RU2685679C1 - Method for evaluation of inclusion potential in children with heavy perinatal damages of the brain - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, neurology, is used to assess the inclusion potential in children with cerebral lesions of the perinatal nature. Method defines a complex of traits for determining a child's state in "palliative status". Provides psychological and pedagogical support of correctional and developing activities corresponding to the level of their mental development.EFFECT: method characterizes a level of motor activity, generalized tonic phenomena, reactivity to external stimuli of different significance and a level of mental functions.1 cl

Description

The technical field to which the invention relates.

The invention relates to the field of medicine, namely, neurology, and can be used to assess the abilitation potential in children with brain lesions of perinatal nature. In particular, the invention defines a set of criteria (features) that allow objectifying the child’s condition in a “palliative status” to provide psychological and pedagogical support in the framework of remedial and developmental activities corresponding to their level of mental development.

The level of technology

In Russia in recent years, important decisions have been taken on the organization of palliative care for children. Infrastructure has been created, specialized personnel are being trained. Assistance is provided by various state and non-state organizations. Gradually open children's hospices, dogs, palliative centers.

At the same time, the problem of providing complete assistance to such children is still far from being resolved. In many ways, the reason for this is the disunity of the medical and social aspects. The same situation is observed in the direction of psychological studies of children with multiple developmental disorders. The lack of tools for an objective assessment of the psycho-physiological status of children in such a serious condition dictates the need to develop adequate methods for assessing their condition.

The complexity of the work is determined by a deep violation of motor and mental functions.

The prior art discloses a method for evaluating motor functions (Palisano, R., Rosenbaum, P., Walter, S., Russell, D., Wood, E. and Galuppi, B. (1997) motor function in children with cerebral palsy. Developmental Medicine and Child Neurology, 39, 214-223 (http: //dx.doi.0rg/10.1111/j.1469-8749.1997.tb07414.x). The method is a scoring of motor activity and is used in evaluating that in children with motor pathology, including in cases of gross damage to the motor functions of a perinatal nature in such diseases as cerebral palsy. The scale was created to assess the level of motor deficiency and does not have in its structure a mechanism for accounting for reflex motor reactions, decortication and decerebration phenomena in relation to determining the severity of damage to brain structures.

From the prior art known method of assessing the neuro-psychological development of a child Zhurba-Mastyukova (Zhurba LT, Mastyukova EM Disruption of the psychomotor development of children of the first year of life. M .: Medicine, 1981, 272 p.), Based on a comparison of actual child development indicators with regulatory, obtained as a result of a survey of large groups of children with an uncomplicated history and the absence of violations of the process of neuropsychic development. In this case, the method does not imply a quantitative (scoring) expression of the results of the assessment.

The ability of this method to assess the level of mental activity in a child with a gross brain damage is extremely low due to the high measurement threshold. In addition, the method requires a certain level of special training and using it by a mid-level pediatrician is difficult.

The prior art also knows the methodology for assessing psychomotor development on the Griffiths scale (Griffiths R., UK: The Test Agency Ltd, 1984). This methodology is also focused on measuring deviations from the normal level of a child’s development, and takes into account the age-specific adherence of certain skills and mental response options to the environment, typical of a child’s normal development when he reaches a certain age. Thus, the threshold of sensitivity of this scale, calculated from the level of the normal development of the child, is too high to assess the functioning of the child with a gross impairment of functions in the palliative status.

However, the known methods (Griffits and Zhurba-Mastyukova scales, Gross Motor Function Scale motor assessment scales) do not provide division into groups and do not allow for a comprehensive assessment of involuntary generalized tonic phenomena, arbitrariness or involuntary in the motor sphere and mental functions.

The closest to the claimed solution is a method of assessing mental functions in children with severe perinatal brain lesions, based on the division of children into three groups according to the level of consciousness and the development of intellectual-mnestic functions to further provide palliative care (Sokolov P.L., et al. Professional and ethical aspects of palliative care for children with neurological pathology.Qanum Satis 1.3-4 (2017): 96-100.) The first group includes children with a safe level of intellectual-mnestic functions, the second is children with boundedness level intellectual-mental functions, the third - the children with deep defects intellectual-mental functions. However, this mention of the possibility of such separation of children does not directly contain methodological instructions, using which one can determine the level of motor and mental deficiency or the degree of development of motor and mental functions at its initially extremely low level in children with severe brain lesions.

DISCLOSURE OF INVENTION

The technical problem solved by the invention is the creation of a method for assessing the state of mental and motor functions in children with severe perinatal brain lesions, which is sufficiently sensitive to assess their minimum manifestations and allow an assessment of the level of habilitation potential in such children in order to plan activities for their habilitation. conditions of the clinic and at home.

The technical result, the achievement of which the claimed invention is directed, is the possibility of obtaining objective data expressed in points by assessing the child's motor capabilities, their level of arbitrariness or reflex nature, and the level of development of mental functions — also from reactive to possible formation of emotions, which additionally will allow to assess the degree of divergence of the levels of motor and mental functions.

One of the main signs of the palliative state is the lack of rehabilitation potential (Order of the Ministry of Health of the Russian Federation dated April 14, 2015 N 193n "On approval of the procedure for providing palliative medical care to children." At the same time, the group of "palliative" children with gross brain pathology is characterized by an essential originality First of all, because their life expectancy, in contrast to the condition of children with non-curable oncological pathology, is determined not so much by the underlying disease as by sopu pathologies (pressure sores, dysfunction of the respiratory system due to aspiration and infectious complications, etc.). In addition, the child’s brain, even when deeply affected, does not stop developing from the moment of birth. It’s hardly possible to talk about rehabilitation Since rehabilitation means the restoration of any functions that have been lost, whereas these children’s functions are inherently deeply disturbed. In this case we can only speak of habilitation — that is, the development of child's functions. However, the assessment of motor and mental functions in children with their deep defect cannot but differ methodologically from that of children who are higher in development. Thus, the assessment scale of patients with deep depression of consciousness contains a component of the degree of reflexivity of their reactions to external stimuli. In this case, when developing the proposed method, a set of evaluation criteria was used, including the severity of generalized tonic activity, generally reflecting the depth of the brain lesion (decortication and decerebration phenomena), the degree of reflexivity / randomness of movements and the degree of reflexivity / arbitrariness of reactions to visual and auditory stimuli.

The use of these indicators made it possible to determine (by assessing the degree of arbitrariness / reflex of reactions) the level of perception of external stimuli by the child, and thereby predict the promise of habilitation taking into account the available possibilities, - assess the actual habilitation potential.

The very assessment of habilitation potential will allow, based on objective signs, to divide a group of children with severe brain lesions according to degree of development and perception into groups that need a different approach to shaping habilitation measures, from a purely reflex impact, aimed at stimulating the development of a sensitive sphere, to applying emotionally significant stimuli in children, capable of forming emotion as such.

The technical result is achieved by the fact that the method of determining the abilitational potential in children with severe perinatal brain lesions includes an assessment of the complex of features in points, which characterize the following groups:

- generalized tonic phenomena (GTP);

- the level of involuntary and minimal voluntary motor activity (YES);

- the level of reactivity to external stimuli, emotional reactions and arbitrary sounds that characterize mental functions (PF);

at the same time, the PF group is characterized by the presence of a subgroup, where for each group and subgroups the value of the score is determined, which corresponds to the attribute characterizing the child’s condition

where as signs of GTP (in this group one or two signs can be detected in one child at a time, the identification of two signs is usually characterized by a combination of dystonic attacks with any of the remaining signs) assess the following signs, in points:

full decerebration rigidity (-five), separate elements of decerebration rigidity (-four), complete decortication rigidity (-3), separate elements of decortication rigidity  (-2) presence of dystonic attacks (-one);

as signs of YES (in this group only one sign is determined at a time in one child), the following signs are evaluated, in points:

total immobility (-five), reflex movements, which are caused only within the motor reflexes (-four), involuntary physical activity non-reflex nature (-3), minimal random activity (3);

as signs of PF assess the signs of each of the subgroups, in points:

- in the subgroup “visual reaction to a light source”, with the exception of the pupillary reflex, in the absence of amaurosis, the signs are evaluated in the form:

no reaction (-3), undifferentiated motor activity (-one), fixing the gaze of any duration (one), gaze tracking of any duration (2)

- in the subgroup "visual response to the visual image", in the absence of amaurosis, assess the signs in the form:

no reaction (0) fixing the gaze of any duration (3) gaze tracking of any duration (four),

- in the subgroup "reaction to the addressed speech", in the absence of hearing impairment, assess the signs in the form:

no reaction (-2) undifferentiated motor activity (-one), fixing the gaze on speech (2)

- in the subgroup "emotional reactions", evaluate the signs in the form:

lack of emotion (-one), negative emotions in the absence of visible signs of consciousness (for example, as a moan) (0) negative emotions in a child is conscious (2) positive emotions (for example, in the form of a smile) (3)

- in the “arbitrary sounds” subgroup, the signs are evaluated in the form:

lack of arbitrary sounds (0) the presence of arbitrary sounds for any severity (3);

at the same time, for the GTP group, one or two signs are detected at one time, and when two signs are found that characterize the presence of dystonic attacks in combination with any of the remaining signs, the total score for the identified signs is used for assessment,

for the group YES, only one sign is determined at a time,

for the group PF, only one feature from each subgroup is simultaneously determined,

and in the case of a combination:

the values of the estimated traits in the GTP group are less than (-3) points (i.e., obtain values (-4) or (-5) or (-6))

negative values in the group YES,

and in the absence of a positive value of the evaluated signs in any of the subgroups of the PF group,

make a conclusion about the child’s full reactivity and lack of habilitation potential, in which the habilitation measures are not shown;

negative values of the estimated traits in the GTP group more than (-3) points, (i.e., obtaining the value of (-2) or (-1))

the values of the trait in the YES group (-3) or (3) points,

positive values of the estimated signs in any of the subgroups of the PF group,

It is concluded that the child has a reflex-type reactivity and that he has an abilitation potential, at which abilitation measures with sensory load are shown;

the values of the trait in the GTP group (-1) point,

the values of the trait in the YES group (3) points,

positive values of the assessed traits in at least two subgroups of the PF group,

make a conclusion about the presence of a child's reactivity with signs of initial development of mental functions, and the availability of abilitation potential, which shows the implementation of abilitation measures taking into account the existing disorders in the child.

Thus, the essence of the invention consists in determining the complex of signs characterizing the level of motor activity, generalized tonic phenomena, reactivity to external stimuli of various significance and the level of formation of mental functions, the formation of a scoring scale from them to determine the abilitation potential in children with severe perinatal brain lesions with recommendations for habilitation activities.

For this purpose, the estimated signs for all three groups are highlighted:

1. Generalized tonic phenomena (decerebration rigidity, decortication rigidity, tonic attacks) (GTP).

2. The level of motor activity of involuntary (reflex motility) and the minimum arbitrary nature (YES).

3. The level of reactivity to external stimuli (significant and insignificant visual and auditory), as well as emotional reactions and arbitrary sounds (PF).

Signs summarized in three main groups are scored. The points are assigned on the basis of the presence or absence of specific clinical symptoms of the patient, whose knowledge is included in the general educational level of the pediatrician and does not require special training. The balance of scores according to the degree of clinical and physiological significance allows us to determine the objective level of preservation or prevalence of the studied group of functions.

The implementation of the invention

Below is a more detailed description of the claimed invention.

The table presents a complex of three groups of symptoms, each of which is assigned a specific value in points, designed to assess the mental functions in children with severe perinatal brain lesions.

The study involved children who were divided into two starting groups and two main groups:

Starting group 1 - children of the first year of life with consequences of severe perinatal lesions of the central nervous system (10 people)

Starting group 2 - children aged 1-3 years with the consequences of severe perinatal lesions of the central nervous system (10 people).

Main group 1 - children of the first year of life with consequences of severe perinatal lesions of the central nervous system (15 people)

Main group 2 - children aged 1-3 years with the consequences of severe perinatal lesions of the central nervous system (15 people).

In conducting the study, the following methods were used:

Collecting anamnesis of life and disease, collecting complaints;

Clinical study with the assessment of neurological and mental status, using the model of the rating scale.

MRI of the brain.

In order to obtain the required information, the doctor should examine the child, consistently fixing the existing symptoms and reactions to external stimuli.

As generalized tonic phenomena (GTP) are consistently evaluated:

De-cerebral rigidity is complete or elements, if present, a negative score of (-5) or (-4) is assigned, respectively.

The decortication rigidity is complete or the elements, if present, are assigned a negative score (-3) or (-2), respectively.

In the presence of dystonic attacks, a negative score (-1) is also assigned.

According to the results of the assessment, a point value is determined for the signs of this group; when two signs are revealed in the group, the total value of the score is calculated.

In assessing motor functions in the presence of:

Complete immobility is assigned a negative score (-5).

In the presence of movements, caused only within the framework of motor unconditioned reflexes, a negative score (-4) is assigned.

Involuntary motor activity of a non-reflex nature (spontaneous) allows you to assign a negative score (-3).

The presence of an arbitrarily pronounced minimum of arbitrary activity implies a positive score with a high weight (+3) due to a special (arbitrariness factor indicates a qualitatively higher level of brain functioning involving cortical mechanisms of its regulation) of the estimated significance of a sign of arbitrariness.

Based on the results of the assessment, a score is determined on the basis of this group.

In assessing reactivity and mental functions, reactions to insignificant and significant visual stimuli, auditory stimuli, the ability to form emotions and the presence of elements of speech are distinguished.

A prerequisite for the assessment of reactivity to external stimuli is objective confirmation of the preservation of the child's visual and auditory functions at the reception level.

Visual reactivity to a light source is evaluated (non-pupillary reflex, in the absence of amaurosis). The lack of reaction is rated negative (-3). Undifferentiated motor activity upon presentation of a visual stimulus (light source) - (-1). Fixing the gaze of any duration is estimated by a positive score (+1), tracking a light source of any duration by a higher positive score (+2).

The visual reactivity of the visual image (which can be a bright toy or the face of the investigator facing the child with positive facial expression (smile)) is evaluated by a relatively high positive score - fixing the gaze of any duration (+3), tracking - (+4). Non-response is rated neutral - (0).

The reaction to the addressed speech is also a reaction to the undifferentiated sound stimulus - therefore, it is evaluated comprehensively as follows: in the absence of a reaction, a negative score (-2) is assigned, the detection of undifferentiated motor activity (startle, etc.) is also evaluated by a negative score (-1) , since it is also a nonspecific reaction, whereas fixing the gaze on speech, as a sign of an arbitrary action in response to an external stimulus, is evaluated positively (+2).

When evaluating emotional reactions to the absence of emotions (both positive and negative), assign a negative score (-1); negative emotions in the absence of visible signs of consciousness (moan) are assessed neutral (0). If there are signs of consciousness, negative reactions (crying, moan) are already evaluated positively (+2), the presence of a smile is estimated by a higher score (+3).

If the patient has speech skills, signs of random speech (+3) are available in any degree of expression, and if they are absent, a neutral point (0).

The rating scale allows one to quantitatively take into account the state of each of the functions studied, which is fundamentally important in determining the abilitation potential and in shaping the habilitation program.

According to the assessment, children are divided into three groups:

Fully areoactive children with no rehabilitation potential, with a combination of:

values of estimated traits in the GTP group are less than (-3) points,

negative values in the group YES,

negative values for all subgroups of the PF group,

Children with a reflex-type reactivity with the presence of an abilitation potential, which are shown to perform abilitation measures with a sensory load, with a combination of:

negative values of the estimated traits in the GTP group are more than (-3) points,

the values of the trait in the YES group (-3) or (3) points,

positive values of the estimated signs in one of the subgroups of the PF group,

Children with a sufficient level of reactivity, signs of the initial development of mental functions and the presence of habilitation potential, at which habilitation measures are shown taking into account the existing disorders in a child, with a combination of:

the values of the trait in the GTP group (-1) point,

the values of the trait in the YES group (3) points,

positive values of the assessed traits in at least two subgroups of the PF group,

Evaluation options in typical clinical cases are listed below.

Example 1. Child V., age 3 years 6 months., Diagnosis of holoprostancephalia, severe psychomotor development delay, symptomatic epilepsy with generalized clonic-tonic seizures.

In the clinical picture - decerebration rigidity, dystonic attacks, movements only within the framework of reflex responses, complete lack of response to external stimuli. These changes indicate that the child has a deep brain damage, reactivity at the reflex level, a complete lack of responsiveness to visual and auditory stimuli, and no signs of mental activity. Score on the scale of GTP (-6), YES (-4), PF (-1), Abilitation readiness is absent. The child needs only care. Within 3 months of observation, the child’s condition remained stable. When conducting measurements on a scale of dynamics was not observed.

Example 2

Child A., age 1 year 7 months, diagnosis cerebral palsy, GMFCS grade V, impaired speech and mental development.

In the clinical picture - decortication rigidity, dystonic attacks, undifferentiated spontaneous locomotor activity. Short-term fixation of a look at a light irritant. Undifferentiated locomotor activity on the auditory stimulus (speech). Crying while trying to turn over or manipulate. The absence of arbitrary speech activity in any form. This picture suggests that the child has a deep brain damage, motor activity is only spontaneous, there is reactivity to light and auditory stimuli (stimuli) in the absence of signs of mental activity. Score on the scale of GTP (-4), YES (-3), PF (0). Regarding abilitational readiness: the perception of visual and auditory stimuli allows for short-term sensory training sessions, possibly music therapy options, to use a sound series to achieve muscle relaxation with increased tone. Reactivity to passive motor activity implies the possibility of performing tonotonic correction.

When conducting kinezodiagnostiki identified posture in the half-sitting position in which the likelihood of dystonic attacks was minimal. A three-week kinesitherapy course aimed at strengthening the muscles that secure the child in this position was held. The frequency and severity of tonic attacks during the day objectively decreased, the child’s well-being improved.

Example 3

Child S., age 4 years 8 months. Diagnosis - cerebral palsy, spastic tetraparesis, GMFCS grade V. assessment. Speech and mental development delay.

In the clinical picture - elements of decortication rigidity with sensory irritation. Spontaneous and provoked dystonic attacks. Fixing the gaze at the source of light and at the sound stimulus (speech) is a short-term positive emotional response (smile). This picture indicates the presence of a deep brain damage in a child without persistent manifestations of decerebration and decortication. Reactivity for auditory and visual stimuli is present. The possibility of forming a positive emotional response as a sign of higher cortical activity. Score on the scale of GTP (-3), YES (-3) PF (2). In terms of habilitation potential - the perception of visual and auditory stimuli allows for short-term sensory training sessions, perhaps - music therapy options, to use a sound series to achieve muscle relaxation with increased tone. Reactivity to passive motor activity implies the possibility of performing tonotonic correction. Unclear pronounced decerebration and decortication symptoms imply the possibility of holding massage sessions with elements of therapeutic gymnastics. The presence of a positive emotional response dictates the need for defectological occupations in order to develop perceptions and the emotional sphere (including the prevention of deprivation changes). Conducted kinezdiagnostika. Revealed posture, the least provoking dystonic attacks. In the process of doing kinesitherapy fixed. A course of relaxing massage aimed at reducing muscular excitability. The condition of the child has improved. In the chosen position, the frequency and severity of dystonic attacks during the day significantly decreased.

Example 4

Child M., age 2 years 9 months. Diagnosis: the effects of perinatal hypoxic-traumatic lesions of the central nervous system, cerebral palsy, double hemiplegia, occlusive hydrocephalus, the state after surgery of ventriculoperitoneal shunting from 04.2017, symptomatic epilepsy.

In clinical status, the absence of decerebration and decorticating rigidity. Minimum voluntary motor activity (compresses a finger, smiles). Fixation of speech. These changes indicate the presence of differentiated reactivity to external stimuli, the possibility of the formation of positive emotions to a positively perceived external stimulus. Score on the scale of GTP (0), YES (2), PF (7). Regarding habilitation prospects, the following can be pointed out: the presence of emotional reactivity to visual and auditory stimuli implies the possibility of conducting defectological studies aimed at developing the emotional sphere and perception. The absence of persistent tonic phenomena makes it possible to conduct massage and therapeutic exercises as a motor and sensory stimulating effect.

The child underwent medical gymnastics with the use of passive movements, massage of the upper and lower extremities in order to reduce the severity of muscle hypertonia, correctional exercises with staff aimed at expanding voluntary motor activity and achieving emotionally significant contact. Against the background of exposure for three weeks, the expansion of the voluntary motor capabilities of the right upper limb with the participation of the muscles of the forearm and hand was noted, the emotional reactions became richer, and initial signs of smoking appeared.

Thus, by assessing unconditioned reflex, spontaneous and voluntary motor activity, reactivity to external stimuli and mental functions, according to the method developed, determine the level of the motor and mental development of the child. The assessment is carried out according to specially developed criteria, which can be presented in a form that is easy to fill and implies fixation with assignment of a specific score to specifically prescribed clinical phenomena, the assessment of which is available to a pediatrician of average qualification and is included in the range of knowledge defined by the primary vocational training program. The application of the proposed method allows to adequately assess the level of motor and mental development of children with severe perinatal brain lesions, assign it to one of three groups in terms of development, and in accordance with the group, make an adequate appointment of measures that ensure a proper existence even in palliative status, and to determine the volume of objectively shown abilitation measures.

Claims (36)

The method for determining the abilitation potential in children with severe perinatal brain lesions, including an assessment of a complex of signs in points characterizing the following groups: - generalized tonic phenomena (GTP); - the level of involuntary and minimal voluntary motor activity (YES); - the level of reactivity to external stimuli, emotional reactions and arbitrary sounds that characterize mental functions (PF); while for each group determine the value of the score corresponding to the characteristic characterizing the state of the child, where, as signs of GTP, the following signs are evaluated, in points: full decerebration rigidity (-five) separate elements of decerebration rigidity (-four) complete decortication rigidity (-3) separate elements of decortication rigidity (-2) presence of dystonic attacks (-one), as signs of YES evaluate the following signs, in points: total immobility (-five) reflex movements that are caused only within motor reflexes (-four) involuntary physical activity non-reflex nature (-3) minimal random activity (3) as signs of PF estimate the following signs for each of the subgroups, in points: - visual reaction to the light source, with the exception of the pupillary reflex, in the absence of amaurosis in the form of: no reaction (-3) undifferentiated motor activity (-one) fixing the gaze of any duration (one) gaze tracking of any duration (2) - visual response to the visual image in the absence of amaurosis in the form of: no reaction (0) fixing the gaze of any duration (3) gaze tracking of any duration (four), - reaction to the speech in the absence of hearing impairment in the form of: no reaction (-2) undifferentiated motor activity (-one) fixing the gaze on speech (2) - emotional reactions in the form of: lack of emotion (-one) negative emotions in the absence of visible signs of consciousness (for example, as a moan) (0) negative emotions in a child is conscious (2) positive emotions (for example, in the form of a smile) (3) - arbitrary sounds in the form: lack of arbitrary sounds (0) the presence of arbitrary sounds for any severity (3) at the same time, for the group of GTP, one or two signs are detected at one time, and when two signs are found that characterize the presence of dystonic attacks in combination with any of the remaining signs, the total value of points for the identified signs is used for assessment, for the group YES, only one sign is determined at a time, for the group PF, only one feature from each subgroup is simultaneously determined, and in the case of a combination: values of traits evaluated in the GTP group are less than (-3) points, negative values in the group YES, negative values for all subgroups of the PF group, make a conclusion about the child’s full reactivity and lack of habilitation potential, in which the habilitation measures are not shown; negative values of the estimated traits in the GTP group are more than (-3) points, the values of the trait in the YES group (-3) or (3) points, positive values of the estimated signs in one of the subgroups of the PF group, It is concluded that the child has a reflex-type reactivity and that he has an abilitation potential, at which abilitation measures with sensory load are shown; the values of the trait in the GTP group (-1) point, the values of the trait in the YES group (3) points, positive values of the evaluated signs in at least two subgroups of the PF group, make a conclusion about the presence of a child's reactivity with signs of initial development of mental functions and the availability of habilitation potential, at which habilitation measures are shown taking into account the existing disorders in the child.