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Cerebral infantile paralysis (CIP) is the main neurologic reason of children's disability all over the world. A competent choice of time and methods of rehabilitation allows social adaptation of children with this pathology and improves their motor and mental development prognosis. The article gives modern data on the neuronal plasticity, spare capacities of the developing brain, pathophysiological aspects of restoration and compensation of damaged structures of central nervous system. The emphasis is put on the consideration of neuroplasticity mechanisms from the point of view of their clinical relevance and role in the formation of pathological and compensatory patterns of movement and perception at CIP. Variants of restoration of motor and sensory functions in upper extremities of children with CIP based on the time and topics of brain damage are analyzed in detail. Approaches to pathogenetically grounded choice of methods and time of rehabilitation are discussed on the basis of the given data on spare capabilities of children's nervous system with the emphasis on restoration of upper extremities' function as one of the most complicated, although prospective, aspects of CIP treatment.

Clinical Experience of the Repeated Multilevel Injections of the Botulinum Toxin Type A (Abobotulinum toxin A) in the Spastic Forms of Cerebral Palsy Objective: Our aim was to analyze the dosages of Abobotulinum toxin A used for each muscle in the clinically effective and safe repeated multilevel injections in CP children, and the intervals between injections. Methods: Retrospective analysis of 229 injection sessions into 359 muscles of the upper and 361 muscles of the lower extremities in 133 children (2-18 years) with spastic CP. Analysis included only patients who were injected for the first time and demonstrated decrease of spasticity in injected muscles according to modified Ashworth and/or Tardieu scales without significant side effects 2-4 weeks after injections.

The origin of contractures in spastic forms of cerebral palsy (CP) is unclear. Tomorrow the early appearance and persistence of spasticity are not qualified as the main reason of growths disturbances, musculo-skeletal system deformations and secondary orthopedic complications. The latest investigations have shown prominent changes in the spastic muscles on the different structural levels and stages of muscle development. This study describes the histological, morphological, and biomechanical changes in the spastic muscles that play a pathophysiological role in the formation of CP contractions. The authors discuss the changes in the muscle fiber size, differentiation and elastic properties, degrees of the lengthening resistance in the bundles of muscle fibers, extracellular matrix proliferation, structural and mechanical changes, disturbances in gene expression and regulation in the tendons and muscle tissue, changes in the length and number of sarcomers, as well as the length and cross-section of the whole muscle. Therefore, the movement limitations and contractions in CP do not depend on one universal mechanism. It is a combination of different structural changes in the muscles and the failure of the central movement and postural control.

1 Национальный научно-практический центр здоровья детей, Москва, Российская Федерация 2 Российский национальный исследовательский медицинский университет им. Н.И. Пирогова, Москва, Российская Федерация ВВЕДЕНИЕ Детский церебральный паралич (ДЦП) -наибо-лее частая причина тяжелых двигательных нарушений и формирования спастичности в детском возрасте [1,2]. ДЦП -результат непрогрессирующего поврежде-ния развивающегося головного мозга ребенка в пре-, пери-или постнатальном периоде, характеризующийся нарушением развития моторики и поддержания позы, а также многообразной сопутствующей патологией: рас-стройством чувствительности и перцепции, когнитивны-ми и коммуникативными дисфункциями, нарушениями речи и развития, симптоматической эпилепсией [3]. Ботулинотерапия остается наиболее эффективным и безопасным методом снижения локальной спастичности у паци-ентов с детским церебральным параличом (ДЦПДвигательные нарушения при ДЦП являются след-ствием поражения верхнего мотонейрона и условно подразделяются на симптомы со знаком «+» (позитив-ные) и «-» (негативные). К «позитивным» симптомам отно-сят повышение сухожильных рефлексов, общей рефлек-торной возбудимости (стартл-рефлекса) и спастичность, отмечаемую более чем у 90% пациентов с ДЦП [4][5][6], к «негативным» -мышечную слабость (центральный парез), утрату дифференцированного мышечного кон-троля (патологические синергии) и контроля тонких дви-жений. Несмотря на названия, обе группы симптомов отрицательно сказываются на двигательном развитии ребенка с той лишь разницей, что «+»-симптомы в боль-шей степени поддаются терапевтической, в том числе фармакологической, коррекции. При этом абсолютное большинство предлагаемых лечебных и реабилитаци-онных мероприятий направлено на коррекцию спастич-ности и ее последствий [7,8].Спастичность -скоростьзависимое повышение мышечного тонуса вследствие поражения верхнего мотонейрона и гипервозбудимости рецепторов растя-жения скелетных мышц. При ДЦП спастичность может клинически проявляться уже на первом году жизни, стойко присутствовать на всем протяжении активно-

Spasticity treatment is one of the key aspects of the contemporary cerebral palsy (CP) rehabilitation that influences on the effectiveness of other methods. The paper presents the first Russian document that unites the recommendations for the BTA treatment of CP and could be used as the guideline for the multilevel injections. The Russian consensus on the multilevel botulinum toxin A (BTA) treatment of spastic CP is based on the international data and the results of national studies. The authors describe typical CP spasticity patterns in the upper and lower extremities, give recommended intervals for the BTA (Abobotulinum toxin A) dosages for the whole injection procedure and for the separate muscles. The method of dosage calculation for functional segments is also described. Attention is paid to the frequency, optimal intervals between the repeated injections and the whole duration of BTA treatment. The authors discuss effectiveness and safety of BTA, factors that potentially influence the results of the injections, including ultrasound and electromyography control, and indications for the continuation and termination of treatment.

Background: Diffusion tensor tractography -a new method of magnetic resonance imaging, that allows to visualize the pathways of the brain and

Aim: to investigate the dynamic of general motor function and manual abilities in children with spastic forms of cerebral palsy (CP) after complex rehabilitation combined with single and repeated injections of botulinum toxin A (BTA). Patients and methods: the article presents 18 month follow-up of 52 patients with mono- and bilateral spastic forms of CP after single and multiple injections of botulinum toxin A and complex rehabilitation/ Patients received totally 74 injection sessions: 17 (32,7%) children — twice, 5 (9,6%) children — three times. Motor development assessment was done according to the GMFCS and GMFMS-88 scales and centile curves of normal motor development connected with these scales, hand function was classified according to the MACS scale. For the first time results of botulinum toxin therapy and rehabilitation were compared with the natural motor development of patients with different levels of motor disturbances according to centile tables. Results: patients with bilateral cerebral palsy improved slowly than hemiparetic and changes lasted for longer period. Level according to the MACS scale didn’t depend on the gestational age of the patients, was higher in children with hemiparesis and changed for 1 level in 4 (7,7%) patients after the first botulinum toxin A injections.