1. Introduction

Cerebral palsy is defined as persistent disorders of the formation of motor skills and maintaining posture, leading to restriction of optimal functioning and movement disorders due to non-progressive damage and/or abnormality of the brain forming in the fetus or newborn child [1,10]. At the present stage of the development of medical science, cerebral palsy is considered a polyethological disease that includes various clinical variants of the course and is characterized by a diverse pattern of manifestations [3,9].

Leading scientists from all over the world are involved in the study of this serious disease. Despite this, the specific causes of cerebral palsy are still not fully understood, therefore, there is a lack of clarity in the prevention of this severe pathology. In most cases, there are several reasons for the occurrence of cerebral palsy. Adverse factors are found both during pregnancy and directly during childbirth, but which of them play the most significant role is still unknown [4,14,15,16].

Thus, cerebral palsy is a symptom complex with a large clinical polymorphism as a result of perinatal, mainly antenatal, brain damage [14]. But questions about the true causes and characteristics of the course of this disease still do not have unambiguous answers [8,11].

It is believed that the diagnosis of cerebral palsy can be determined by the end of the first year of a child's life. By this period, a delay in motor development can already be clearly formed, a core arises for the development of a pathological motor stereotype in the patient, and it becomes obvious that the identified violations are not compensable. Naturally, it is very important to exclude other pathologies of the central nervous system, which can display a similar clinical picture of motor disorders [5,7].

To assess the functional abilities of children with cerebral palsy, large motor function assessment systems (GMFCS), the Manual Skills Classification System (MACS), and the communication Skills Assessment System (CFCS) are currently used.

The use of GMFCS is possible in children with cerebral palsy from the age of 1.5 years. The advantage of this classification system is the ability to identify not only the severity of motor disorders, but also to predict the formation of global motor functions of a child during his or her lifetime [2,12,13].

Gait analysis using GMFCS is used to objectively assess the level of motor disorders in children with cerebral palsy, based on their functionality, the need for auxiliary devices (walkers, support frames, crutches, sticks, strollers) and movement capabilities, and to a lesser extent on the quality of the child's movements [13].

This classification was developed by the staff of the Canadian McMaster University, translated into many languages of the world and is currently a generally accepted international standard. According to the GMFCS classification, all patients with cerebral palsy are divided according to their motor abilities into five levels:

1) level "I" corresponds to children who can walk without restrictions, but cannot cope with more complex motor tasks;

2) children can walk independently with a slight restriction and cope with the simplest motor tasks;

3) children move satisfactorily with the help of additional support, take several independent steps;

4) children can hardly move with the help of additional support, but do not require constant support from an accompanying person;

5) level "5" corresponds to patients with very limited opportunities for independent movement, even with auxiliary equipment and weak control of the position of the trunk and head.

In order to determine the function of the upper extremities in patients with cerebral palsy, all patients were assessed for their manual skills according to the MACS classification system (Manual Ability Classification System). The MACS functional class I determines the patient's ability to use the upper limb to its full extent, that is, the function is not impaired. Patients with class II manual skills in most cases effectively use the upper limb, but some actions are performed more slowly or less efficiently than patients with class I MACS. The III functional class of MACS defines the difficulty of the functional capabilities of the upper limb. The patient needs to prepare for action or is forced to adapt it to his abilities. Functional class IV is typical for patients with limited upper limb function, and its use is possible only in an adapted situation. The V class of MACS defines a complete violation of the function of the upper limb, regardless of the situation created.

The purpose of the study. To assess functional disability in patients with cerebral palsy using the classification of gross motor Functions (GMFCS) and manual skills (MACS).

2. Materials and Research Methods

The research was conducted at the Department of Neurology with Pediatric Neurology of TashPMI, at the clinic of LLC "REACENTER-TASHKENT" and the children's Neuropsychiatric hospital named after U.K. Kurbanov. The work is based on the analysis of 134 patients with motor disorders. The age of the children ranged from 3 years old to 15 years old. To assess the ability of patients with cerebral palsy to walk independently and self-care, we conducted a study of the level of development of large motor functions (GMFCS) and manual skills (MACS) in these children.

3. Results and Discussions

The class of development of large motor functions according to the classification of large motor functions (GMFCS) was identified. The first functional class, which corresponded to walking without any restrictions, was determined in 71 sick children (53±0.25%), the 2nd functional class, characterized by the ability of patients to walk with restrictions, was noted in 36 patients (27±0.2%), the 3rd functional class according to GMFCS (walking with manual devices) was observed in 17 patients (13±0.11%), 4th and 5th classes of GMFCS, this is the ability of patients to move using motorized means and complete dependence on others were determined in 7 (5±0.05%) and 3 (2±0.02%) cases, respectively (Figure 1).

Figure 1. Distribution of patients (number of patients) by classes of major motor functions (GMFCS)

The 1st and 2nd functional classes of GMFCS were most common. 53±0.25% of the examined children with cerebral palsy had the opportunity to walk independently, and 27± 0.2% of patients could move with restrictions. The first functional class was detected statistically significantly more often than other functional levels according to GMFCS (p<0.05).

With a bilateral spastic form of cerebral palsy, in 76 ±0.18% of cases, the 1st functional class according to GMFCS was noted, that is, the possibility of independent walking. In 24±0.18% of children with bilateral spastic variant, limitations of large motor functions of varying severity were determined. In 14±0.12%, the 2nd functional class according to GMFCS was observed, that is, the ability to walk with restrictions. In 10 ±0.09% of patients, the 3rd functional class was found, that is, the ability to move only with the use of manual devices (Figure 2.).

Figure 2. Distribution of children with bilateral spastic cerebral palsy by functional classes of large motor functions

Among patients with unilateral spastic cerebral palsy, 80±0.16% of children had the 1st functional class according to GMFCS. In 20±0.16% of cases, the 2nd functional class was determined according to GMFCS (Figure 3.).

Figure 3. Distribution of children with unilateral spastic cerebral palsy by functional classes of large motor functions

In patients with a mixed variant of cerebral palsy, the 1st functional class according to GMFCS was registered in 43±0.25%. In 31±0.21% of cases, the 2nd functional class according to GMFCS was detected, that is, walking with restrictions. In 15=0.13% of the examined children with a mixed variant of cerebral palsy, the 3rd functional class according to GMFCS was noted, that is, the ability to move with the help of hand devices. In 8 ±0.07% of the observations, the 4th functional class according to GMFCS took place, that is, the movement of these patients only when using motorized means. In 3±0.03%, complete dependence on others was determined (carriage in a wheelchair / wheelchair). Thus, patients with impaired walking function dominated among patients with mixed cerebral palsy (Figure 4.).

Figure 4. Distribution of children with a mixed variant of cerebral palsy by functional classes of large motor functions

In 71±0.2% of patients with dyskinetic cerebral palsy, the 1st functional class was determined according to GMFCS. In 29±0.2% of the observations, the 2nd functional class according to GMFCS was detected (Figure 5.).

Figure 5. Distribution of children with dyskinetic variant of cerebral palsy by functional classes of large motor functions

Thus, in patients with mixed type, the 1st functional class according to GMFCS was statistically significantly less common than in children with other variants of cerebral palsy (χ2=7.27, p=0.007). There were no statistically significant differences in the frequency of prevalence of other functional classes of large motor functions in the examined children (Figure 6.).

Figure 6. Distribution of children with different clinical variants of cerebral palsy by functional classes of large motor functions

The level of formation of manual abilities according to the MACS classification system was revealed in all children with cerebral palsy. The first functional class corresponding to the use of the upper limb without restrictions was determined in 50 patients (37±0.23%), the 2nd functional class, characterized by delayed execution of actions by the upper limbs, was determined in 51 infants (38±0.24%), the 3rd functional class according to MACS (help is needed to capture an object and hold it or a special situation) was observed in 23 patients (17±0.14%) of the examined group, 4th and 5th classes of MACS, this is the ability to capture an object only in an adapted situation and complete inability to capture an object, It was determined in 6 (4±0.04%) and 4 (3±0.03%) cases, respectively (Figure 7.).

Figure 7. Distribution of children with cerebral palsy (number of patients) by classes of manual abilities (MACS)

In patients with bilateral spastic cerebral palsy, the 1st MACS functional class, that is, manual skills in full, was recorded in 66±0.22% of cases. Disorders of upper limb function of varying severity were detected in 34±0.22% of patients. In 31±0.21%, children of the 2nd functional class were found, that is, with delayed or lower-quality reproduction of actions by the upper extremities. In 3±0.03%, the 3rd functional class was noted, that is, this category of patients was characterized by difficulty in functional capabilities when performing manual skills (Figure 8).

Figure 8. Distribution of children with bilateral spastic cerebral palsy by functional classes of manual skills

Functional class 1 was determined in 80±0.16% of patients with unilateral spastic form. In 20±0.16% of patients, mild upper limb function limitations were noted (Figure 9).

Figure 9. Distribution of children with unilateral spastic cerebral palsy by functional classes of manual skills

MACS functional class 1 was identified in 26±0.19% of children with a mixed variant of cerebral palsy. In 41 ±0.24% of patients with this form of cerebral palsy, upper limb dysfunction was noted in the form of delayed or less optimal reproduction of actions by the upper limbs (2nd functional class). The third functional class was found in 23±0.17% of patients. In 6±0.06%, the 4th functional class according to MACS was determined. In 4±0.04% of cases, there was complete inability to use the upper limb, that is, the 5th functional class according to MACS.

Thus, among the examined children with a mixed variant of cerebral palsy, patients with a disorder of upper limb function of varying severity dominated (Figure 10).

Figure 10. Distribution of children with mixed cerebral palsy by functional classes of manual skills

Among patients with dyskinetic cerebral palsy, 43±0.25% had the 1st functional class according to MACS (no restrictions). In 43 ±0.25% of the subjects, the 2nd functional class was determined, these are mild limitations of the functions of the upper extremities. The 3rd functional class among children with this clinical form of cerebral palsy was observed in 14±0.12% of cases. Thus, mild and moderate upper limb dysfunction prevailed in patients (Figure 11).

Figure 11. Distribution of children with dyskinetic cerebral palsy by functional classes of manual skills

So, based on the above results, it can be seen that in children with a mixed variant, the 1st functional class according to MACS was statistically significantly less common (χ2=15.27, p<0.01) than in patients with other forms of cerebral palsy. At the same time, the 3rd functional class of manual skills development was statistically significantly more often (χ2=5.47, p=0.19) observed in patients with mixed type than in patients with bilateral spastic form. Functional classes 4 and 5 were identified only in patients with a mixed variant of cerebral palsy (Figure 12).

Figure 12. Distribution of children with different clinical variants of cerebral palsy by functional classes of manual skills

The greatest severity of upper limb dysfunction was observed in patients with a mixed variant of cerebral palsy, which is evidence of the presence of spastic, hyperkinetic and atactic disorders in their upper extremities.

The first and second functional classes according to GMFCS were detected in 107 sick children with cerebral palsy, and the 1st and 2nd functional classes according to MACS were determined in 101 children (Figure 13).

Figure 13. Distribution of GMFCS and MACS classes across the entire group of examined patients

The frequent occurrence of the first two functional classes according to GMFCS and MACS in the same patients is explained by the fact that outpatient patients prevailed in the study, who, in addition to the possibility of independent or assisted walking, had satisfactory manual skills, combined to ensure their adaptation to everyday life. In children of the second and third functional classes according to GMFCS and MACS, the ratio increased in favor of patients with manual disabilities, which indicates the dominance of motor disorders at these levels that limit the functioning of the upper extremities. This circumstance can confirm the existence of a relationship between manual skills and large motor functions in patients with cerebral palsy.

4. Conclusions

1. The frequent occurrence of the first two functional classes according to GMFCS and MACS in the same patients is explained by the fact that the study was dominated by outpatient patients who, in addition to the possibility of independent or assisted walking, had satisfactory manual skills, combined to ensure their adaptation to everyday life.

2. Thus, as the GMFCS class increases, there is also a deterioration in the functionality of the upper extremities according to MACS.

3. The most pronounced disorders of large motor functions and manual skills were noted with a mixed form of cerebral palsy, which indicates the presence of various types of motor disorders in their clinical picture and allows us to consider this variant of the course of the disease unfavorable.