RU2203610C2 - Static proprioceptive stimulation method for determining posture reflexes in children having cerebromotor disorders - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out static proprioceptive stimulation alternatingly in individual ortheses like corset seats, corset verticalizers as practical activity sessions of 20-30 min duration repeating and alternating within daytime in the course of correction and game occupations, leisure activities, in feeding patients having the ortheses on to 5-6 h per day. EFFECT: enhanced effectiveness in restoring anti-gravitation system functioning; assuming self- standing body postures in sitting and standing. 2 dwg

Description

 The invention relates to medicine, namely to neurology and orthopedics, as well as to corrective pedagogy, and can be, in particular, used for static proprioceptive stimulation of postural reflexes in young children with perinatal and early postnatal pathology of the central nervous system (c. from.).

 From the practice of medicine, methods of rehabilitation treatment for cerebral palsy (cerebral palsy) are known, including massage and physiotherapy exercises, which are aimed at normalizing muscle tone, suppressing neck-tonic reflexes responsible for pathological stereotype, stimulating motor reactions, and developing motor skills. (Badalyan L.O., Zhurba L.T., Timonina O.V. Cerebral palsy. Kiev: Zdorovya, 1988, pp. 19-32; Bortfeld S.A., Rogacheva E.N. Therapeutic physical training and massage for cerebral palsy. L .: Medicine, 1986, p.24-29; Efimenko N.I., Sermeev B.V. Contents and methods of physical education with children suffering from cerebral palsy. M: Soviet Sport, 1991 , p.15; Ivanitskaya I. N. Cerebral palsy. Almanac "Healing." M., 1993, 1, p. 44-45; Comprehensive rehabilitation of children with cerebral palsy. Methodical recommendations. M.-S. Petersburg Urg, 1998, vol. 1, pp. 58-88).

 The disadvantage of these methods is the complexity of educating the vertical installation of the torso and sitting skills. Known methods of kinesiotherapy are carried out in a horizontal or semi-horizontal position, in which the gravity factor is minimal, while the pathology of the functional antigravity system (PSA) is manifested by the fact that in a horizontal position of the body, muscle tone disorders are minimal.

 The closest way to the proposed one is the method of fixing the standing skill, which consists in the child performing physical exercise exercises in a vertical position, which is created using a device in the form of a board shield fixed to the gymnastic wall at a certain angle. The child is fixed with elastic bandages 2-3 times a day for 20-30 minutes (Tekoryus V.V. Correction of motor disorders in cerebral palsy (Methodical recommendations), Moscow, 1987, 19 pp.).

However, the prototype has the following disadvantages:
- it can only be used in children with partially developed standing skills;
- such fixation does not provide stability and correction of the pathological positions of the limbs, especially the hip joints, the most prone to deformation.

 The aim of the invention is the restoration of the functioning of the anti-gravity system and the achievement of an independent posture of the body in the "sitting" and "standing" positions.

 The goal of the invention is achieved by the fact that static proprioceptive stimulation of postural reflexes is carried out alternately in individual orthoses: seat corsets and vertical corsets in the form of practical sessions of 20-30 minutes, during alternating and repetitive during the day corrective and game exercises, during leisure activities, feeding with a total stay in orthoses up to 5-6 hours per day.

 It is known that the motor development of young children is the result of a constant interaction between motor, cognitive and perceptual functions and is largely dependent on sensory-vestibular afferentation (Foudriat et al., 1993).

 In cerebral palsy, a kind of violation of the motor functional system occurs, when the brain development is delayed at primitive levels, and the transition to new levels associated with the formation of postural reflexes - head retention, sitting and standing - does not occur at all or is formed pathologically. The kinesthetic analyzer loses the main stimulating factor - proprioceptive afferentation. This, in turn, inhibits the development of Gnostic and intellectual processes. Children with cerebral palsy are doomed to complete immobility, bedriddenness.

 Based on numerous studies of domestic and foreign scientists, it was found that in children with perinatal brain pathology, especially with cerebral palsy, functional systems are formed in a pathological way. One of the leading pathophysiological mechanisms of the development of cerebral palsy is a violation of the development of the functional antigravity system (PSA), which determines the formation of statics and locomotion. In children with severe forms of cerebral palsy, the kinesthetic analyzer loses the main stimulating factor - proprioceptive afferentation. This leads to a sharp inhibition, up to the complete disappearance, of the biorhythm of the brain.

 According to many authors, the main unfavorable prognostic sign for cerebral palsy in 91% of cases is the onset of sitting after 2 years, which is one of the main reasons for the violation of not only statics and locomotion, but also visuospatial praxis, speech and other higher mental functions .

 Thus, the vertical installation of the body can be considered as a criterion for the formation of anti-gravity structures, which are of great importance in the differentiation of arm and speech movements.

 The skill of seating in its development goes through 4 stages.

 1. The sharply limited motor capabilities of the child do not allow him to sit on his own.

 2. The motor abilities of the child are limited. Independently maintaining the sitting posture under conditions of constant overcoming of the forces of gravity leads to muscle overwork, prevents the implementation of other movements, such as manipulating objects, which nullifies the benefits of this posture and does not reduce the child’s dependence.

 3. The child is able to independently take a sitting pose, but there is a risk of developing orthopedic complications from the spine and hip joints.

 4. The motor abilities of the child allow him to completely independently maintain the sitting position for a long time and correctly. It is in the first three stages that static proprioceptive stimulation using special orthoses is indicated.

 Normally, a healthy child of the second year of life, having mastered the skill of sitting and upright, spends in these poses at least 2 hours a day. With the development of game activity and the mastery of fine motor skills, this time increases to 5-6 hours per day.

 The therapeutic approach for cerebral palsy and other diseases of the perinatal and early postnatal period consists in accelerating the development of normative skills at an accelerated pace by stimulating the impact on all functional systems of excessive specific afferentation. It is carried out in the form of artificially and alternately created sitting and standing poses with the help of individual orthoses: corset-seat and corset-upright.

 As you know, the education of a child’s skill is more successful when it is supported by positive motivation. For this purpose, being in the orthosis should be combined with the performance of some activity. That is, postural stimulation is carried out alternately during the period of corrective exercises, games, leisure activities, feeding, etc., alternating throughout the day. The time spent in the corset-seat and corset-upright should be at least 20 minutes in each position. The total time the child is in the orthosis with 4 degrees of sitting and standing skills should not exceed 2-3 hours per day, with 3 degrees - 5-6 hours. When the child reaches stage 2 of the development of these skills, the time of postural stimulation decreases, since the child masters sufficient skill of sitting and standing and can independently control them. Being in the orthosis is necessary only in those classes that require special concentration - performing subtle hand movements: writing, manual labor.

 Recommended orthopedic regimen for children with postural orthoses.

 1. Breathing exercises in a sitting position - 20 min.

 2. Breakfast in the corset seat - 20 min.

 3. Individual lesson with a teacher in a corset seat - 30 minutes.

 in the verticalizer - 30 minutes

 4. Correctional group lesson either in the corset-seat or in the verticalizer - 20 minutes.

 5. Lunch in the corset seat - 20 minutes.

 6. An afternoon snack in a corset seat - 20 min.

 7. Correctional group session with the teacher in the orthosis - 20 min.

 8. Dinner in the seat corset - 20 minutes.

 9. An individual lesson at home with parents in a corset seat or in a vertical corset - 30 minutes.

 10. Leisure (eg, watching a television program) - 30 minutes.

 Our proposed method consists in the use of special individual orthoses: corsets-seats and corsets-uprights (Tacis Project “Transfer of French technologies of motor education and orthotics of disabled children of the Astrakhan region to specialists of the Center for Medical and Pedagogical Rehabilitation of Children with Cerebral Palsy and Orthopedic Enterprise of Astrakhan ". Contract 96-5462, 1997 Document Tacis, Brussels, 1997), providing a stable, corrected position of the trunk and limbs with the aim of carrying out propriocept ivnoy stimulation in a motivated activity of the child: while feeding, recreational or rehabilitative training. The antigravity mechanisms of voluntary postural control that develop as a result of this contribute to the development of sitting and standing skills and lead to the development of the activity of all functional systems and the brain as a whole.

 It combines the method of pedagogical correction with proprioceptive stimulation for children from one year of age with severe disorders of vestibular and antigravity functions, unable to sit and stand on their own. It allows you to prepare children for domestic rehabilitation, achieve high results and prepare them for the transition to a higher level of psychomotor development, begin the process of learning everyday and school skills.

 The main goal of the method of static proprioceptive stimulation in a corrected position is to restore the functioning of the antigravity system (AGS) and the formation of postural reflexes, that is, maintaining the body position "sitting" and "standing". On this basis, the formation of a normal static-motor function is achieved.

 The method consists of 3 stages.

 1. Preparatory phase: aimed at creating a positive emotional attitude of the child to stay in the "sitting" and "standing" positions with the help of an orthosis. Based on the results of the examination of postural and anti-gravity functions, muscle tone, skin integument, the minimum time spent in the orthoses is established, but it should not exceed 2 hours per day: during meals and 2 game sessions, one of which the child spends in corset seat (20 min), the second - in the vertical corset (20 min).

 2. The main stage: consists in developing the skills of standing and sitting in conditions of motivated activity: in the corset-seat: during feeding (4 times for 20 minutes), 2 games (for 20-30 minutes), 1 correctional lesson (20 minutes) ; in the vertical corset: at 2 games, 2 correctional exercises and 1 leisure (for example, watching a TV show - 30 minutes). The time of sitting and standing in the orthosis should be 2.5 hours per day in each. The total time of postural stimulation should be 5 hours per day.

 3. Fastening stage: aims to automate skills. The skills of sitting and standing acquired through orthoses are trained throughout the day in constantly repeating situations of everyday life, the so-called functional situations: when feeding, washing, washing hands, practical activity (drawing, designing, writing, sculpting, manual labor), correctional classes with a speech therapist, music director, defectologist, psychologist.

 At this stage, the child spends in a sitting and upright position for 30 minutes. The total time spent in the corset seat is 3-3.5 hours per day, in the vertical corset - 2-2.5 hours per day. The total time of postural stimulation is 5-6 hours per day.

 The proposed method was tested on 26 children in the Center for medical and pedagogical rehabilitation of children with cerebral palsy in Astrakhan during 1997-2000

 Below are the results of testing.

 Example 1

 The history of the development of the child A., born in 1992

 Diagnosis: Severe spastic diplegia. Unfixed flexion-adducing contractures of the hip and shoulder, flexion - of the knee and ankle joints, pronator-flexion - of the wrist joints. Obsolete dysarthria.

 The first 3 years were regularly treated stationary: massage, exercise therapy, physiotherapy, paraffin baths, step-by-step gypsum treatments, posture treatment with the help of longet and laying in a horizontal position. The dynamics in the development of the child was insignificant and unstable.

 Upon admission to the Center at the age of 4 years: spastic tetraparesis is expressed. He keeps his head badly. With difficulty only carries out a turn from the back to the stomach, not sitting, not standing. With the slightest external irritation, it immediately loses postural control, drops sharply back. No self-service skills. Very low level of motivation for cognitive activity. The level of perception of the environment corresponds to 1.5 years, although intelligence, expressive speech are preserved over short distances with the help of walkers. Postural stimulation of the standing skill was started in the game classes (2 lessons per day for 20 minutes: music therapy and construction). The seat skill was developed in a corset chair during feeding at the Center and at home (4 times for 20 minutes). That is, the total time of postural stimulation was 2 hours per day (40 minutes in vertical and 80 minutes in a sitting position). The preparatory phase lasted 2 months. Then, the time spent in the corset seat increased to 120 minutes per day (2 lessons of 30 minutes, meal time 4 times for 20 minutes). In the corset-upright, the boy freely spent 1 hour (3 lessons of 20 minutes). The total duration of postural stimulation reached 3 hours per day.

 With the upbringing of standing and sitting skills, the motivation for cognitive and subject-practical activity increased. The number of classes on the development of speech, fine motor skills, design, drawing, visual-kinesthetic perception increased.

 At the 2nd stage of postural stimulation, the boy spent 3 hours a day in the corset-seat (30 minutes each at correctional lessons, and then at lessons and during meals), and in the vertical corset-2 hours (20 minutes each at separate lessons and during leisure time: singing, watching TV shows, etc.). The total time spent in the orthoses reached 5 hours per day. After 3 years from the beginning of postural stimulation and kinesitherapy, he learned to confidently sit without a corset-seat, stand with support for the arm, crawl on all fours, walk. He mastered the skills of self-service: dresses independently, eats, visits the toilet, formed graphic skills, mastered the work on the computer. Currently, the boy is successfully studying in grade 1 according to the regular program.

 Example 2

 The history of the development of the child P., b. 1996

 Diagnosis: cerebral palsy, double athetosis. Subcortical anarthria. Unfixed adductive contractures in the hip and flexion in the knee joints. Delay in psychomotor development.

 In the first 2 years of his life, he received treatment in a hospital: drug treatment, physiotherapy, massage, exercise therapy, position treatment with a span, laying in a horizontal position.

 As a result, upon admission to the Center: he does not sit on his own, does not stand, does not turn over, does not hold his head. Asymmetry of muscle tone with the formation of scoliotic posture. A fixed turn of the head to the left. He understands the addressed speech, but communication is impossible due to anarthria and hyperkinesis. He eats poorly, mastication is impaired due to impaired articulatory motility, cerebral hypotrophy (according to height-weight indicators, it corresponded to 8 months of age). Over 2 years, he gained 600 g in weight and 1 cm in height. Colds, obstructive bronchitis up to 6-8 times a year. He underwent bilateral bronchopneumonia with atelectasis of the left lung. According to the level of mental development, it corresponded to 6 months of age. At 2 years old, he began to receive postural therapy from 2 hours (80 minutes in a sitting position and 40 minutes in a vertical position). The adaptation period lasted 6 months. Treatment was often interrupted due to frequent colds of the boy. After 6 months, postural therapy was brought up to 3 hours a day (120 minutes in a sitting position and 60 minutes in a vertical position). At present, the boy spends up to 5 hours a day in orthoses: in a corset-seat for up to 3 hours in correctional classes and during meals, in a vertical corset - 2 hours a day.

 For 2 years there is the following dynamics: fully grown, rarely sick (no more than 3 times a year), removed from the register of a pulmonologist. He gained 5 kg in weight and 6 cm in height. He keeps his head upright, freely turns it to the side, muscular torticollis is slightly pronounced, turns over from back to stomach and back; the severity of hyperkinesis decreased, tonic spasms with head tilting stopped. The asymmetry of muscle tone has disappeared. The chewing function has improved. Initial communication skills have been formed: he can communicate using an index gesture, head movements, and eyes. Holds small toys for a short time, draws with fingers. Stock of knowledge and ideas, passive vocabulary approached the age norm. In class, sits in a corset seat, stands in a vertical corset with pleasure, for a long time maintaining attention and interest in obtaining information. The use of the method of postural stimulation has shown its high efficiency.

 In children, the general condition improved, they became physically stronger and were much less likely to have bronchopulmonary diseases. Graph 1 (Fig. 1) shows the comparative growth dynamics for 3 years of children treated in a hospital using the usual methods who did not receive ATP (group 1) and patients of the Rehabilitation Center who underwent ATP (group 2). In the first group, only 25% of children had an increase of no more than 2 cm. In the second group, an increase in growth was noted in 92.8% of children by 2-10 cm. Improved motor abilities of children against the background of decreased muscle tone, elimination of contractures and increased mobility joints shown in graph 2 (figure 2). Children who were previously bedridden had the opportunity to learn with their peers, develop independence and acquire new skills for them. Deterioration was observed only in 0.8% of children, which was due to the progression of the underlying disease or a long interruption of treatment at the Center.

 Thus, postural stimulation allows you to create postural reflexes, to achieve reflex interaction of antigravity muscles and hip flexor muscles, which ensures the preservation of a stable vertical posture. Proprioceptive impulse corrected with the help of orthoses promotes the development of a functional gravity system, as evidenced by the development of children's own standing and sitting skills.

 The method can be applied in rehabilitation centers, educational correctional institutions for children with cerebral palsy and other cerebro-motor disorders.

Claims (1)

 The method of static proprioceptive stimulation of postural reflexes in young children with cerebro-motor impairment, which consists in the development of sitting and standing skills, characterized in that the static proprioceptive stimulation of postural reflexes is carried out alternately in individual orthoses: seat corsets and vertical corsets in the form of practical sessions 20-30 minutes during alternating and repetitive during the day corrective and game exercises, during leisure activities, feeding with a common stay in the orthoses up to 5-6 hours per day.

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