflexes. Like pathological reflexes, protective reflexes, or reflexes of spinal automatism, arise due to the isolation of reflex arcs from the higher parts of the brain that close at the level of the spinal segments. They are involuntary movements of paralyzed parts of the body in response to their irritation. Irritants for jtom can be injections, pinch-like compression of the skin, irritation with ether, etc. (Fig. 4.15a). Protective reflexes can also be obtained in response to rapid passive movement in any joint of the paralyzed limb - Fig. 4.15. Protective reflexes. A - etheric method, b - Bekhterev-Marie-Foy method. ty due to the resulting irritation of proprioceptors. Thus, with passive plantar flexion of the toes of a paralyzed leg (Fig. 4.15a, b), a pull-up of the leg occurs due to its spontaneous flexion in the hip and knee joints (Bekhterev-Marie-Foy reflex). With the Remak protective femoral reflex, in response to streak irritation of the skin of the anterior surface of the thigh, plantar flexion of the foot and fingers occurs. Protective reflexes can also arise from random irritations of the body: touching a sheet, air movement, etc. In cases where the stimulus goes unnoticed, such reflexes are often called “spontaneous” protective reflexes. Protective reflexes, as a rule, occur with combined damage to the corticospinal tracts and extrapyramidal-spinal polysynaptic connections, and are especially pronounced when the pyramidal and extrapyramidal tracts are damaged at the spinal level. The level below which tissue irritation leads to the emergence of protective reflexes can help identify the lower pole of the pathological focus in the spinal cord. Pathological synkinesis. Synkinesis, or conjugate movements, are called involuntary movements that join voluntary ones. Synkinesias can be physiological and are observed in healthy people. Thus, clenching the hand into a fist is usually accompanied by extension in the wrist joint; when walking, accompanying arm movements occur (cheirokinesis), etc. With central paresis and paralysis, due to the weakening of the inhibitory effect on the reflex arcs that close at the spinal level, prerequisites arise for the development of pathological synkinesis, which can be global, or spastic, coordination and imitation. Global, or spastic, syncynesias are observed in spastic hemiplegia. Attempts to actively move painful limbs or sudden muscle tension healthy side body causes involuntary flexion in the paralyzed arm and extension in the leg. Global synkinesias in a paralyzed part of the body can occur with general emotional reactions, as well as with yawning, coughing, sneezing. Coordination synkinesis are movements that the patient cannot perform in isolation, but during a complex motor act they arise as additional ones and then cannot be voluntarily delayed. An example of coordination synkinesis can be the Raymist symptom, which consists of Fig. 4.16. The Wernicke-Mann position with central hemiparesis is blind. involuntary abduction and adduction of the paralyzed leg when the examiner attempts to adduct or abduct the healthy leg of the patient lying on his back and offering resistance to the examiner. Another example of coordination synkinesis - the tibial Strümpel phenomenon - is that in a patient who could not straighten the foot due to central paresis of the leg, when trying to bend the affected leg at the knee, overcoming the resistance of the examiner, involuntary extension occurs foot, and sometimes the big toe. Imitative synkinesias are rarely observed, usually in cases of massive damage to the pyramidal and extrapyramidal tracts. With them, involuntary movements occur in the paralyzed limb, identical to those that are voluntarily performed in a symmetrical healthy limb, for example, flexion and extension of the fingers, pronation and supination of the forearm, etc.

Paralysis is the complete loss of voluntary movements in certain muscle groups, paresis is the partial (incomplete) loss of voluntary movements. Let us recall that in order to carry out voluntary movements, the preservation of the cortico-muscular pathway is necessary - a two-neuron pathway connecting the cerebral cortex with the skeletal (striated) muscles. The body of the first (upper, or central) neuron is located in the cortex of the precentral gyrus, its axon is directed to form a synapse with the second (lower, or peripheral) motor neuron located in the spinal cord. The axons of the peripheral motor neuron go directly to the muscle. Paralysis (paresis) occurs when both central and peripheral neurons of the corticomuscular pathway are damaged.

Spastic (central) paralysis occurs when the upper (central) motor neuron of the corticomuscular tract is affected, indicating that the lesion is located in either the brain or the spinal cord. The main characteristic manifestations of central paralysis (paresis) are the following [P. Duus, 1995]:

spastic increase in muscle tone (hypertension);

decline muscle strength in combination with loss of the ability to make fine movements;

increased deep (proprioceptive) reflexes;

decrease or loss of exteroceptive reflexes (abdominal, cremasteric, plantar);

the appearance of pathological reflexes (Babinsky, Oppenheim, Gordon, etc.);

absence of degenerative muscle atrophy.

Hypertension, or muscle spasticity, determines another name for central paralysis - spastic. The muscles are tense, dense to the touch; During passive movements, a clear resistance is felt, which is sometimes difficult to overcome. This spasticity is the result of increased reflex tone and is usually unevenly distributed, leading to typical contractures. With central paralysis, the upper limb is usually brought to the body and bent in a elbow joint: The hand and fingers are also in a flexed position. The lower limb is extended at the hip and knee joints, the foot is bent and the sole is turned inward (the leg is straightened and “elongated”). This position of the limbs with central hemiplegia creates a peculiar Wernicke-Mann position, the interpretation of the patterns of its occurrence from the point of view of the history of the development of the nervous system was given by M.I. Astvatsaturov.

The gait in these cases is of a “circumducing” nature: due to the “lengthening” of the leg, the patient has to “circle” the affected leg (in order not to touch the floor with the toe).

Increased tendon reflexes (hyperreflexia) are also a manifestation of increased, disinhibited, automatic activity of the spinal cord. Reflexes from the tendons and periosteum are extremely intense and are easily caused by even minor irritations: the reflexogenic zone expands significantly, i.e. the reflex can be evoked not only from the optimal area, but also from neighboring areas. An extreme degree of increase in reflexes leads to the appearance of clonus (see above).

In contrast to tendon reflexes, skin reflexes (abdominal, plantar, cremasteric) do not increase with central paralysis, but disappear or decrease.

Concomitant movements, or synkinesis, observed with central paralysis, can occur in the affected limbs reflexively, in particular when healthy muscles are tense. Their occurrence is based on the tendency to irradiate excitation in the spinal cord to a number of neighboring segments of its own and opposite sides, which is normally moderated and limited by cortical influences. When the segmental apparatus is disinhibited, this tendency to spread excitation is revealed with particular force and causes the appearance of “additional” reflex contractions in the paralyzed muscles.

There are a number of synkinesis characteristic of central paralysis. Here are some of them:

1) if the patient, according to the instructions, resists with his healthy hand the extension in the elbow joint produced by the examiner, or strongly shakes his hand with his healthy hand, then a concomitant reflex flexion occurs in the paralyzed arm;

2) the same flexion of the affected arm occurs when coughing, sneezing, or yawning;

3) under the mentioned conditions, involuntary extension is observed in the paralyzed leg (if the patient is sitting with his legs hanging over the edge of the couch or table);

4) the patient lying on his back with his legs extended is asked to adduct and abduct his healthy leg, in which he is resisted. In this case, an involuntary corresponding adduction or abduction is observed in the paralyzed leg;

5) the most constant of the accompanying movements with central paralysis is the symptom of combined flexion of the hip and trunk. When the patient tries to move from a horizontal position to a sitting position (the patient lies on his back with his arms crossed on his chest and straightened legs apart), the paralyzed or paretic leg is raised (sometimes adducted).

Pathological reflexes are a group of very important and constant symptoms of central paralysis. Of particular importance are pathological reflexes on the foot, which are observed, of course, in cases where the lower limb is affected. The most sensitive symptoms are Babinski (perverted plantar reflex), Rossolimo and Bekhterev. The remaining pathological reflexes on the foot (see above) are less constant. Pathological reflexes in the hands are usually weakly expressed and of great importance in practice clinical trial did not purchase. Pathological reflexes on the face (mainly a group of “oral” reflexes) are characteristic of central paralysis or paresis of muscles innervated by cranial nerves, and indicate bilateral supranuclear lesions of the tractus cortico-bulbaris in the cortical, subcortical or brainstem regions.

The development of paralysis due to organic factors is known: due to physical damage, severe poisoning, metabolic or nutritional disorders, vascular pathology, cancer, infections, hereditary or congenital pathologies.

Central paralysis syndrome occurs after infections that have developed in the brain or spinal cord - syphilis, tuberculosis, viral encephalitis, meningitis, polio.

Paralysis due to intoxication means poisoning with heavy metal derivatives, alcoholic neuritis, lack of vitamin B1, and lack of nicotinic acid.

Multiple sclerosis, the nature of which has not been identified, causes dysfunction of movements varying degrees. Wounds and fractures are fraught with similar consequences if motor centers or pathways are damaged.

Paralysis can occur even under the influence of psychogenic factors.

Central paralysis more often affects older people, but now there is a clear trend towards its “rejuvenation”. According to statistics, more than half of cases of paralysis are a consequence of a stroke. A thrombus, like hemorrhages, can lead to disruption of blood supply by blocking blood vessels in the area of ​​the brain responsible for movement or pathways. Infantile paralysis usually occurs as a result of birth injuries or as a result of inherited spastic paraplegia.

Pathogenesis

The most common pathological conditions of the nervous system are destruction, degenerative, inflammatory processes, sclerotic changes, demyelination. Paralysis occurs due to pathological conditions brain or due to damage to peripheral nerves.

There are two types of central palsy: cerebral (brain) and spinal. The nature of spinal paralysis is pathological changes in the neurons responsible for movement. Cerebral palsy implies a capsular, bulbar, cortical or subcortical nature.

Two types of neurons are responsible for movement. They differ in functional load and their structure. Therefore, if pathological changes have occurred in them, two are distinguished various types signs: affected nerve cells responsible for movement cause spastic paralysis, while peripheral nerve cells cause flaccid paralysis.

There are no internal causes for paralysis of a psychogenic nature, so it masquerades as any of the types, exhibits general signs of central and peripheral paralysis, or any combination of them.

Central paralysis may combine symptoms of peripheral paralysis, or may exhibit exclusively pure symptoms; it is often accompanied by disturbances in vascular tone, sensitivity, and digestion. A common manifestation of peripheral paralysis is sensory disturbances.

In a body with paralysis, motor function often suffers entirely and does not selectively affect muscles. Paralyzed muscle tissue is in permanent tension and does not atrophy (this is possible solely due to complete inactivity). In immobilized limbs, deep tendon reflexes are maintained or exacerbated, and clonus (fast convulsive contractions) are often detected. On the side affected by paralysis, abdominal reflexes weaken or disappear completely.

Symptoms of central paralysis

We list the first signs of central paralysis:

• muscle hypertonicity;
• expanding the scope of reflective reactions;
• increased reflective reactions;
• rapid convulsive contractions of the muscles of the knees or feet (clonus).

With hypertonicity, the muscles are too dense. High muscle resistance is noted. High degree muscle tension is fraught with the appearance of contractures. Therefore, movements are limited partially or entirely. Contracture is characterized by an unnatural frozen position of the limb.

Most notable visible signs paralysis is provoked by an expansion of the area of ​​action of reflex reactions. Convulsive rhythmic contractions of the muscles of the knees or feet appear due to stretching of the tendons. Typically, such contractions appear due to the intensification of tendon reflex reactions. The contraction of the feet is the result of accelerated dorsiflexion. Reflexive twitching of the leg is a response to such an impact. Clonus kneecap noticeable during rapid abduction of the limb. Pathological reflexes in the feet or hands are a visible symptom of pyramidal tract pathology. The most typical are the reflex reactions of Oppenheim, Rossolimo, Zhukovsky, Babinsky Gordon and Schaeffer.

Protective reflexes, manifested by trembling of the affected limb, reacting to mechanical irritation, are also a manifestation of central paralysis syndrome.

Sykinensia is another symptom of paralysis. Synchronizations are reflexive simultaneous movements in the affected limb with conscious active movements. Like, say, swinging your arms while walking, flexion - extension of the limbs simultaneously with directed movements on the half of the body that is not subject to paralysis. There are many types of synkinesia that indicate the development of paralysis.

Muscle spasms due to hypertonicity are often distributed unequally. More often the left or right side the entire body, the arm is usually pressed down, the hand and fingers are curled, the leg is straightened, and the foot is bent and turned inward.

With central paralysis, reflexive reactions in the tendons are more pronounced, and abdominal, muscular and plantar reactions disappear completely or become noticeably weakened.

The most obvious symptoms central paralysis:

• Unnatural body position;
• Weakened or increased mobility;
• Weakening of facial muscles;
• Articulation and speech disorders;
• Convulsive contractions and trembling of muscles;
• Unnatural gait;
• Accidental opening of the mouth;
• Closing the eyes;
• Undirected shoulder movements;
• Random flexion and extension of the joints of the arms or legs;
• Muscular hypertonicity.

The symptoms accompanying central paralysis help to accurately separate it from other types of motor dysfunction and even identify the area of ​​the pyramidal tract susceptible to pathological processes.

Central facial paralysis occurs due to disturbances in cortical processes or pathology nerve pathways leading to the facial nerve. Facial paralysis appears opposite the affected area and is usually located in the lower region.

Facial muscles contract randomly due to the connection of the nerve with the extrapyramidal system. It looks like a tic or spasm. This type of paralysis may be accompanied by epileptic seizures.

The development of central paralysis of the limbs occurs due to pathological changes in the descending system of nerve fibers. A noticeable manifestation of pathology is reflex reactions in the tendons, muscle hypertonicity, and manifestations of pathological reflex reactions. Such symptoms may appear in conjunction with other signs of organic paralysis.

With paralysis of functional etiology, the reflex reactions of the tendons do not undergo changes and normal muscle tone is maintained.

Central spastic paralysis indicates that the area of ​​the brain in the hemisphere opposite to the affected limb is damaged.

Combined pathologies of the limbs are characteristic of disorders in the brain stem.

Cross paralysis indicates disturbances at the junction site medulla oblongata and dorsal.

When the limbs are paralyzed only on the left or right, and the nerves of the skull have not been injured, this indicates a failure of the descending system of the nervous tissues of the cervical region.

Central paralysis of the legs means pathology or along the way lateral funiculus spinal cord, in the convolutions of the brain, corona radiata.

Infantile central palsy

Infantile central paralysis unites a whole group of diseases characterized by damage to the central nervous system, motor dysfunction, slow development of the psyche. Infantile central palsy does not develop. This may indicate perinatal paralysis of the central nervous system or brain damage during childbirth, when lack of oxygen, birth trauma, or stroke causes the development of encephalopathy. Paralysis is often associated with impaired oxygen supply to brain cells. Complications of hypoxia are insufficient development of areas of the brain responsible for balance, coordination and ensuring the functioning of reflexes. This is why asymmetric muscle tone develops and pathological motor reactions appear.

Diagnosis of central paralysis

Instrumental diagnosis of central paralysis includes: neuroimaging (CT and MRI), radiography of the bones of the spine and skull, electromyography, puncture of the spinal cord fluid, histology and histochemistry of a biopsy of the affected muscles.

Differential diagnosis

Differential diagnosis includes assessment of the volume and severity of paralysis. A map of the affected muscles can indicate the area of ​​pathological processes in the central nervous system.

In case of paralysis of the limbs, it is necessary to assess its volume: immobility of four limbs means damage to the spinal cord in the area in the neck; paralysis of the limbs on one side is characteristic of the pathology of the internal capsule; paralysis of the legs - for spinal cord disorders in the chest or lower back; The cause of paralysis of one limb lies in peripheral nerve disorders.

It can paralyze other muscles. For example, dysfunction eye muscles- this is a pathology of the cranial nerves; immobility of facial muscles - pathology of the facial nerve or central motor neuron of the opposite hemisphere; laxity of the sternocleidomastoid and trapezius muscles means disturbances in the accessory nerve; lethargy of the tongue muscles - the hypoglossal nerve is damaged.

For diagnosis, it is necessary to clarify the circumstances of the appearance of paralysis: how it began, whether it was accompanied by injuries, impaired consciousness, fainting, high temperature, signs of an infectious disease. It is important to analyze whether others have emerged neurological symptoms: sensory disorders, ataxia, vision problems, wasting disorders bladder, bowel cleansing.

For the differential diagnosis of central and peripheral paralysis, electromyography is effective, which notes pathologies inherent in damaged neurons of the anterior horn of the spinal cord and resulting neuropathies. These disorders are not characteristic of central paralysis. With central paralysis, the H-reflex changes. It manifests itself in all affected muscles, when normally it is detected exclusively in the lower leg.

Treatment of central paralysis

Patients are treated for the main disease with treatment of the paralysis itself at the same time. If the vessels are affected, the immobilized limb is given a position that does not interfere with the normal blood supply.

In parallel with the prevention of contractures, they are treated with medications. The therapy intensifies metabolism in the nerves, circulation in small vessels, and improves nerve and synaptic conduction.

Conservative treatment brings results when the morphological substrate has survived, allowing the regeneration of muscle functions. If it remains possible to resume muscle function, the goal of conservative treatment is to avoid contractures and deformities and accelerate the resumption of muscle function.

Physiotherapeutic treatment, balneotherapy, physical therapy, and reflexology are widely used.

Physiotherapy for central paralysis is prescribed after some time. The timing of physical therapy depends on the factors causing the paralysis: inflammation, injury or stroke.

Electrophoresis of medications helps restore blood circulation to the affected area of ​​the brain. For inflammation, UHF and microwave treatment is used. Electrical stimulation in the area of ​​the immobilized limb is carried out at the motor points of the antagonist muscles. This helps relieve hypertonicity and reduce the reflex response of paralyzed muscles. Electrical stimulation is combined with taking muscle relaxing drugs and acupuncture. To reduce the risk of contractures, therapy is carried out with warm ozokerite or paraffin. Positive dynamics are possible when using cold, especially with spastic infantile central palsy.

Physical rehabilitation for central paralysis begins with massage, and after a week or a week and a half, physical therapy begins.

The first exercises involve working on maintaining the occupied position of the limb. When working on the development of conscious movements, they use special equipment: frames with blocks and various ropes attached to the bed, balls, expanders.

When the patient can already sit independently, the next stage of therapeutic exercises is learning to walk. First, the methodologist helps, and then the patient tries to move independently, using crutches and sticks. Then they begin to master more subtle movements: buttoning clothes, lacing shoes, controlling equipment using a remote control or keyboard.

Drug treatment for paralysis

The main drugs are benzodiazepines, baclofen, dantrolene. How these medications work has not been reliably established. Medicines are prescribed if disturbances in normal muscle activity occur every day. Medication therapy will give excellent results if you use two or more medications and combine them with other methods of therapy.

• Baclofen has an inhibitory effect, affecting gamma-aminobutyric acid receptors that are not susceptible to bicuculline. The dose is prescribed individually in each case in order to identify the minimum effective dosage that is not associated with side effects. Results are usually obtained with dosages ranging from 30 to 75 mg daily.

For the first 3 days, half a tablet is prescribed 3 times a day (if the dosage of the tablet is 10 mg); 4-6 days – a whole tablet; Days 7–9, 1.5 tablets 3 times a day; Days 10–12 - 2 tablets. A gradual increase in dosage ensures good tolerability of the drug. Abruptly stopping taking baclofen is fraught with hallucinations and exacerbation of signs of paralysis.

• Benzodiazepines enhance the postsynaptic effects of GABA by promoting presynaptic inhibition. Medicines also affect processes in the brain stem. The drug diazepam is very often used. Dosage – within 2–8 mg 2 times a day. A course of diazepam involves complete restriction of alcohol. Adverse reactions include liver dysfunction and blood disorders. Extreme care should be taken when administering diazepam and when discontinuing it for patients taking blood thinning medications.

Diazepam can cause drowsiness, dizziness, slow down the reaction, provoke allergies, nausea, and vomiting.

• Dantrolene inhibits the release of calcium in the muscles by dividing electromechanical coordination. That is, it reduces tone, increasing muscle weakness. For hypertonicity, the drug gives noticeable results, but it is usually prescribed to patients with plegia. For administration, it is prescribed in a dosage of 4-8 mg per day in 3 or 4 doses. Dantrolene is excreted through metabolism in the liver, and is therefore limited for use in patients with unhealthy livers. Special care is also needed when prescribing dantrolene to people with problems with the lungs or heart.
• Sirdalud acts on the polysynaptic pathways of the spinal cord, reducing the production of excitatory signals to alpha motor neurons. The drug's effectiveness on muscle hypertonicity is similar to baclofen, but sirdalud has better tolerability. Sirdalud is prescribed to adults, starting with a dosage of 1 to 2 mg per day (in 2-3 doses) with a gradual increase in dosage to 12-14 mg, distributed over 3 or 4 doses. May cause a reaction in the form of weakness, dry mouth, and sleep disturbances.

Anticholinesterase drugs are also used to treat central palsy. Anticholinesterase drugs quickly enter the central nervous system, intensifies the transmission of signals to the muscles from the nerves and weakens the signs of central nervous system dysfunction.

Surgical treatment of paralysis

Before the operation, the functional capabilities of the muscles are identified, measures are taken to strengthen them, and measures to eliminate contractures that have arisen. After the operation, measures are developed to promote the growth and strengthening of the function of the implanted muscles, and then training of movements that are difficult in terms of coordination. Surgical intervention is more often performed for flaccid paralysis or cerebral palsy, when conservative therapy didn't improve the situation.

Surgery is advisable for neurogenic deformity, when the muscles of the limb are partially affected, changes in the mechanical axis, shape, and size are noticeable, for example, with complete paralysis of the muscular portion of the limb. Then surgical treatment- This preparatory stage before subsequent prosthetics.

Surgery for cerebral palsy seeks to remove deformation of the limb, distorting statics. Such intervention is advisable when conservative treatment methods have failed. It is also effective if areas with fixed deformation are found, which are caused by disorders of the tendon-muscular system and ligaments of the system. Sometimes operations are aimed at eliminating reflective contractures.

Operations are divided into three different types:

• operations on tendons and muscles;
• ligament surgeries;
• operations on bones and joints.

It happens that operations combine elements of all types.

The success of the operation and recovery time depend on a set of conservative therapy measures.

Folk recipes

Traditional medicine advises patients to drink the juice of fresh celery, nettle or plantain.

If the cause of paralysis lies in pathologies of blood circulation in the brain, feijoa will help. A noticeable improvement comes from taking the juice and the fruits themselves.

For paralysis, drink a tincture of cleft wolfberry. For 5 grams of bark or roots you need to take 0.5 liters of vodka or alcohol. Take a two-week course of 1 - 2 drops three times a day. The ointment with the tincture is rubbed externally. To prepare, pour 20 ml of tincture into 50 g of heated lanolin, and, without stopping stirring, gradually pour in 50 g of Vaseline. The ointment is applied along the entire path of the nerve, and the treated area is wrapped in woolen cloth.

Baths can also help recovery from paralysis. To prepare a bath with a decoction of rosehip roots, take 4-6 teaspoons of crushed roots, add a liter of boiling water, and boil for 20-30 minutes. Then the broth is poured into the bath. For a bathroom, the water temperature should be moderate - 38 degrees is enough. You can also prepare a juniper decoction for the bath: 4 - 6 teaspoons of juniper branches or fruits, pour a liter of water, boil for 20-30 minutes. For baths, one plant is used up to 10 times, and then it must be replaced with some other one.

Brew 1 teaspoon of roots with a liter of boiling water, and after an hour strain through a sieve or cheesecloth. Take an infusion of peony roots, 1 tablespoon 3 times before meals. The roots infused with alcohol are drunk in a dosage of 30-40 drops 3 times a day.

• A decoction of sumac leaves.

1 tbsp. A spoonful of tinting sumac or tanning sumac is brewed in 0.5 liters of boiling water and left for an hour. Take 1 tablespoon of decoction 3-4 times a day.

• Tincture of pine cones

10-15 ripe pine cones are prepared for the tincture. The cones are filled with vodka (0.5-0.6 liters) and infused for a month. Drink 1 teaspoon of tincture 3 times a day.

Homeopathy

Optimally combine homeopathic medicines with classical medicine medications. Homeopathy does not replace primary treatment, but can complement a set of measures that stimulate the body to recover.

• The homeopathic drug Konium relieves seizures. Its basis is an extract from spotted hemlock, an extremely poisonous plant. Conium is indicated for paralysis accompanied by paresthesia, and the patient feels weak, suffers from insomnia, and often freezes. Dissolve 8 granules 5 times a day. Conium is taken for up to 2 months.
• Fibiaron – complex drug. Acts as a prevention of paralysis, in addition, it is indicated for treatment. Belladonna, white mistletoe, and ambergris in Fibiaron harmonize the excitation-inhibition mechanism and protect the central nervous system. Dosage - 5-7 granules 3 to 5 times a day. Fibirion is taken for 6 to 8 months.
• Barium aceticum is available in granules and drops. Prescribed for paralysis rising from the limb to the center. The drug is prescribed for absent-mindedness, hesitation before making decisions, a feeling of “pins and needles”, a feeling of cobwebs on the face, tingling and pain spreading along the left leg. Barium aceticum acts almost like Barita acetica.
• Bothrops is made from the venom of a spearhead snake and is produced in the form of granules or drops. Bothrops is prescribed for paralysis with signs of speech impairment, signs of paralysis right side bodies.
• CAUSTICUM (Caustic) is effective for paralysis caused by lead intoxication.

Rehabilitation after central paralysis may take months or perhaps years, the most important thing is to follow the recommendations, regularly practice independently, try to expand motor functions, and gradually move on to sports loads: exercises in the pool, jogging, jumping.

Subject:Voluntary movements and their disorders.Aanatomy and physiology of voluntary movements. Phenomenology of peripheral paresis syndrome with different lesion localizations. Rehabilitation of patients with central paresis

Voluntary movements form the basis of human life. They arise as a result of the close interaction of motor (efferent) and sensory (afferent) systems. Voluntary movements are provided by many motor systems, among which one of the main places is occupied by corticomuscular tract.

The corticomuscular tract includes the central motor neuron (motor neuron), peripheral motor neuron, and muscle.

Central (upper) motor neurons are located primarily in the precentral gyrus (posterior parts of the frontal lobe). Betz's giant pyramidal cells are located in the primary motor cortex; fast-conducting axons from them make up 3-5% of all fibers of the pyramidal tract. Along with Betz giant cells, the primary motor cortex contains small pyramidal cells, the axons of which form about 40% of all fibers of the pyramidal tract. In the upper section of the precentral gyrus and in the paracentral lobule there are neurons innervating the lower limb and trunk, in the middle section there are neurons innervating the upper limb; in the lower section - neurons innervating the muscles of the face, pharynx, and larynx. This projection to a certain extent corresponds to a person standing on his head.

Peripheral (lower) motor neurons are located in the motor nuclei of the cranial nerves and in the anterior horn of the spinal cord. The axons of the cells of the anterior horns of the spinal cord form the anterior roots, which, connecting with the dorsal root, form the spinal nerves. From the spinal nerves, plexuses are first formed, then peripheral nerves. Peripheral motor neurons innervating the neck muscles are located in the upper cervical segments (C 1 -C 4), motor neurons innervating the upper limbs are in the cervical thickening (C 5 -Th 2 segments of the spinal cord); motor neurons innervating the lower limbs - in the lumbar enlargement (Th 12 -S 2 segments of the spinal cord); motor neurons innervating the trunk muscles - in thoracic region spinal cord.

Reflexes play an important role in ensuring voluntary movements. Unconditioned reflexes are closed in the segmental apparatus of the spinal cord and brain stem. A two-neuron reflex arc consists of a receptor, a sensory neuron, a motor neuron, and a muscle. The three-neuron reflex arc additionally includes an interneuron between the sensory neuron and the motor neuron.

Methodology for clinical study of voluntary movements. The study of the motor system includes an external examination of the musculoskeletal system, assessment of the volume, strength and tempo of voluntary movements, study of muscle tone and deep (tendon and periosteal) and superficial (skin) reflexes, and study of gait. During an external examination, muscle atrophy and fasciculations can be detected - spontaneous non-rhythmic contractions of muscle bundles. Of particular importance is the identification of local (local) muscle atrophy. When studying active movements in the limbs of the body, their volume is first determined, then their strength. If movements are limited in volume in any joint, passive movements are examined in it, during which osteoarticular changes can be identified, for example, arthrosis, which explains the limitation of movements. In these cases, the limitation of movements is not caused by pathology of the corticomuscular pathway. To test muscle strength, the examinee is asked to perform a movement that involves that muscle and hold that position while the examiner attempts to perform a movement in the opposite direction. For example, to test the strength of the biceps brachii muscle, the examinee is asked to bend the arm at the elbow joint and try to hold the arm in this position while the doctor tries to straighten it. To quantify muscle strength, additional devices can be used, such as a dynamometer to assess hand muscle strength. When assessing the results of the study, it is necessary to take into account the physical development of the subject, his age and gender. It is advisable to compare muscle strength on both sides, taking into account that in right-handed people, the strength in the right limbs, as a rule, is slightly greater than in the left, and in left-handed people, on the contrary, the strength is greater in the left limbs.

To identify hidden limb paresis, you can use Bare sample. To identify paresis in the upper extremities, the examinee is asked to raise them, close their eyes and hold the upper extremities in this position for several seconds. To detect paresis in the lower extremities, the examinee is asked to lie on his stomach, close his eyes, bend his lower extremities at the knee joints and hold them in this position for several seconds. If there is paresis in one of the limbs, then it may lower or deviate from a given position in comparison with the healthy side. Muscle tone is assessed by the resistance that occurs in a relaxed muscle in response to its passive stretching (passive movements of the patient's limbs); the study is carried out in all joints of the upper and lower extremities. For example, when bending the elbow joint, a passive stretch of the triceps brachii muscle and its reflex tension occurs; when extending the elbow joint, a passive stretch of the biceps brachii muscle and its reflex tension occurs. Normally, a slight tension in the muscle is felt in response to its passive stretching. With an increase in muscle tone, significant muscle tension is noted, with muscle hypotension

The study of reflexes is of great importance. On the upper extremities, reflexes from the tendon of the biceps brachii muscle (biceps reflex), from the tendon of the triceps brachii muscle (triceps reflex) and the carporadial reflex (carpal radial reflex) are examined. lower limbs− knee and Achilles reflexes. Tendon and periosteal reflexes are examined using a neurological hammer. Hammer blows should be applied lightly and infrequently, with equal force when comparing reflexes on the right and left sides. When a hammer hits a muscle tendon, not only irritation of the tendon receptors occurs, but also stretching of the muscle, which leads to excitation of the receptors located in the muscle and the occurrence of a reflex, therefore, from a physiological point of view, the tendon reflex is more correctly regarded as a reflex to stretch the muscle (myotatic reflex). In addition to tendon and periosteal reflexes, deep and superficial abdominal reflexes, plantar reflex, anal and cremasteric reflexes are also examined. When studying reflexes, pay attention to their symmetry and liveliness. Therefore, it is better to examine each reflex immediately from the right and left sides, comparing their vivacity. Each reflex is assessed according to the degree of vividness: normal, increased (hyperreflexia), decreased (hyporeflexia), absent or lost (areflexia). Reflexes have significant individual variability, but normally they are the same in vividness on the left and right sides.

Symptoms of central and peripheral paresis

Central paresis (spastic paresis) is a paresis that occurs when the upper (cortical) motor neuron and/or the main motor pathway (syn. corticospinal and corticobulbar tract, pyramidal tract) are damaged at the level of the brain or spinal cord. In clinical practice, hemiparesis is most common with lesions in the brain, and lower paraparesis with lesions of the spinal cord. The causes of the development of central paresis (CP) are:

Acute diseases and brain damage (stroke, trauma, encephalitis);

Acute diseases and injuries of the spinal cord (trauma, spinal stroke, acute myelitis);

Tumors (and other space-occupying diseases) of the brain and spinal cord;

Progressive diseases of the central nervous system of vascular origin (dyscirculatory encephalopathies, myelopathies), autoimmune (multiple sclerosis), hereditary (Strumpell's disease), amyotrophic lateral sclerosis, diseases of other, often unclear origins;

Cerebral palsy (pre-, peri- and postnatal encephalopathy).

Paresis- a disorder of voluntary movements in the form of a decrease in strength and range of movements, it is caused by damage to the cortico-muscular pathway.

Plegia, or paralysis, − complete lack of movement. Paresis or paralysis of the limbs with damage to the cortico-muscular tract in any area: brain, spinal cord, anterior roots, plexuses, nerves, neuromuscular junction and muscle. Paresis does not include limitation of movements due to pain due to damage to the osseous-ligamentous apparatus. The degree of paresis can be assessed quantitatively, for example, using a 5-point system: 5 points - movements in full force (no paresis); 4 points – slight decrease in strength; 3 points – moderate decrease in strength, but full range of motion even under the influence of gravity; 2 points - significant decrease in strength, full range of movements is possible only when gravity does not act on the limb (for example, in a lying position the patient cannot raise the leg, but in the horizontal plane he flexes the leg at the hip joint in full); 1 point - minimal movement or only visible muscle contraction without movement of the limb; 0 points – lack of movement (plegia, or paralysis). Paresis of 4 points is regarded as mild, 3 points as moderate, 1 and 2 points as deep.

Paresis (plegia) of one limb is defined as monoparesis (monoplegia), paresis in the named limbs − hemiparesis (hemiplegia), paresis in the upper and lower extremities - respectively upper and lower paraparesis (paraplegia), paresis in three limbs − triparesis (triplegia), paresis in all limbs − tetraparesis (tetraplegia).

There are two types of paresis - central and peripheral, differing in their clinical signs and arising, respectively, from damage to the central or peripheral motor neuron.

Central paresis (spastic paresis) develops when the pyramidal (corticospinal) tract in the brain or spinal cord is damaged. With central paresis in the limb, as a rule, muscle tone increases, tendon and periosteal reflexes are revived, and pathological reflexes appear (Babinsky, Rossimo, Hoffmann, etc.). With central paresis, muscle tone often increases by type of spasticity− the degree of increase in muscle tension depends on the speed of passive movement, the “jackknife” phenomenon is observed (maximum resistance to passive movement at the beginning of the study), the tone is increased to the maximum in the flexors of the upper limb and extensors of the lower limb, adductor muscles of the shoulder and thigh. The revitalization of reflexes is often accompanied by an expansion of their reflexogenic zone.

Reasonswe have paresis. Among central paresis of the limbs, the most common is hemiparesis, which in acute development is often caused by a stroke, and in gradual development - by a brain tumor. Central monoparesis of an arm or leg is much less common and is usually caused by a stroke, traumatic brain injury, multiple sclerosis, or a tumor of the brain or spinal cord. Central paresis of both legs (lower paraparesis) is most often caused by multiple sclerosis, a tumor or other disease of the spinal cord, less often by bilateral damage to the cerebral hemispheres due to perinatal damage (cerebral palsy), traumatic brain injury or tumor.

Superficial reflexes (abdominal, cremasteric, anal, plantar) can be reduced or even lost with central limb paresis. Muscle wasting with central paresis may not be observed, however, if paresis persists for a long time (months, years), it is usually noted, although it is less pronounced than with peripheral paresis limbs. May be observed defensive reflexes− involuntary movements in paretic limbs that occur in response to intense irritation of skin receptors or deeper tissues, for example, the application of painful irritation to the skin in the form of an injection. When moving in paretic limbs, there may be pathological synkinesis(friendly movements), for example, raising the arm in the shoulder joint when trying to squeeze the hand or when sneezing, laughing, yawning.

With central paresis of the limbs, disturbances in posture and gait may occur. With central hemiparesis, the Wernicke-Mann position is observed: the upper limb is bent at the elbow and wrist joints, brought to the body, the lower limb is carried forward when walking, describing a circle.

In the acute period of some neurological diseases (cerebral stroke, spinal cord injury), muscle hypotonia and hyporeflexia may develop due to decreased excitability of the segmental apparatus of the spinal cord (stage " spinal shock"). However, in the future, characteristic signs of central paresis are usually observed - muscle hypertension of the type of spasticity and hyperreflexia.

Rehabilitation of patients with central paresis

The main methods of motor rehabilitation of patients with spastic paresis include:

LH in the pool;

Orthosis therapy;

Neuromuscular ES;

Training using biofeedback;

Physiotherapy.

Therapeutic gymnastics

Complexes of therapeutic exercises for patients with spastic paresis include both physical exercises aimed at general training of the body, and special exercises that act directly on the affected area and help restore functions impaired due to the disease. Complex physical exercise for special training for spastic paresis consists of a set of exercises aimed at:

Strengthening muscle strength and increasing range of motion in joints;

Reduction and normalization of increased muscle tone;

Elimination of pathological friendly movements;

Improving coordination capabilities;

Balance function training;

Reducing sensitivity disorders;

Teaching the most important motor skills (standing, walking, household self-care skills).

These are primarily exercises in an isometric mode, which ensures muscle contraction without shortening it, i.e. without movement in the joints. As a rule, these exercises are used in patients who have no or minimal voluntary muscle activity. When performing exercises in this mode, it is necessary, firstly, to ensure a certain position of the limb or part of the body, the muscles are trained, and, secondly, to use special support from the LH instructor. So, in order to achieve isometric contraction of the extensors of the hands and fingers, the patient is placed on his back, the arm is bent at the elbow joint and the forearm is placed in a vertical position. Then you should straighten (straighten the hand and fingers so that they form 180° with the forearm). Holding the paretic arm by the forearm, the patient is asked to hold the hand and fingers in this extended position. In the same starting position, but holding the paretic arm by the hand, the patient is asked to hold the forearm in a given vertical position. This exercise is aimed at training the forearm flexors in an isometric manner. To train the forearm extensors, the patient’s paretic arm is extended at the elbow joint and raised vertically, fixing the patient’s shoulder; he is asked to hold his arm in the raised position. To do this, he must tense the extensors of the forearm. Isometric contraction of the abductor muscles of the shoulder is carried out with the patient positioned on the healthy side. The paretic arm is raised up and bent at the elbow joint at an angle of 90°. While supporting the forearm, ask the patient to hold his hand in this position. The hip flexors are trained isometrically with the patient in the supine position. The paretic leg is bent at the knee joint, lightly holding it by the shin. The patient is asked to hold the leg in this position, preventing it from straightening at the knee joint. In the same starting position, you can train the hip abductors. Slightly moving the leg bent at the knee joint to the side, the patient is asked to hold it in a fixed position. These exercises make up the initial complex of active gymnastics. In the first days of classes, they should be performed 2-3 times, gradually increasing the number of exercises to 5-10. When independent isolated movements appear in patients, they begin to train the latter using so-called lightweight exercises aimed at eliminating the undesirable influence of gravity. It is best to carry them out using various suspensions, hammocks and blocks. Lightweight exercises should not cause pain. They are performed at a slow pace, in a volume accessible to the patient. First of all, exercises are carried out for muscles whose tone usually does not increase. So, for example, supporting a paretic arm with a hammock or placing it on a ball, the patient is asked to perform those active movements that he has already developed. This is abduction and adduction of the shoulder, flexion and extension of the forearm, extension of the hand.

Easier abduction and adduction of the hip is trained with the patient in the supine position; turning the patient onto the healthy side and supporting the affected leg, train the extension and flexion of the lower leg; when the range of active movements increases over time, exercises with light dosed resistance should be added. This is done like this: for example, when actively extending the lower leg, you should try to slightly impede this movement by pressing on top of the lower leg and preventing the leg from extending at the knee joint. Exercises with light resistance are carried out similarly for the remaining muscle groups. It must be remembered that resistance exercises are included in the complex of active gymnastics only when active isolated movements appear in a sufficiently large volume. While performing these exercises, the patient should not hold his breath. Resistance exercises should be combined with passive relaxation exercises. To suppress pathological synkinesis, such as flexion of the arm at the elbow joint while simultaneously flexing the thigh and leg, various techniques are used depending on the severity of the paresis:

1) conscious suppression of synkinesis (with mild paresis);

2) orthopedic fixation (using splints, elastic bandage, orthopedic shoes, special orthoses) of one or two joints in which synkinesis is most pronounced; 3) special anti-friendly passive and active-passive exercises performed with the help of a methodologist and consisting in breaking down the usual synergistic stereotype.

A set of such exercises is known, aimed at combating synkinesis, for example, to suppress synkinesis in a paretic arm during passive or active movement in a paretic leg. An example is the following exercise: the patient sits at a table with his feet shoulder-width apart. The arms are extended at the elbows and lie on the table, the hand of the healthy hand fixes the hand of the paretic hand. The patient begins to slowly bend and straighten his leg at the knee joint (if this is difficult to do, then you should help the sore leg with the help of the healthy one), while simultaneously holding the paretic arm in an extended position with your healthy hand. You can also, while sitting on a chair, stretch your arms forward (paretic on the bottom, healthy on top) and put them on a cane, which is located on the side of the sore leg. It is necessary to keep your arms extended during the next movement of your legs: put the sore leg on the healthy knee, return to the starting position, put the healthy leg on the sick knee, return to the starting position. Of great interest is the use of robotic devices to overcome pathological muscle synergies that arise when a patient with severe spastic paresis attempts to make any voluntary movement.

The robotic orthosis, fixed on the patient’s paretic arm, is programmed in such a way that it prevents the appearance of flexion synergy in the arm during voluntary movements. Train with this robotic orthosis for 8 weeks. (3 times a week) leads to a significant decrease in the severity of synergy and increases the functionality of the hand. To overcome pathological flexion synkinesis in the elbow joint while teaching the patient motor skills (for example, turning on and off the light), you can use a special orthosis that prevents flexion of the arm at the elbow joint.

Exercises to improve coordination are aimed at increasing the accuracy and precision of movements (movements with sudden stops, changes in speed and direction, training to aim and hit a stationary or moving target with the index finger, throwing a ball), exercises with small objects (assembling and disassembling construction sets), etc. .

Exercises aimed at training the balance function are given particular importance in the treatment of patients with spastic paresis. According to some researchers, the early inclusion of these exercises in the therapeutic-gymnastic complex in such patients not only helps to train the balance function, stability of the vertical posture, and a more even distribution of weight between the paretic and healthy leg, but, most importantly, prevents the development of severe spasticity. To train balance in a standing position and when walking, use walking in a straight line or along a stencil, sideways, backwards, on an uneven surface, on toes, with eyes closed, exercises with an exercise ball, exercises with pushing by introducing the patient from an equilibrium state into a sitting position , standing) with provided support from the LG instructor.

Exercises aimed at reducing sensory disorders include primarily all exercises aimed at improving motor functions (from exercises for training muscle strength to exercises for teaching the most important motor skills). In addition, special therapeutic and gymnastic techniques are used aimed at improving sensitivity, which include training in dosed muscle efforts and the development of various motor qualities (speed, accuracy, endurance). Restoration of muscle-articular sensation is carried out by strengthening other types of sensitivity, retraining motor skills by ensuring optimal replacement of lost functions. A significant role in these trainings belongs to increasing the patient’s concentration on the sensation of the muscle contraction he performs. In addition, tactile stimulation is widely used (for example, in the form of irritation of the skin of a paretic limb with ice, vibration, pressure), which also helps the patient to understand the position of his affected limb in space. When using these special therapeutic and gymnastic techniques, visual control and informing the patient about the accuracy of his movement are important.

Teaching the most important motor skills occupies an important place in the PH complex in patients with spastic paresis. Currently, numerous studies are being conducted to study the possibility of using so-called forced training in patients who have suffered a stroke.

For patients with mild post-stroke hemiparesis and a disease duration of more than 1 year. The essence of the proposed method is that the healthy arm is fixed to the body with the help of special devices, so that the patient cannot use it. This creates conditions under which the patient's entire attention is fixed on the use of the paretic arm while learning various motor skills.

Walking recovery goes through a number of successive stages: imitation of walking lying down, sitting, standing by the bed, walking with support, walking with support on a chair or on a 3-4-support cane, walking with support on a stick within a room (ward, hospital department, apartment), training in walking up stairs, walking outdoors (in the yard, on the street), using public transport. First, the patient is taught to move from a lying position to a sitting position, then to sit with his legs down. An important point is to teach the patient how to get out of bed or chair correctly. After the patient can confidently, holding onto a support, stand independently on both legs, they move on to teaching him how to alternately transfer the weight of the body to the healthy and sore leg. To do this, the patient is asked to place his feet shoulder-width apart and perform gentle rocking from side to side. It is necessary to support it while performing this exercise. When the patient has mastered this exercise, it is necessary to move on to learning to stand on one leg. When performing this exercise, it is necessary that the patient has reliable support: a high headboard, a bedside frame, a bracket driven into the wall. There should be a chair behind him for safety or rest.

Currently, gait training using treadmills with body weight-supporting systems is considered the most effective technology for restoring gait for patients with post-stroke hemiparesis. As a result of such training, patients' walking speed significantly increases and the biomechanical parameters of their step improve. In recent years, the systems under consideration have been supplemented with computerized robotic orthoses that provide passive movements in the lower extremities simulating a step. According to experts, such orthosis robots primarily facilitate the work of exercise therapy instructors.

Learning household skills also goes through certain stages: first, this is learning the simplest skills - independent eating, personal hygiene, then learning how to dress independently, use the toilet and bathroom. Using the bathroom on your own is the most difficult part of regaining self-care. Training is also carried out on how to use a telephone, a TV, a computer if necessary, various household appliances, for example, turning a gas or electric stove on and off, using an electric kettle, a razor, opening a lock with a key, etc. For this purpose, training stands with various household items built into them are widely used.

Therapeutic gymnastics in the pool

According to some authors, hydrotherapy (treatment in a pool) is a unique method of rehabilitation therapy for patients with central spastic paresis. Immersion of the patient in the pool, leading to a significant decrease in gravity, provides maximum freedom of movement and allows you to practice exercises aimed at muscle stretching, reducing contractures, learning motor patterns, balance and reactions to balance, and walking. LH in the pool is most widely used in patients with consequences of spinal cord injury.