cerebruli dambla

cerebruli damblaklinikuri praqtikis erovnuli rekomendacia(gaidlaini)1

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)`cerebruli dambla~ miRebulia klinikuri praqtikis erovnulirekomendaciebis (gaidlainebi) da daavadebaTa marTvissaxelmwifo standartebis (protokolebi) SemuSavebis,Sefasebis da danergvis erovnuli sabWos 2008 wlis 5 noembris#1 sxdomaze da damtkicebulia saqarTvelos Sromis,janmrTelobisa da socialuri dacvis ministris 2008 wlis 18dekembris # 278/o brZanebiT.2

cerebruli damblagaidlainis aucileblobacerebruli dambla bavSvTa asakis mZime unarSezRudulobis gamomwvevierT-erTi yvelaze xSiri da farTod gavrcelebuli mdgomareobaa(mtkicebulebis done III). misi ZiriTadi damaxasiaTebeli niSnebia:spastiuroba, moZraobis darRvevebi, kunTTa sisuste, ataqsia darigiduloba. is gavlenas axdens moZraobis, wonasworobisa da pozisSenarCunebis unarze. cerebruli damblis mqone adamians, SemTxvevaTaumravlesobaSi, aqvs sirTuleebi yoveldRiuri cxovrebiseuliaqtivobebis ganxorcielebaSi.daavadebis garkveuli maxasiaTeblebis aRmofxvra SeuZlebelia yvelazewarmatebuli marTvis SemTxvevaSic, ris gamoc cerebrul damblas mTelicxovrebis mdgomareobas uwodeben. cerebruli dambla arsebiT gavlenasaxdens pacientebisa da maTi meurveebis funqciasa da janmrTelobasTandakavSirebul sicocxlis xarisxze.mdgomareobis qronikuloba ganapirobebs mkurnalobis mravalialternatiuli midgomis arsebobas, rac pacientTa da mSobelTadezorientacias iwvevs. sabolood es mkveTrad uaryofiTad aisaxebazogadad marTvaze da Sedegad viRebT maRali xarisxisunarSezRudulobas, sazogadoebrivi cxovrebidan srul izolacias.amdenad, am daavadebis marTvis gaidlainis arseboba aucilebeliamkurnalobis swori midgomebis farTod danergvisa da saerTaSorisostandartisadmi Sesabamisobis uzrunvelyofisaTvis.1. daavadebis definiciacerebruli dambla aris heterogenuri jgufi klinikuri sindromebisa,romlebic xasiaTdeba anomaluri motoruli (moZraobiTi) aqtebiTa daposturaluri meqanizmebiT. es sindromebi aris ganviTarebadi Tavistvinis araprogresirebadi anomaliebis gamoxatuleba.Tavis tvinis momwifebis procesSi neiropaTologiuri dazianebebisgamovlineba da maTi klinikuri gamoxatuleba SeiZleba ganicdidescvalebadobas, magram es ar niSnavs aqtiuri daavadebis arsebobas.termini "cerebruli dambla" gamoxatavs centraluri nervuli sistemisdazianebis an anomalurobis Sedegad meoradad ganviTarebul motoruldisfunqcias. misi gamoyeneba ar gulisxmobs mizezobriobasa da simZimes.2. klasifikaciacerebruli damblis sindromebi klasificirdeba motoruli anomaliistipisa da ganawilebis mixedviT. klasifikaciebi efuZneba: deformacias ananomalurobas, deformaciis an anomalurobis anatomiur distribucias(ganawilebas), an centraluri nervuli sistemis dazianebislokalizacias.3

mileris klasifikacia (Miller 1992)1. spastiuria) diplegiaxelis kargi funqciiT;xelis cudi funqciiT;asimetriuli.b) hemiplegiaxeli CarTuli metad vidre fexi;fexi CarTuli iseve rogorc xeli an metad.g) kvadriplegiaoTxive kiduri CarTuli daaxloebiT Tanabrad.2. diskinezuria) umTavresad distoniuri;b) umTavresad aTetoiduri.3. ataqsiuria) martivi ataqsia;b) ataqsiuri diplegia.4. atonuri.(rekomendaciis xarisxi A).3. epidemiologia da demografiacerebruli dambla Sedegia ganviTarebadi Tavis tvinis dazianebisa,romelic SeiZleba aRmocendes nayofis mucladyofnis, mSobiarobis ansicocxlis pirveli ori wlis manZilze (mtkicebulebis done I).misi gavrcelebis areali da sixSire dauzustebelia. jandacvis msoflioorganizaciisa da sxvadasxva literaturuli monacemebis mixedviT,saSualod misi sixSire aris 2,5–4 yovel 1000 bavSvze (mtkicebulebisdone III).cerebruli damblis dros Tavis tvinis dazianeba Seuqcevadia. daavadebisperiferiuli (garegnuli) gamoxatuleba damokidebulia dazianebislokalizaciaze, gavrcelebasa da xarisxze. simZime SeiZleba varirebdesmsubuqi motoruli darRvevidan Zalian mZimemde, roca CarTulia mTelisxeuli.ganviTarebul qveynebSi, axalSobilTa intensiuri movlis gaumjobesebamda ukiduresad mcire wonis axalSobilTa gadarCenis maRalma sixSiremgazarda cerebruli damblis ganviTarebis riski (mtkicebulebis doneVa).cerebrul damblasTan asocirebuli darRvevebi motoruli disfunqciisgarda TiTqmis yovelTvis moicavs cerebruli funqciis sxva darRvevebs,maT Soris, kognitur (SemecnebiT), mxedvelobis, smenis, metyvelebis,qerquli mgrZnobelobis, yuradRebis, qcevis darRvevebs, epilefsias.daaxloebiT 65%-s cerebruli damblis mTeli populaciisa, aReniSnebasxvadasxva xarisxis mentaluri retardacia da swavlis siZneleebi(mtkicebulebis done III).4

4. etiologiadroul axalSobilebSi cerebruli dambla Cveulebriv prenataluriwarmoSobisaa. intranatalurma movlenebma SeiZleba Seasrulos naklebadmniSvnelovani roli da es movlenebi ZiriTadad ganpirobebulia adrearsebuli anomaliebiT – antenataluri hipoqsiur-iSemiuri movlenebiT,fetaluri da dedis hemoragiebiT, placenturi infarqtiT, SokiT,fetaluri infeqciebiT (gansakuTrebiT, meningiti an ventrikuliti)(mtkicebulebis done III). cerebruli dambla intranatalur asfiqsiasTanasocirdeba SemTxvevaTa daaxloebiT 10-20%-Si. daaxloebiT 10-18%cerebruli damblis SemTxvevebisa, ZiriTadad spastiuri tipis, yalibdebaneonataluri periodis Semdeg. mizezebi moicavs travmas,cerebrovaskulur darRvevebs, mZime anoqsiur da hipoqsiur movlenebs,cns-is infeqciebs.cerebruli damblis ganviTarebis riski izrdeba gestaciuri asakissimciresTan erTad. es riski 20-jer izrdeba 1500g-mde wonisaxalSobilebSi. miuxedavad amisa, dRenakl axalSobilebSic ki,prenatalurma faqtorebma SeiZleba Seasrulon didi mizezobrivi roli.ZiriTadi dazianebani, romlebic dRenakl bavSvebSi mogvianebiT gvaZlevencerebruli damblis suraTs, aris periventrikuluri leikomalacia,intrakraniuli hemoragia, posthemoragiuli hidrocefalia,bronqopulmonuri displazia (mtkicebulebis done III).5. paTofiziologiacerebruli dambla Sedegia Tavis tvinis e.w. motoruli qerqispermanentuli statikuri dazianebisa, dabadebamde, dabadebisas, andabadebidan sicocxlis 2 wlis manZilze (mtkicebulebis done I).miuxedavad imisa, rom dazianeba TavisTavad ucvleli rCeba, icvleba misiklinikuri manifestacia (gamoxatuleba) bavSvis zrdasa daganviTarebasTan erTad. cerebruli damblis mqone bavSvTa umravlesobismotoruli (moZraobiTi) unar-Cvevebi umjobesdeba zrdasTan erTad, magramgaumjobesebis xarisxi da tempi yovelTvis dabalia janmrTel bavSvebTanSedarebiT.motorul funqciaTa darRvevebis mizezi SeiZleba iyos sxvadasxvanevrologiuri deficiti. cerebrul damblasTan asocirebulicentraluri nervuli sistemis paTologia moicavs: hemoragias, meqanikurdazianebas, Rrma struqturebis hipoqsias, qerqis hipoqsias, gardamaval anSeuqcevad iSemias, romlis saboloo Sedegi aris ujredTa nekrozi(mtkicebulebis done I). SemTxvevaTa daaxloebiT 50%-Si cerebrulidamblis etiologias gansazRvravs specifikuri hipoqsiuri movlenebi,asocirebuli ujredTa swraf da Seuqcevad kvdomasTan. Tavis tviniszogierTi ubani gansakuTrebiT advilad eqvemdebareba sxvadasxvadazianebas. magaliTad, zogierTi ubnis sisxlmomaragebis variabelurobada "metabolur moTxovnilebaTa" unikaluroba zrdis hipoqsiisadmisensitiurobas nayofis baqteriuli an virusuli infeqciebis dros(mtkicebulebis done Va). periventrikuluri TeTri nivTierebaganskuTrebulad advilad eqvemdebareba dazianebas gestaciis 26 – 34kviraze. am periodSi moqmedma sxvadasxva etiologiurma faqtorebmaSeiZleba gamoiwvion periventrikuluri leikomalacia spastiuri5

diplegiiT (mtkicebulebis done III). periventrikuluri leikomalaciabevrad ukeTesi prediqtoria daavadebisa, vidre, magaliTad, pirveli dameore xarisxis intraventrikuluri hemoragia. es aris gverdiTiparkuWebis gareTa kuTxeebis dorzolateralurad ganlagebuli TeTrinivTierebis nekrozi, gansakuTrebiT monros xvrelis midamoSi. mizeziSeiZleba iyos rogorc hemoragia, aseve iSemiuri infarqti.analogiurad, nayofis Tavis tvinis bazaluri gangliebis unikaluri"metaboluri moTxovnebi" gestaciis 38-40 kviraze, qmnis dazianebisadmiseleqtiur daqvemdebarebas, ris saboloo Sedegsac warmoadgens distoniaan uneblie moZraobebi. citoqinebis fetaluri produqcia SeiZlebagaxdes neironebis, preoligodendrocitebis da sisxlZarRvTaendoTeliuri ujredebis dazianebis mizezi da xeli Seuwyosintraventrikulur hemoragias.zeda motoneironis dazianeba amcirebs qerqul impusaciasretikulospinalur da kortikospinalur traqtebze, rac Tavis mxrivgavlenas axdens e.w. motorul kontrolze, amcirebs efeqturi motorulierTeulebis raodenobas da iwvevs kunTovan sistemaze anomalurkontrols da sisustes. imavdroulad, retikulospinalur traqtze dasxva sistemebze daRmavali inhibitoruli impulsaciis dakargva zrdisgama- da alfa-neironebis agznebadobas, rac sabolood iwvevs kunTTaspastiurobas. cerebrul damblasTan asocirebulma spastiurobamSeiZleba gamoiwvios iseTi garTulebani ZvalkunTovani sistemis mxriv,rogoricaa kontraqturebi, tkivili da qveamovardniloba (mtkicebulebisdone III). eqstrapiramiduli sistemis dazianebam SeiZleba gamoiwviosmoZraobaTa iseTi darRvevebi, rogoricaa aTetozi, qorea, distonia anrigiduloba.sabolood, nevrologiur darRvevTa klinikuri gamoxatulebadamokidebulia dazianebis tipsa da xarisxze, Seuqcevadi dazianebislokalizaciaze, centraluri nervuli sistemis adaptaciisa dareorganizaciis unarze dazianebis Semdeg.diplegia asocirdeba periventrikulur leikomalaciasTan; diskinezia –hiperbilirubinemiasa da bazaluri gangliebis dazianebasTan; hemiplegia,Cveulebriv, viTardeba droulad dabadebul bavSvebSi da asocirdebaerTi hemisferos dazianebasTan SemTxvevaTa umravlesobaSi. kvadriplegiaasocirdeba Tavis tvinis difuzur dazianebasTan.6. daavadebis diagnozicerebruli damblis diagnostika saWiroebs pacientis istoriis srulkvlevas, fizikur gasinjvas da damatebiT gamokvlevebs. istoria undaSeicavdes gestaciisa da perinataluri movlenebis detalur aRricxvas,ganviTarebis etapebis dokumentaciur asaxvas. fizikuri gasinjva undamoicavdes pozis, aqtiur da pasiur moZraobaTa sifarTis, mgrZnobelobis,Zalis, kunTTa tonusis (spastiurobis), moZraobaTa darRvevis tipisa daxarisxis, kidurebis deformaciebis Sefasebas (rekomendaciis xarisxi A).garkveul SemTxvevebSi mniSvnelovani diagnostikuri Rirebuleba aqvs e.w.neirogamosaxviT kvlevas. es gamokvlevebi gansakuTrebiT mniSvnelovaniaadreuli diagnostikisaTvis Semdgomi adreuli Carevis uzrunvelsayofad,prognozisaTvis, aseve, rTulad sadiagnostiko SemTxvevebisaTvis, rocaklinikuri gamoxatuleba, istoria da Sefasebis instrumentebi ar iZleva6

zusti diagnostikisa da sindromis dadgenis saSualebas. kraniuliultrasonografia, magnitur-rezonansuli gamosaxva, kompiuterulitomografia da sxva specialuri testebi gamoiyeneba centralurinervuli sistemis dazianebis xarisxis SefasebisaTvis. amJamad, funqciurimagnitur-rezonansuli gamosaxva da transkraniuli magnituristimulacia cerebruli damblis mqone bavSvebSi ZiriTadad gamoiyenebasamecniero kvlevis mizniT. Tumca, am saSualebebma momavalSi SeiZlebaSeiZinon diagnostikuri da prognostikuli Rirebuleba.rig SemTxvevebSi aseve saWiroa genetikuri kvleva metabolizmisTandayolil defeqtebze da sxva genetikur darRvevebze, diferenciulidiagnostikisaTvis (mtkicebulebis done III).diferenciuli diagnozi unda gatardes Semdeg daavadebebTan damdgomareobebTan:• neirodegeneraciuli daaavadebebi;• metabolizmis Tandayolili defeqtebi;• zurgis tvinis ganviTarebiTi an travmuli dazianebebi;• nerv-kunTovani daavadebebi;• neoplazma;• progresirebadi hidrocefalia;• subduruli hematoma.(rekomendaciis xarisxi A).simZimis xarisxi damokidebulia Seuqcevadi dazianebis lokalizaciaze,gavrcelebis arealze, cerebruli damblis klinikur tipze, asocirebuldarRvevebze, centraluri nervuli sistemis adaptaciisa dareorganizaciis unarze dazianebis Semdeg (mtkicebulebis done I).simZimis xarisxis SefasebisaTvis gamoiyeneba "cerebruli damblissimZimis rusmanis da geijis Skala" (Severity of Cerebral Palsy by Russman andGage) (rekomendaciis xarisxi C).7. klinikuri manifestaciaspastiuri sindromebispastiuri sindromebi SeiZleba iyos simetriuli, asimetriuli,dominanturad CarTuli iyos orive fexi (rogorc diplegiis SemTxvevaSi),oTxive kiduri (rogorc kvadriplegiis SemTxvevaSi), sami kiduri, anmxolod erTi kiduri. am variacaTa gamovlena mniSvnelovaniaetiologiis, asocirebuli klinikuri niSnebisa da prognozisTvalsazrisiT.spastiuri cerebruli damblis mqone pacientebs aReniSnebaT zedamotoruli neironis dazianebis sindromi, romelic moicavs e.w. pozitiurda negatiur niSnebs. pozitiuri niSnebia: spastiuri hipertonia,hiperrefleqsia, eqstenzoruli plantaruli paterni da klonusi.negatiuri niSnebia: neli, gaZnelebuli nebiTi moZraobebi, natifimotoruli funqciis darRveva, calkeuli moZraobis izolirebuladSesrulebis gaZneleba da sisuste.7

spastiurobis paternebi droTa ganmavlobaSi iwvevs myeskunTovanierTeulis damoklebas, kunTovan da saxsrovan kontraqturas, Zvlisdeformacias, saxsris qveamovardnilobas an dislokacias. dinamiurideformaciebi da moZraobaTa darRvevebi gansakuTrebiT iCens Tavsgadaadgilebisas an raime sxva aqtivobis Sesrulebisas.pozebi, romlebic SemTxvevaTa umravlesobaSi aReniSnebaT spastiuricerebruli damblis mqone pacientebs, moicavs: zemo kidurSi – mxrisSigniTa rotacia, xelis idayvSi moxra, winamxris pronacia, mtevnismoxra, TiTebis moxra, ceris adduqcia. qvemo kidurSi – barZayis fleqsiada adduqcia, muxlis fleqsia, terfis eqvinusi, terfis valgusi, cerisfleqsia.paTologiuri siaruli da statikuri anomaliebi moicavs: fexiswverebzesiaruls (terfis eqvinusi); Caxril siaruls (barZayis fleqsia, muxlisfleqsia, terfis kalkaneusi (quslismieri terfi)); biZgisebr siaruls(barZayis fleqsia, muxlis fleqsia, terfis eqvinusi); jvaredin siaruls(barZayis adduqcia).cerebrul damblasTan asocirebuli spinaluri deformaciebi moicavssqoliozs, kifozs da lordozs.diskinezuri sindromebidiskinezuri sindromebi xasiaTdeba uneblie moZraobebiT, aTetozis,qoreis an distoniis saxiT. am tipis cerebruli damblis mqone CvilbavSvebs Cveulebriv aReniSnebaT kunTTa hipotonia, primitiulirefleqsebis SenarCuneba, hipersalivacia, uneblie grimasi, Senelebulifsiqomotoruli ganviTareba. am sindromebisaTvis, spastiurisindromebisagan gansxvavebiT, ar aris damaxasiaTebeli kontraqturebi.tipiuri niSnebi ufro TvalsaCino xdeba mogvianebiT, bavSvis zrdasTanerTad. anomaluri moZraobebi gansakuTrebiT TvalsaCino xdeba daxSirad provocirdeba emociiT, pozis SecvliT an nebiTi, mizanmimarTulimoZraobiT.Cveulebriv, diskinezuri sindromebis dros aRiniSeneba araerTi formisuneblie moZraoba. Tumca, ZiriTadad aRniSnaven am sindromTa or tips,umTavresad aTetoidurs _ qoreiformuli, aTetoiduri, an kombinirebulimoZraobebiT, normaluri an daqveiTebuli kunTTa tonusiT(gansakuTrebiT adreul asakSi) da umTavresad distoniurs _ romlisdrosac dominirebs distoniuri komponenti, daWimuloba, SenarCunebuliaxalSobilTa primitiuli (arareducirebuli) refleqsebi.umTavreasad distoniuri tipis diskinezuri sindromis mqone bavSvebs,Cveulebriv, axasiaTebT mZime motoruli da inteleqtualuriunarSezRuduloba. xSiria piramiduli niSnebi da anarTria. arsebobs orzemoTaRweril tips Soris gardamavali formebic.ataqsiuri sindromebiataqsiuri sindromebi aRiniSneba droul bavSvebSi, adreuliprenataluri etiologiiT. es aris klinikurad da etiologiuradheterogenuri jgufi. zogierTi SemTxveva genetikuri memkvidreobisSedegia. pacientTa SedarebiT mcire raodenobas aReniSneba naTxemis8

kongenitaluri hipoplazia, romelic ganisazRvreba terminiT "sufTaataqsia".cerebruli damblis dros termini "ataqsia" ufro asaxavs motorulifunqciis gavrcobil darRvevas. neirogamosaxviTi kvlevis SedegadSeiZleba aRiniSnos norma an bilateraluri da infratentoriulidazianeba. praqtikaSi, diagnostika saWiroebs eqskluzias (gamoricxvismeTods), radgan cerebruli damblis mqone yvela pacients aReniSnebagarkveuli inkoordinacia da pozis darRveva. klinicisti undadarwmundes, rom es niSnebi ar aris sisustis, spastiurobis, distoniis anqoreoaTetozis Sedegi. ufro metic, progresirebadi neirodegeneraciulidarRvevebic Tavdapirvelad SeiZleba "gamoiyurebodes" rogorcataqsiuri cerebruli dambla.ataqsiuri cerebruli damblis mqone pacientTa umravlesobasdabadebidanve aReniSneba hipotonia, Senelebuli motoruli dametyvelebiTi ganviTareba. droTa ganmavlobaSi pacientTa umravlesobismdgomareoba umjobesdeba. ZiriTadad, magram ara yovelTvis,gansakuTrebiT mZimea motoruli funqciis darRveva da asocirebuliunarSezRudulobebi. metyvelebis ganviTareba damokidebuliainteleqtualur unarze. SemTxvevaTa umravlesobaSi metyveleba arisneli, wyvetli (biZgisebri) da "feTqebadi".Aatonuri sindromebiarsebobs heterogenuri jgufi, Cveulebriv, drouli Cvili bavSvebisa,romelTac didi xnis manZilze aReniSnebaT kunTTa mniSvnelovanihipotonia, viTardebian Zalian nela da verasodes SeZlebendamoukideblad dgomasa da siaruls. am bavSvebs xSirad aReniSnebaTcerebruli disgenezia, mikrocefalia da Rrma mentaluri retardacia.nevrologiuri gasinjviT ar vlindeba cerebruli damblis sxvasindromebisTvis damaxasiaTebeli niSnebi. tonusi variabeluria dazogjer SeiniSneba momatebulis SegrZnebac, magram am hipertoniisxasiaTi gansxvavebulia spastiuri sindromebis dros arsebulihipertoniisagan. am tipis hipertonia ufro ganisazRvreba rogorc"paratonia" – saxsarSi pasiuri moZraobis dros aRmocendeba zrdadiwinaaRmdegoba, romlis intensiuroba proporciulia Zalisa, romliTacsruldeba pasiuri moZraoba. zogjer es winaaRmdegoba SecdomiT aRiqmebarogorc nebiTi moZraoba. atonuri forma didi xania aRwerilia, magramsul ufro iSviaTad moixsenieba Tanamedrove klasifikaciebSi.aucilebelia yuradReba gamaxvildes faqtze, rom klinikuri suraTicerebruli damblis dros, yovelTvis ar aris "sufTa". spastiurisindromebis dros xSirad aRiniSneba uneblie moZraobebi, diskinezuri daataqsiuri sindromebis dros ki piramiduli niSnebi. ufro metic,cerebruli damblis yvela sindromi garkveuli xarisxiT xasiaTdebaanomaluri motoruli aqtebiTa da poziT, ise, rom nebiTi moZraoba,romelic normaSi aris kompleqsuri, koordinirebuli damravalferovani, xdeba arakoordinirebuli, stereotipuri daSezRuduli. mZime dazianebis SemTxvevaSi nebiTi moZraobis dawyebismcdelobam SeiZleba gamoiwvios piramiduli refleqsebis realizeba,agonisti da antagonisti kunTebis erTdrouli SekumSva da masiuri,generalizebuli moZraobebi. amave dros calkeuli, izolirebuli9

moZraobis Sesruleba SeuZlebeli xdeba. iTvleba, rom sindromissaboloo da TvalsaCino Camoyalibeba umTavresad xdeba 5 wlis asakSi(mtkicebulebis done Va).Tumca cerebruli damblis sindromebs Cveulebriv Tan axlavs Tavistvinis statikuri disfunqciis sxva gamovlinebani, am sindromTadiagnoscireba Zalzed mniSvnelovania, imdenad, ramdenadac yovelmaTgans gaaCnia mkurnalobis specifikuri programa da prognozi(rekomendaciis xarisxi B).8. Sefasebis instrumentebicerebruli damblis mqone pacientTa SefasebisaTvis gamoiyeneba Semdegifunqciuri instrumentebi da janmrTelobasTan dakavSirebulisicocxlis xarisxis sazomi:globaluri funqciis SefasebisaTvis: "funqciuri damoukideblobissazomi bavSvebisaTvis" (WeeFIM – Functional Independence Measure for Children)(rekomendaciis xarisxi B);msxvili motoruli funqciis SefasebisaTvis: "msxvili motorulifunqciis sazomi" (GMFM – Gross Motor Function Measure) (rekomendaciisxarisxi B);spastiurobis gazomvisa da analizisaTvis: "aSuorTis spastiurobisSkala" (Ashworth Spasticity Scale) (rekomendaciis xarisxi B);simZimis SefasebisaTvis: "cerebruli damblis simZimis rusmanis da geijisSkala" (Severity of Cerebral Palsy by Russman and Gage) (rekomendaciis xarisxi B);kognituri unarebisa da gonebrivi ganviTarebis SefasebisaTvis(sxvadasxva asakobrivi jgufebisaTvis): "Cvili bavSvis ganviTarebisbeilis Skala" (Bayley Scales of Infant Development); "kaufmanis batarea bavSvisSefasebisaTvis" (Kaufmann Assessment Battery for Children); "veqslerisinteleqtis Skala bavSvebisaTvis" (Wechsler Intelligence Scale for Children)(rekomendaciis xarisxi B);janmrTelobasTan dakavSirebuli sicocxlis xarisxi moicavs fizikurifunqcionirebis, fsiqlogiuri sakiTxebis, socialuri funqcionirebis,dazianebis, simptomebis da unaRSezRudulobis gazomvasa da Sefasebas.SemuSavebulia ramdenime instrumenti. mizanSewonilia, gamoyenebul iqnas"bavSvis janmrTelobis kiTxvari" (CHQ – Child Health Questionnaire)(rekomendaciis xarisxi B).9. prognoziadreuli prognozireba rTulia, im SemTxvevaTa garda, roca saqme gvaqvsmZime dazianebasTan. prognozi ZiriTadad dakavSirebulia cerebrulidamblis klinikur tipTan, motoruli ganviTarebis tempTan, axalSobilTarefleqsebis evoluciasTan, inteleqtualur deficitTan, sensoruldarRvevebTan, emociur-socialuri adaptaciis xarisxTan.bavSvebs, romlebic siaruls iwyeben 2 wlamde asakSi, ufro xSirad, aqvTnormaluri an mosazRvre inteleqti (mtkicebulebis done III). ZiriTadad,rac ufro mZimea motoruli deficiti, miT mZimea inteleqtualuridarRveva. prognozi damoukideblad siarulisTvis cudia im bavSvebSi,10

omelTac 20 Tvemde Tavi ver uWiravT, 24 Tvemde ar xdeba primitiulirefleqsebis reducireba da ar aris ganviTarebuli posturalurireaqciebi, ar aris cocva 5 wlamde. bavSvebi, romlebic damoukidebladjdebian 2 wlamde da cocaven 30 Tvemde, Cveulebriv momavalSidamoukideblad dadian (mtkicebulebis done III).umravlesoba bavSvebisa, romlebic jdebian 3-dan 4 wlamde asakSi, dadisdamxmare saSualebebiT da maTi gadaadgileba funqciurad metadSezRudulia. Zalzed saeWvoa, rom 9 wlis Semdeg, cerebruli dambliTdaavadebulma bavSvma daiwyos siaruli damxmare saSualebebiTac ki(mtkicebulebis done Va).faqtiurad, yvela bavSvma hemiplegiuri cerebruli dambliT, aseve, bevrmaaTetoziTa da ataqsiiT, adeqvaturad warmarTuli menejmentisSemTxvevaSi, unda SeZlos damoukideblad siaruli (mtkicebulebis doneIII). prognozi umjobesdeba adreuli Carevis SemTxvevaSi. adreuli Carevaganapirobebs kontraqturebisa da deformaciebis nawilobriv prevencias,rac xels uwyobs pozisa da funqciis optimizacias (mtkicebulebis doneII, rekomendaciis xarisxi B).cerebruli dambliT daavadebulTa 90% aRwevs zrdasrul asaks(mtkicebulebis done III). es dakavSirebulia mraval faqtorTan –inteleqtTan, fizikur funqciasTan, komunikaciis unarTan, pirovnulTvisebebTan. umravlesoba cocxlobs xangrZlivad, gamonaklisiamravlobiTi unarSezRudulobis mqone pacientebi. sikvdilianobismaCvenebeli maRalia da sicocxlis xangrZlivoba dabalia im bavSvebSi,romelTac aReniSnebaT mZime kvadriplegia, hidrocefalia, ZiriTadifunqciuri unar-Cvevebis deficiti, refraqteruli gulyrebi da Rrmamentaluri retardacia (mtkicebulebis done III). pacientTa am jgufissikvdilianobaze garkveul gavlenas axdens agresiuloba da meurveobis(movlis) xarisxi. sikvdilis yvelaze xSiri mizezia respiratorulidaavadeba.10. mkurnaloba (marTva)arcerT specialists izolirebulad, ar ZaluZs efeqturadganaxorcielos cerebruli dambliT daavadebuli pacientisaTvisaucilebeli mravlobiTi samedicino, socialuri, fsiqologiuri,saganmanaTleblo da Terapiuli RonisZiebebi. yovelmxrivi, amomwuravimarTva moiTxovs multidisciplinur gunds, romlis wevrebic iyenebenmizanze orientirebul midgomas, romelic dafuZnebulia adeqvaturcodnaze, sxva disciplinebis rolisa da faseulobis swor gagebaze(mtkicebulebis done Va).menejmentis prioritetebia: komunikacia, socialuri da emociuriganviTareba, ganaTleba, maqsimalurad SesaZlebeli damoukideblobayofacxovrebaSi, normaluri garegnoba, kveba, mobiluroba.dasawyisSi dasaxul unda iqnas realuri funqciuri miznebi, romlebicperiodulad unda gadafasdes. es miznebi unda efuZnebodes eqspertTaSefasebas da prognozs. mizani unda iyos maqsimaluri SedegiganviTarebis yvela sferoSi. menejmenti ar unda gaxdes ararealurisamkurnalo procedurebis seria, romelSic ar iqnebian CarTulimSoblebi an ZiriTadi meurveebi.11

mkurnaloba unda iyos mizanze orientirebuli da Sedegad mogvcespozitiuri gamosavali.mkurnalobis midgomebia:a) Terapiuli intervencia;b) farmakologiuri (medikamenturi) Terapia;g) orTopediuli qirurgia;d) damxmare (teqnologiuri) saSualebebi.Terapiuli intervenciaTerapiuli intervencia moicavs:• fizikur Terapias;• okupaciur Terapias;• metyvelebis da enis Terapias.mkurnalobis am sam midgomas saWiroebs cerebruli damblis mqonebavSvTa umravlesoba (mtkicebulebis done I, rekomendaciis xarisxi A).cerebruli damblis mqone bavSvTa garkveul raodenobas, mogvianebiTasakSi, aseve esaWiroeba fsiqologiuri koreqcia.fizikuri Terapiafizikuri Terapia (romelic cnobilia aseve fizioTerapiis saxeliT)cerebruli damblis mqone bavSvTa mkurnalobis erT-erTiumniSvnelovanesi disciplinaa (rekomendaciis xarisxi A). es arisfizikuri disfunqciis mkurnaloba Terapiuli varjiSebis, kunTTatreningisa da damxmare saSualebebis gamoyenebiT, normaluri funqciis,ganviTarebis, mobilurobis, stabilurobis, damoukideblobisa dasicocxlis xarisxis amaRlebis xelSewyobisaTvis.fizikuri Terapiis erT-erTi ZiriTadi mimarTulebaa funqciisgaumjobeseba aqtiur moZraobaTa stimulirebisa da anomalur moZraobaTaSezRudvis xarjze.fizikuri Terapiis programis upirvelesi mizania dazianebis Sedegebisminimizacia, unarSezRudulobis Semcireba da funqciis optimizacia.mniSvnelovania adreuli Careva kontraqturebis prevenciisa da kunTTaanomaluri tonusis inhibiciis mizniT (rekomendaciis xarisxi A).fizikuri Terapiis specializaciis sferoebs warmoadgens:a) motoruli unar-Cvevebi – koncentrirebiT msxvil motorulfunqciebze;b) adaptaciuri saSualebebi;g) poza da jdoma;d) oralur-motoruli unar-Cvevebi;e) orTezebi – ZiriTadad qvemo kidurebis;v) sensoruli integracia;z) tkivilis menejmenti;T) siarulis analizi da treningi;i) balansi;k) poza;12

l) moZraobis amplituda.okupaciuri Terapiaokupaciuri Terapia aris sakuTari Tavis movlis, Sroma/produqtiuliaqtivobebis da TamaSi/dasvenebis aqtivobebis Terapiuli gamoyenebadamoukidebeli funqciis gaZlierebis, ganviTarebis gaumjobesebis daunarSezRudulobis prevenciisaTvis (rekomendaciis xarisxi A).es aris fizikuri, fsiqologiuri da unarSezRudulobis gamomwvev sxvamdgomareobaTa Sefaseba da mkurnaloba seleqtiuri aqtivobebismeSveobiT, yoveldRiur cxovrebaSi efeqturi funqcionirebisaTvis.okupaciuri Terapiis mizania, daexmaros adamians im fizikuri unar-Cvevebis gamomuSavebaSi, romlebic mas esaWiroeba funqcionirebisa dadamoukideblobisaTvis.okupaciuri Terapiis specializaciis sferoebs warmoadgens:a) motoruli unar-Cvevebi – koncentrirebiT natif motorul funqciebze;b) adaptaciuri saSualebebi;g) poza da jdoma;d) kveba,e) Tavis movla, yofiTunarianoba;v) orTezebi – ZiriTadad zemo kidurebis;z) sensoruli integracia;T) komunikacia;i) moZraobis amplituda;k) vizualur-motoruli percefcia (aRqma).metyvelebis da enis Terapiametyvelebis da enis Terapia exmareba adamians komunikaciuri unarCvevebisganviTarebaSi, sakuTari azrebis gamoxatvisa da sxvaTa mier gamoxatuliazrebis gagebisaTvis (rekomendaciis xarisxi A).cerebruli damblis mqone bavSvebTan metyvelebisa da enis Terapia asevemuSaobs kvebis problemebze.metyvelebisa da enis Terapiis specializaciis sferoebs warmoadgens:a) komunikacia da ena;b) damatebiTi saSualebebi komunikaciis gaumjobesebisaTvis;g) Jestebisa da niSnebis ena;d) kveba;e) oralur-motoruli Cvevebi;v) respiracia;z) fonacia;T) artikulacia;i) ylapva;k) sensoruli integracia.fsiqologiuri koreqciacerebruli damblis mqone bavSvTa garkveul raodenobas esaWiroebafsiqologiuri daxmareba, rac moicavs fsiqologiur testirebas,13

kognituri unarebisa da gonebrivi ganviTarebis Sefasebas specialuriSkalebis meSveobiT, fsiqologiur koreqcias (rekomendaciis xarisxi C).kognituri unarebisa da gonebrivi ganviTarebis SefasebisaTvissxvadasxva asakobriv jgufebSi gamoiyeneba Semdegi Skalebi:• "Cvili bavSvis ganviTarebis beilis Skala" (Bayley Scales of InfantDevelopment);• "kaufmanis batarea bavSvis SefasebisaTvis" (Kaufmann AssessmentBattery for Children);• "veqsleris inteleqtis Skala bavSvebisaTvis" (Wechsler IntelligenceScale for Children).farmakologiuri (medikamenturi) Terapiacerebruli damblis dros medikamentebi gamoiyeneba kunTTa anomaluritonusis mkurnalobisaTvis. oralurma medikamentebma, romlebicgamoiyeneboda am mizniT, imedgacrueba gamoiwvia da sul ufro iSviaTadgamoiyeneba. aseve imedgacrueba gamoiwvia oralurma medikamentebma,romlebic gamoiyeneboda diskineziis, distoniis, aTetozisa dahemibalizmis mkurnalobisaTvis (mtkicebulebis done I).botulinis neirotoqsinis Semcveli adgilobrivi miorelaqsantebikunTTa anomaluri tonusis mkurnalobisaTvis gamoiyeneba saineqciobotulinis toqsinis Semcvelo saineqcio medikamentebi. am rigismedikamentebidan amJamad saqarTveloSi registrirebulia disporti dabotoqsi. botulinis toqsini amcirebs acetilqolinis gamoyofas nervkunTovanikavSiris presinafsur midamoSi. botulinis toqsinis ineqciaspecifikur kunTSi asustebs am kunTs, iwvevs mis nawilobriv damblas.spastiuri kunTis modunebas da agonisti kunTis gaZlierebas minimumamdedahyavs kontraqturebis Camoyalibebis SesaZlebloba (mtkicebulebisdone I, rekomendaciis xarisxi A). meTodi gamoiyeneba roca deformaciaganpirobebulia spastiur kunTTa SezRuduli raodenobiT. tkiviliminimaluria da grZeldeba araumetes 5 wT-isa. efeqti grZeldeba 3-6 Tve,zogjer erTi welic, ris Semdegac xSirad saWiro xdeba ineqciisgameoreba.botulinis neirotoqsinis Semcveli medikamentebis efeturoba izrdebafizikur Terapiasa da orTezirebasTan kombinirebis SemTxvevaSi(mtkicebulebis done I, rekomendaciis xarisxi A).bolo xanebSi botulinis neirotoqsinis Semcveli medikamentebisineqciebi xSirad gamoiyeneba orTopediuli qirurgiuli CarevissaWiroebis Semcirebis an garkveuli droiT gadadebisaTvis.botulinis neirotoqsinis efeqturoba kunTTa anomaluri tonusismkurnalobaSi cerebruli damblis dros, naCvenebia mravalirandomizebuli, "ormagi-brma" da placebo-kontrolirebadi kvleviT(mtkicebulebis done I, rekomendaciis xarisxi A).gama-aminobutiratis mJavis agonistebi14

ig SemTxvevebSi, kunTTa anomaluri tonusis mkurnalobisaTvis asevegamoiyeneba gama-aminobutiratis mJavas agonistebi. medikamenti SehyavTintraTekalurad implantirebuli tumbos meSveobiT. mowodebuliapacientTaTvis, romelTac aReniSnebaT kunTTa generalizebulihipertonia da es aris ZiriTadi mizezi moZraobiTi funqciis darRvevisa.gama-aminobutiratis mJavas agonistebi Znelad gadalaxaven hematoencefalurbariers, amitom peroraluri gamoyenebisas saWiroauzarmazari dozebi, rac ufro leTargias iwvevs, vidre spastiurobisSemcirebas. gama-aminobutiratis mJavis agonistebis intraTekaluriineqciebi kunTTa generalizebuli hipertoniis mkurnalobis efeqturisaSualebaa (mtkicebulebis done I). mkurnalobis es meTodi siZvirisa dateqnologiuri miuwvdomlobis gamo, jerjerobiT saqarTveloSi arxorcieldeba.antiepilefsiuri farmakoTerapiacerebruli damblis mqone bavSvTa 35%-s aReniSneba epilefsiurigulyrebi, ris gamoc maT esaWiroebaT eleqtroencefalografiuli kvlevada antiepilefsiuri medikamenturi mkurnaloba (mtkicebulebis done I).orTopediuli qirurgiacerebrul damblasTan asocirebuli zogierTi mdgomareobisaTvisrekomendebulia orTopediuli qirurgiuli Careva kunTebze, myesebze,nervebze an saxsrebze. operaciebma SeiZleba xeli Seuwyos jdomis,siarulis, xelis funqciis gaumjobesebas, tkivilis Semcirebas, movlisgaadvilebas mSoblebisa da meurveebisaTvis.cerebruli damblis mkurnalobis orTopediuli qirurgiuli teqnikamoicavs neiroeqtomias, tenotomias, arTrodezs, osteotomias, myesisdagrZelebas, gadanergvas, myeskunTovan dagrZelebas, an am proceduraTasxvadasxva kombinacias. arcerTma randomizebulma kontrolirebadmakvlevam ar daadastura romelime kombinaciis optimaluroba an romelimezemoCamoTvlili operaciuli midgomis upiratesoba sxva midgomebze(mtkicebulebis done I).bolo wlebSi, orTopediuli qirurgiuli Carevis saWiroebis Semcirebisan garkveuli droiT gadadebisaTvis xSirad gamoiyeneba botulinistoqsinis ineqciebi (rekomendaciis xarisxi A).yovelgvari samedicino da orTopediuli qirurgiuli Careviswarmatebuloba mniSvnelovnad aris damokidebuli fizikur Terapiasa daokupaciur Terapiaze, maqsimaluri SedegianobisaTvis (mtkicebulebisdone I).damxmare (teqnologiuri) saSualebebiorTezirebamenejmentis am midgomebidan erT-erTi yvelaze mniSvnelovaniaorTezireba (rekomendaciis xarisxi A). cerebruli damblis mqonebavSvebSi kunTebi ar izrdeba Zvlebis zrdis Sesabamisad. kontraqturebi,romlebic am dros yalibdeba, arRvevs balanss da moZraobis meqanizms.15

orTezebi, fizikur Terapiasa da sxva Terapiul CarevebTan kombinaciaSi,xels uwyobs am garTulebaTa Tavidan acilebas spastiuri kunTebisgaWimvis (dagrZelebis) meSveobiT. stabiluroba, kontraqturebisprevencia da moZraobis sifarTis SenarCuneba, romelic miiRweva am gziT,xels uwyobs funqciis normalizacias (mtkicebulebis done I).yvelaze xSiri gamoyeneba aqvs terf-wvivis orTezebs. fiqsirebulikontraqturebis ararsebobis SemTxvevaSi orTezebi aumjobesebskinematikas da kinetikas, nabijis sigrZes, koordinacias da funqcias(mtkicebulebis done I).sxva damxmare saSualebebicerebruli damblis menejmentSi farTo gamoyeneba aqvs damxmaresaSualebebs mobilurobis, gadaadgilebis, dgomis, jdomis, komunikaciisada garemosTan adaptaciis xelSewyobisaTvis. maT Soris, e.w. invalidisetli, xeljoxi, yavarjeni, "stenderi" (sadgomi), "uolkeri" (sasiarulo),specialuri aveji (skami, magida da sxv.) amdenad, sareabilitaciomkurnalobaSi didi mniSvneloba eniWeba damxmare saSualebebisgamoyenebis swavlebas (mtkicebulebis done I, rekomendaciis xarisxi A).mSobelTa an ZiriTad meurveTa ganaTleba da treningicerebruli damblis menejmentis mniSvnelovani komponentia mSobelTa anZiriTad meurveTa ganaTleba da treningi Terapiisa da movlissakiTxebze (mtkicebulebis done Va).11. gaidlainis gadasinjvis da ganaxlebis vada – 3 weli.12. gaidlainis miRebis xerxi/wyarowinamdebare gaidlaini warmoadgens sxvadasxva gaidlainebis (ix.literatura) Sejerebis da adaptaciis Sedegs.13. alternatiuli gaidlaini ar arsebobs14. gamoyenebuli literatura:1. L Andrew Koman, Beth Paterson Smith, Jeffrey S Shilt. Cerebral palsy. The Lancet, Vol 363ay 15, 2004. 1619-1631;2. Kuban KC, Leviton A. Cerebral palsy. N Engl J Med 1994; 330:188–95;3. Nelson KB, Ellenberg JH. Epidemiology of cerebral palsy. Adv Neurol 1974;19:421-435(+);4. Boyle CA, Yeargin-Allsopp M, Doernberg NS, Holmgreen P, Murphy CC, Schendel DE.Prevalence of selected developmental disabilities in children 3-10 years of age: theMetropolitan Atlanta Developmental Disabilities Surveillance Program, 1991. Morb MortalWkly Rep CDC Surveill Summ 1996; 45: 1–14;5. Stanley E, Blair E, Alberman E. How common are the cerebral palsies? In: Cerebral palsies:pidemiology and causal pathways. London: MacKeith Press, 2000: 22–39;16

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15. avtorTa jgufibavSvTa nevrologiisa da neiroreabilitaciis centrinervuli sneulebebiT daavadebul bavSvTa reabilitaciis kavSiri⇒ zaza kakuSaZe _ bavSvTa nevrologiisa daneiroreabilitaciis centris direqtori.⇒ irakli natroSvili _ nervuli sneulebebiT daavadebulbavSvTa reabilitaciis kavSiris Tavmjdomare.eqspertebi:⇒ nana tatiSvili _ saqarTvelos a. laWyepianis sax. bavSvTanevrologTa da neiroqirurgTa asociaciis Tavmjdomare.profesori.⇒ marina janeliZe _ saxelmwifo samedicino universitetisneiromedicinis departamentis xelmZRvaneli. profesori;⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros jandacvis departamenti;⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros jandacvis departamenti.19