АБИЛИТАЦИЯ КОГНИТИВНОГО РАЗВИТИЯ, ПОВЕДЕНИЯ И РЕЧИ У ДЕТЕЙ С ПЕРИНАТАЛЬНЫМ ПОРАЖЕНИЕМ МОЗГА

Белоусова М.В.¹, Уткузова М.А.², Рутенбург Д.Г.³

¹Кандидат медицинский наук, Доцент, КГМА-филиал ФГБОУ ДПО РМАНПО Минздрава России, ²Кандидат медицинский наук, Доцент, КГМА-филиал ФГБОУ ДПО РМАНПО Минздрава России, ³Доктор медицинских наук, Профессор, Институт Остеопатической Медицины им. В.Л.Андрианова

АБИЛИТАЦИЯ КОГНИТИВНОГО РАЗВИТИЯ, ПОВЕДЕНИЯ И РЕЧИ У ДЕТЕЙ С ПЕРИНАТАЛЬНЫМ ПОРАЖЕНИЕМ МОЗГА

Аннотация

В статье содержится информация о структурно-функциональной модели мозга, предложенной А.Р.Лурия, приведены анатомические структуры, входящие в состав трех основных блоков мозга и контролируемые ими функции. Для каждого структурно-функционального блока приведены приемы воздействия и упражнения, способствующие стимуляции работы мозговых структур, входящих в состав этого блока.

В статье рассмотрены патогенетически и онтогенетически обусловленные подходы к составлению программ абилитации когнитивных и речевых функций и поведения для детей с перинатальным поражением мозга, содержащих традиционные методы реабилитации и современные технологии, в соответствии с классическими представлениями об интегративной деятельности головного мозга в рамках структурно-функциональной концепции А.Р.Лурия. Рассмотрены возможности применения остеопатической коррекции, интегративно влияющей на все блоки мозга, в организации комплексной медико-коррекционной помощи детям.

Ключевые слова: абилитация, перинатальное поражение мозга, структура инвалидности, когнитивное и речевое развитие, нарушения речи, поведение, структурно-функциональная модель А.Р.Лурия.

Belousova M.V.¹, Utkuzova M.A.², Rutenburg D.G.³

¹MD, PhD, associate professor, Kazan State Medical Academy - branch of the FGBOU DPO RMANPO of the Ministry of Health of Russia, ²MD, PhD, associate professor, Kazan State Medical Academy - branch of the FGBOU DPO RMANPO of the Ministry of Health of Russia, ³MD, Phd, professor, Institute of Osteopathic Medicine

ABILITATION OF COGNITIVE DEVELOPMENT, BEHAVIOUR AND SPEECH OF CHILDREN WITH PERINATAL BRAIN INJURY

Abstract

The article contains information on the structurally - functional model of the brain, proposed by AR Luria, the anatomical structures that are part of the three main brain blocks and the functions controlled by them are given. For each structurally functional block the methods of influence and exercise promoting stimulation of work of the brain structures which are a part of this block are given.

This article presents pathogenetic and ontogenetic conditional approaches to programming of habilitation of cognitive and speech functions and behavior for children with perinatal brain injury containing traditional methods of rehabilitation and modern technologies according with classical concepts of integrative brain activity in the framework of structural and functional concept by Lyria A.R. The possibilities of use of the osteopathic correction influencing all blocks of a brain in the organization of the complex medico-correctional help to children are considered.

Keywords: rehabilitation, perinatal brain injury, structure of disability, cognitive and speech development, speech disturbance, behavior, structural and functional model by Lyria A.R.

Introduction

Of late years native pediatric service has significantly improved its indices, according to figures from Minister of Health of Russian Federation Skvortsova V.I. infant mortality has declined to 6.5 per 1,000 live births in 2015, which is 24% fewer in comparison with 2012.More than 20 000 children were born with the help of modern technologies which is 9% more than in 2014 and is 56% more in comparison with 2012 [7].

At the same time there is a tendency to an increase of the total number of disabled children in Russian Federation in the last 10 years. So 540 837 disabled children were registered in Russian Federation in 2014 [4, P. 113]

The research of recent years indicate the stability of the structure of disability of children by nosological entity. The leading positions are occupied by nervous system diseases, psychosocial disabilities (more than 70% - mental retardation) and congenital anomaly, which makes more than 60% as a whole. Injuries of the central nervous system in the perinatal and in early postnatal period are the “indices” of the health condition of a child not only during the first year of life, but also in the age periods and require adequate, complex and timely habilitation [1, Р. 36], [2, Р. 9]. They are registered in 40-60% of infants, in 86.0% of cases they lead to neuropsychic dissociations, and in 36.0% of cases they lead to motor disturbance of varying severity, which requires timely functional diagnostics, correction and directional, adequate stimulation of psychomotor development of a child with perinatal brain injury.

For healthy growth of higher psychic and motor functions is required:

• integrity of the nervous system and age-appropriate morpho-functional maturity (including formedness of neuronal affinities, power supply of a system);
• being in demand of a psychic function from outside;
• adequacy and timeliness of external queries.

Just neurobiological maturity of subcortical, commissural, cortical complexes and its connections provide an opportunity to a child to adapt to the requirements of society, applicable to him in the process of development.

Structural and functional model by Lyria A.R characterizes general, system regularities of cerebration as organic whole and is the basis for an explanation of its integrative activity [5].

In the framework of this modelbrain isdivided into 3 structural and functional units:

I - power supply unit (unit of regulation of the brain activity level)

II – unit of reception, processing and storage of exteroceptive information

III - unit of behavior and actions programming, regulation and controlofpsychic activity flow.

For the purpose of each psychic function or complex form of conscious it requires the participation of all 3 units of the brain.

The first (I) unit consists of the following anatomic structures: reticular formation of brainstem, midbrain, diencephalic region, limbic system, mediobasal units of fronto-temporal lobes.

Virtually all brain structures of the I unit early mature in the process of filo- and ontogenesis because functions controlled by themhave vital necessityat birth of a child, these are the levels of closureof the majorityof inborn reflexes, directed to preservation of life in the new conditions.

The first unit performs:

• regulation of activation process and provision of general activation ground, support of the CNS tonus;
• energy provision of consciousness, attention, memory (imprinting, storage and information retrieval)
• control of the formation of motivational attitudes and emotional states
• the structures of the I unit perceive and process information from interoceptors and regulate the condition of the internal environment through neuro-hormonal mechanisms and are involved in the maintenance of homeostasis.

Stimulation of structures of the first functional unit is essential in the process of habilitation. The main purpose is:

• activating effect on the body's energy supply;
• formation and activation of the subcortical-cortical connections and interhemispheric interactions;
• improving the plasticity of sensomotor providing of psychical processes.

Methods of stimulation [6, Р. 110]:

• Body-oriented manipulations – massage (especially facial), exercises – “stretching”, correction of muscle dystonias and synkinesis, therapy of the pathologically fixed postural sets, body tonus optimization, relaxation training
• Oculomotor exercises
• respiratory maneuver – as the only body rhythm, dependent on conscious regulation
• Elaboration of base correlation of hands and feet – synergistic and reciprocal, activation of paired work of hemisphere and interhemispheric transfer on the base subcortical level.

The second functional unit (II) includes cortex of paleoencephalon – they are primary, secondary and tertiary fields of occipitalis, parietal and temporal units.

The second unit provides: modal-specific processes; complex integrative processing of exteroceptive information and accumulation of sensory experience.

It is necessary to use methods in the process of habilitation whereby it is possible to facilitate the development of functional maturity of cerebral structures, concerning to the II unit.

Purpose: functional specialization of paleoencephalon and interhemispheric correlations, for providing the functioning of psychological functions, overbuilding in ontogenesis over the earlier formed sensomotor foundation:

• Formation of visual attention (as releaser of motivation), visual gnosis, hand-eye coordination;
• Somatognosis, processing of tactual information;
• Spatial and quasi-spatial inferences (reclaim of solid space, external space, three-dimensional configurations, designing and copying, logical-grammatical speech constructs);
• Rate processes (dexterity, organization of motor action, graphical skills, sequence, range, time);
• Auditory vigilance, acoustic gnosis and phonetics-phonemic processes (sense of rhythm, differentiation of speech and nonspeach sounds, phonemic hearing)
• Mnestic processes (tactile and motor memory, visual and audio-verbal memory).

Montessory is used for development and stimulation of structures of the IInd functional unit – it is a material destined for the unit of sensor development [8, Р. 24]. The unit of sensor development purposefully widens and enriches spectrum of all modalities of a child’s perceptions:

• visual (form, size, color perception) – with the help of material for visual perception (pink tower, red bars, brown stairs, 4 units of cylinder, color tablets, figures);
• tactile – using rough boarding, fabrics;
• baric (sense of weight) – using weight boarding;
• acoustic (perception of nonspeach sounds): - noise cylinders, bells;
• thermal (perception of temperature) – using thermal cylinders and boarding;
• gustatory – using flacons;
• olfactory – using olfactory cylinders;
• stereognostic perception – using appropriate material: geometrical objects, exercises for assortment, mysterious pouch, constructive triangles, binomial and trinomny cubes, botanic commode, overlapping figures.

A child studding with developing material and learning sensor peculiarities of objects – their length, width, form, flavors, weight and so on, should solidify a sensor experience through the word. So clear words come to his life – definitions of objects and their qualities, which will help a child to create intellectual foundation and strengthen his social competence. An important premise of the brain building development of a child is an ability to compare objects with their qualities. During exercises of this unit a child not only learns to classify objects by the size, form, color, temperature, rough degree, weight, but also thins his feelings, for example, in exercises of matchmaking or during analysis of an object by degree of its evidence. Work with sensor material (indirectly through mechanisms of materialize abstraction, by systemization of material quality) induces to stimulate actively the processes of nomination and hereafter logical thinking.

Accumulative sensor experience by a child is a foundation of his further intellectual development, as it forms multiway visions about objects of the world around. A child sequentially goes from the feelings which his sense organs perceive to the formation of visions, memorizing, analysis and thinking.

The IIIrd functional unit is the latest in filo- and ontogenetic context. It includes motor, premotor, prefrontal units of cortex of frontal lobe of the brain – located forward the front central gyrus.

Function of the III unit is:

• action program composition, directed to the achievement of intended effect
• recording and integration of actually acting signals and formation of active behavior directed to the future
• tactic and strategic goal-setting by means of consolidation of information received from different units and forming-up in priority ranked system of goals, each of which is realized in the process of behavior act.

The goal of habilitation is a formation of sense-making functions of psychical processes and development of voluntary self-regulation of behavior and activity:

• Attention skill formation
• Programming, goal-setting and control (through the introduction of rules (in game and social cooperation), by roles)
• Communication skills development
• Understanding of cause-effect relations and sequences
• Voluntary attention formation
• Multiple meaning and concept hierarchy
• Punishment and encouragement contributory to formation of variative behavior.

Concerning the structures of all three functional units the methods of osteopathic correction are indicated and effective. By being a self-consistent medicine specialty, osteopathy considers the human body in unity its mechanical, hydrodynamic and nervous functions and searches dysfunctions of macro and micromotion of human tissues which cause functional injuries influenced the body altogether [3, Р. 12]. For direct and mediated influence on the structures of brain are used: peculiarly cranial technics (work on cranial sutures, on interseptums of  mutual intention, decompression of sphenobasilar synchondrosis, work on brain structures) and structural technics, “addressed” first of all to boned - ligamentous apparatus, musculofascial structures (soft-tissued, articulation, muscular energy technics by F. Mitchel, trusts, fascial technics, balanced ligamentous tesion) and visceral technic (specified work, directed on harmonization of mobility and motility of internals).

Successfulness of cognitive, speech and motor development of a child is due by two interrelated processes: 1) system-dynamic rebuilding of brain organization and 2) structure change of each psychical function conditional by its speech mediation and widening of communications with world.

Therefore, based on principles of structural and functional concept by Lyria A.R in the construction of rehabilitation programs for children with perinatal brain injury, it is possible to stimulate ontogenetic mediated three units in their consistent, inextricable connection, - for providing adequate cognitive, motor and speech development and voluntary of behavior and activity.

Список литературы / References

1. Батышева Т.Т., Климов Ю.А., Ромашкова Д.М. Анализ перинатальной патологии нервной системы у детей первого года жизни, требующей стационарного лечения. / Сборник материалов Балтийского конгресса по детской неврологии – Санкт-Петербург, 2015. - С. 35 – 37.
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Список литературы на английском языке / References in English

1. Batysheva T. T., Klimov Yu. A., Romashkova D. M. The analysis of perinatal pathology of nervous system at children of the first year of the life requiring hospitalization. / The collection of materials of the Baltic congress on children's neurology – St. Petersburg, 2015. – p. 35 – 37.
2. Batysheva T. T., Lilyin E. T., Bykovo O.V., Glazkov S. V. Problems of modern rehabilitation "Children's and teenage rehabilitation" No. 1 (22) 2014, p. 8-12.
3. Egorova I. A., Mikhaylova E. S. Kranial osteopathy. A management for doctors the 2nd prod. – SPb: "Publishing house SPbMAPO", 2013. – 500 p.
4. Lavrova D. I. Dynamics of disability of the children's population of the Russian Federation//Science and world. – 2015. - No. 9(25). – p. 113-114.
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6. Semenovich A. V. Neuropsychological correction at children's age. Method of replacement ontogenesis. M.: Genesis, 2012. – 474 p.
7. Skvortsova V. I. Speech of the Minister of Health of the Russian Federation Skvortsova V. I. at the enlarged meeting of Board of the Russian Ministry of Health – [An electronic resource] - the access mode: http://www.rosminzdrav.ru/news/2016/04/20/2903 (date of the address 7.07.2016)
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