In addition to speech symptoms, other changes are observed in children with neurological pathologies. Synkinesia in speech therapy is involuntary movements accompanying voluntary ones. For example, when the tongue is raised, the upper lip rises.
Similar phenomena can be observed not only in articulatory motor skills, but also in skeletal muscles. Especially in the areas associated with the speech centers of the cerebral cortex. Sometimes during a conversation a child moves his fingers, although this is not necessary - this is synkinesis. Such involuntary movements are one of the signs of complex speech disorders.
Kinds
There are several types of involuntary accompanying movements that can occur in people with speech disorders.
- Synkinesia of facial muscles. The cause of their occurrence is pathology of the facial nerve. Muscle tension occurs, leading to involuntary contraction. This pathology appears not only at the moment of speech, but also during movements in which the facial muscles are involved (chewing, blinking, etc.).
- Oral synkinesis can be observed in infants. This is a normal phenomenon that goes away by the end of the 3rd month of life. But if they persist, they can have a detrimental effect on the formation of articulatory motor skills, which will lead to impaired sound pronunciation.
- Pathological synkinesis is a reflection of the actions of a healthy limb. For example, when you raise your right leg, your left leg involuntarily rises. Or, during speech, a leg or arm twitching occurs.
Synkinesis often accompanies dysarthric disorders, especially when a person experiences strong psycho-emotional stress. Articulatory motor skills are impaired, and sometimes hypersalivation (excessive drooling) appears.
When diagnosing, a speech therapist notes the presence of tremor (shaking) of the tongue, disruption of the facial muscles, and involuntary movements of the lower jaw. Corrective work on overcoming synkinesis in speech therapy is carried out in parallel with other types of work for speech disorders.
All forms of dysarthria are characterized by disturbances in articulatory motor skills, which are manifested by a number of signs. Muscle tone disorders, the nature of which depends primarily on the location of the brain lesion. The following forms of it in the articulatory muscles are distinguished: spasticity of the articulatory muscles - a constant increase in tone in the muscles of the tongue, lips, facial and cervical muscles. The increase in muscle tone may be more local and spread only to individual muscles of the tongue.
With a pronounced increase in muscle tone, the tongue is tense, pulled back, its back is curved, raised upward, the tip of the tongue is not pronounced. The tense back of the tongue, raised towards the hard palate, helps soften consonant sounds. Therefore, a feature of articulation with spasticity of the tongue muscles is palatalization, which can contribute to phonemic underdevelopment. So, pronouncing the words ardor
and
dust, mole
and
moth,
a child may find it difficult to differentiate their meanings.
An increase in muscle tone in the orbicularis oris muscle leads to spastic tension of the lips and tight closure of the mouth. Active movements are limited. The inability or limitation of the forward movement of the tongue may be associated with spasticity of the genioglossus, mylohyoid and digastric muscles, as well as the muscles attached to the hyoid bone.
All muscles of the tongue are innervated by the hypoglossal nerves, with the exception of the glossopalatine muscles, which are innervated by the glossopharyngeal nerves.
An increase in muscle tone in the muscles of the face and neck further limits voluntary movements in the articulatory apparatus.
The next type of muscle tone disorder is hypotension. With hypotonia, the tongue is thin, spread out in the oral cavity, the lips are flaccid, and there is no possibility of their complete closure. Because of this, the mouth is usually half-open and hypersalivation is pronounced.
A feature of articulation in hypotonia is nasalization, when hypotonia of the muscles of the soft palate prevents the velum from moving sufficiently upward and pressing it against the posterior wall of the pharynx. The air stream comes out through the nose, and the air stream out through the mouth is extremely weak. The pronunciation of labiolabial stop noisy consonants p, p, b, b is impaired.
Palatalization is difficult, and therefore the pronunciation of voiceless stop consonants is impaired; in addition, the formation of voiceless stops requires more energetic lip work, which is also absent in hypotonia.
The labio-labial occlusive nasal sonatas m, m are easier to pronounce, as well
as the labio-dental fricative noisy consonants, the articulation of which requires loose closure of the lower lip with the upper teeth and the formation of a flat gap,
f, f, v, v.
Etiology
Previously, doctors and speech therapists believed that it was impossible to cope with this pathology. It was believed that the cause was an irreversible disruption of the innervation of the facial nerve. But further research and clarification of the definition showed that the etiology of synkinesias is extensive, and accordingly, methods can be selected to overcome them. Causes:
- Disorders of the central nervous system (CNS).
- Disorders of the cerebral cortex (CGM).
- Violations of general muscle tone.
- Dysarthria.
- Pathological reflexes.
- Suffered a stroke.
- Improper functioning of facial muscles.
- Traumatic brain injuries.
All of these reasons are serious and require medical knowledge to choose the right treatment. Therefore, children with a history of synkinesis are provided with comprehensive care, including medical care. This increases the efficiency of correction work.
Tics in children
Tics, or hyperkinesis, are repeated, unexpected short stereotypical movements or statements that are superficially similar to voluntary actions. A characteristic feature of tics is their involuntary nature, but in most cases the patient can reproduce or partially control his own hyperkinesis. With a normal level of intellectual development in children, the disease is often accompanied by cognitive impairment, motor stereotypies and anxiety disorders.
The prevalence of tics reaches approximately 20% in the population.
There is still no consensus on the occurrence of tics. The decisive role in the etiology of the disease is given to the subcortical nuclei - the caudate nucleus, globus pallidus, subthalamic nucleus, and substantia nigra. Subcortical structures interact closely with the reticular formation, thalamus, limbic system, cerebellar hemispheres and the frontal cortex of the dominant hemisphere. The activity of subcortical structures and frontal lobes is regulated by the neurotransmitter dopamine. Insufficiency of the dopaminergic system leads to disturbances of attention, lack of self-regulation and behavioral inhibition, decreased control of motor activity and the appearance of excessive, uncontrolled movements.
The effectiveness of the dopaminergic system can be affected by intrauterine developmental disorders due to hypoxia, infection, birth trauma, or hereditary deficiency of dopamine metabolism. There are indications of an autosomal dominant type of inheritance; However, it is known that boys suffer from tics approximately 3 times more often than girls. Perhaps we are talking about cases of incomplete and sex-dependent penetration of the gene.
In most cases, the first appearance of tics in children is preceded by external unfavorable factors. Up to 64% of tics in children are provoked by stressful situations - school maladjustment, extracurricular activities, uncontrolled watching of TV shows or prolonged work on the computer, conflicts in the family and separation from one of the parents, hospitalization.
Simple motor tics can be observed in the long-term period of a traumatic brain injury. Vocal tics - coughing, sniffing, expectorating throat sounds - are often found in children who often suffer from respiratory infections (bronchitis, tonsillitis, rhinitis).
In most patients, there is a diurnal and seasonal dependence of tics - they intensify in the evening and become aggravated in the autumn-winter period.
A separate type of hyperkinesis includes tics that arise as a result of involuntary imitation in some highly suggestible and impressionable children. This happens in the process of direct communication and under the condition of a certain authority of the child with tics among his peers. Such tics go away on their own some time after the cessation of communication, but in some cases such imitation is the debut of the disease.
Clinical classification of tics in children
By etiology
Primary, or hereditary, including Tourette's syndrome. The main type of inheritance is autosomal dominant with varying degrees of penetration; sporadic cases of the disease are possible.
Secondary or organic. Risk factors: anemia in pregnant women, maternal age over 30 years, fetal malnutrition, prematurity, birth trauma, previous brain injuries.
Cryptogenic. They occur against the background of complete health in a third of patients with tics.
According to clinical manifestations
Local (facial) tic. Hyperkinesis affects one muscle group, mainly facial muscles; frequent blinking, squinting, twitching of the corners of the mouth and wings of the nose predominate (Table 1). Blinking is the most persistent of all local tic disorders. Closed eyes are characterized by a more pronounced disturbance of tone (dystonic component). Movements of the wings of the nose, as a rule, are associated with rapid blinking and are among the unstable symptoms of facial tics. Single facial tics practically do not interfere with patients and in most cases are not noticed by the patients themselves.
| Table 1 Types of motor tics (V.V. Zykov) |
Common tic. Several muscle groups are involved in hyperkinesis: facial muscles, muscles of the head and neck, shoulder girdle, upper limbs, abdominal and back muscles. In most patients, a common tic begins with blinking, which is accompanied by opening the gaze, turning and tilting the head, and lifting the shoulders. During periods of exacerbation of tics, schoolchildren may have problems completing written assignments.
Vocal tics. There are simple and complex vocal tics.
The clinical picture of simple vocal tics is represented mainly by low sounds: coughing, “clearing the throat,” grunting, noisy breathing, sniffing. Less common are high-pitched sounds such as “i”, “a”, “oo-u”, “uf”, “af”, “ay”, squealing and whistling. With an exacerbation of tic hyperkinesis, vocal phenomena may change, for example, coughing turns into grunting or noisy breathing.
Complex vocal tics are observed in 6% of patients with Tourette syndrome and are characterized by the pronunciation of individual words, swearing (coprolalia), repetition of words (echolalia), and rapid, uneven, unintelligible speech (palilalia). Echolalia is an intermittent symptom and may occur over several weeks or months. Coprolalia usually represents a status condition in the form of serial utterance of swear words. Often, coprolalia significantly limits the child’s social activity, depriving him of the opportunity to attend school or public places. Palilalia is manifested by obsessive repetition of the last word in a sentence.
Generalized tic (Tourette's syndrome). Manifests itself as a combination of common motor and vocal simple and complex tics.
Table 1 presents the main types of motor tics depending on their prevalence and clinical manifestations.
As can be seen from the table presented, as the clinical picture of hyperkinesis becomes more complex, from local to generalized, tics spread from top to bottom. Thus, with a local tic, violent movements are noted in the facial muscles; with a widespread tic, they move to the neck and arms; with a generalized tic, the torso and legs are involved in the process. Blinking occurs with equal frequency in all types of tics.
According to the severity of the clinical picture
The severity of the clinical picture is assessed by the number of hyperkinesis in the child during 20 minutes of observation. In this case, tics can be absent, single, serial or status. Severity assessment is used to standardize the clinical picture and determine the effectiveness of treatment.
With single tics, their number during 20 minutes of examination ranges from 2 to 9; they are more common in patients with local forms and in remission in patients with widespread tics and Tourette's syndrome.
With serial tics, during a 20-minute examination, from 10 to 29 hyperkinesis are observed, after which many hours of breaks occur. A similar picture is typical during exacerbation of the disease and occurs in any localization of hyperkinesis.
With tic status, serial tics follow with a frequency of 30 to 120 or more per 20 minutes of examination without a break during the day.
Similar to motor tics, vocal tics can also be single, serial and status, intensifying in the evening, after emotional stress and overwork.
According to the course of the disease
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), there are transient tics, chronic tics and Tourette's syndrome.
A transient , or transient , course of tics implies the presence of motor or vocal tics in a child with complete disappearance of symptoms of the disease within 1 year. Characteristic of local and widespread tics.
Chronic tic disorder is characterized by motor tics lasting more than 1 year without a vocal component. Chronic vocal tics in isolated form are rare. There are remitting, stationary and progressive subtypes of the course of chronic tics.
In a remitting course, periods of exacerbation are replaced by complete regression of symptoms or the presence of local single tics that occur against the background of intense emotional or intellectual stress. The relapsing-remitting subtype is the main variant of the course of tics. With local and widespread tics, exacerbation lasts from several weeks to 3 months, remissions last from 2–6 months to a year, in rare cases up to 5–6 years. With drug treatment, complete or incomplete remission of hyperkinesis is possible.
The stationary type of the disease is determined by the presence of persistent hyperkinesis in various muscle groups, which persist for 2–3 years.
The progressive course is characterized by the absence of remissions, the transition of local tics to widespread or generalized ones, the complication of stereotypes and rituals, the development of tic status, and resistance to therapy. A progressive course predominates in boys with hereditary tics. Unfavorable signs are the presence of aggressiveness, coprolalia, and obsessions in the child.
There is a relationship between the localization of tics and the course of the disease. Thus, a local tic is characterized by a transient-remitting type of course, a widespread tic is characterized by a remitting-stationary type, and Tourette's syndrome is characterized by a remitting-progressive type.
Age dynamics of tics
Most often, tics appear in children aged 2 to 17 years, the average age is 6–7 years, the frequency of occurrence in the pediatric population is 6–10%. Most children (96%) develop tics before age 11. The most common manifestation of a tic is blinking the eyes. At the age of 8–10 years, vocal tics appear, which account for approximately a third of the cases of all tics in children and occur both independently and against the background of motor ones. Most often, the initial manifestations of vocal tics are sniffing and coughing. The disease is characterized by an increasing course with a peak of manifestations at 10–12 years, then a decrease in symptoms is noted. By age 18, approximately 50% of patients become free of tics spontaneously. At the same time, there is no relationship between the severity of the manifestation of tics in childhood and in adulthood, but in most cases in adults the manifestations of hyperkinesis are less pronounced. Sometimes tics first appear in adults, but they are characterized by a milder course and usually last no more than 1 year.
The prognosis for local tics is favorable in 90% of cases. In the case of common tics, 50% of children experience complete regression of symptoms.
Tourette's syndrome
The most severe form of hyperkinesis in children is, without a doubt, Tourette's syndrome. Its frequency is 1 case per 1,000 children in boys and 1 in 10,000 in girls. The syndrome was first described by Gilles de la Tourette in 1882 as a “disease of multiple tics.” The clinical picture includes motor and vocal tics, attention deficit disorder, and obsessive-compulsive disorder. The syndrome is inherited with high penetrability in an autosomal dominant manner, and in boys, tics are more often combined with attention deficit hyperactivity disorder, and in girls - with obsessive-compulsive disorder.
The currently generally accepted criteria for Tourette's syndrome are those given in the DSM III revision classification. Let's list them.
- A combination of motor and vocal tics that occur simultaneously or at different intervals.
- Repeated tics throughout the day (usually in series).
- The location, number, frequency, complexity and severity of tics changes over time.
- The onset of the disease is before 18 years of age, duration is more than 1 year.
- Symptoms of the disease are not associated with the use of psychotropic drugs or central nervous system disease (Huntington's chorea, viral encephalitis, systemic diseases).
The clinical picture of Tourette's syndrome depends on the age of the patient. Knowledge of the basic patterns of disease development helps to choose the right treatment tactics.
The onset of the disease develops at 3–7 years. The first symptoms are local facial tics and shoulder twitching. Then hyperkinesis spreads to the upper and lower extremities, shuddering and turning of the head, flexion and extension of the hand and fingers, throwing the head back, contraction of the abdominal muscles, jumping and squats appear, one type of tics is replaced by another. Vocal tics often join motor symptoms for several years after the onset of the disease and intensify during the acute stage. In a number of patients, vocalisms are the first manifestations of Tourette's syndrome, which are subsequently joined by motor hyperkinesis.
Generalization of tic hyperkinesis occurs over a period lasting from several months to 4 years. At the age of 8–11 years, children experience a peak in clinical manifestations of symptoms in the form of a series of hyperkinesis or repeated hyperkinetic states in combination with ritual actions and auto-aggression. The tic status in Tourette's syndrome characterizes a severe hyperkinetic state. A series of hyperkinesis is characterized by the replacement of motor tics with vocal ones, followed by the appearance of ritual movements. Patients note discomfort from excessive movements, for example, pain in the cervical spine that occurs when turning the head. The most severe hyperkinesis is a throwing back of the head - in this case, the patient can repeatedly hit the back of the head against the wall, often in combination with simultaneous clonic twitching of the arms and legs and the appearance of muscle pain in the extremities. The duration of status tics ranges from several days to several weeks. In some cases, exclusively motor or predominantly vocal tics are noted (coprolalia). During status tics, consciousness in children is completely preserved, but hyperkinesis is not controlled by patients. During exacerbations of the disease, children cannot attend school and self-care becomes difficult for them. It is characterized by a remitting course with exacerbations lasting from 2 to 12–14 months and incomplete remissions from several weeks to 2–3 months. The duration of exacerbations and remissions is directly dependent on the severity of tics.
In most patients, at the age of 12–15 years, generalized hyperkinesis goes into a residual phase , manifested by local or widespread tics. In a third of patients with Tourette's syndrome without obsessive-compulsive disorders in the residual stage, a complete cessation of tics is observed, which can be considered as an age-dependent infantile form of the disease.
Comorbidity of tics in children
Tics often occur in children with pre-existing central nervous system (CNS) conditions, such as attention deficit hyperactivity disorder (ADHD), cerebrasthenic syndrome, and anxiety disorders including generalized anxiety disorder, specific phobias, and obsessive-compulsive disorder.
About 11% of children with ADHD have tics. Mostly these are simple motor and vocal tics with a chronic recurrent course and a favorable prognosis. In some cases, the differential diagnosis between ADHD and Tourette's syndrome is difficult when hyperactivity and impulsivity appear in a child before the development of hyperkinesis.
In children suffering from generalized anxiety disorder or specific phobias, tics can be provoked or intensified by worries and worries, unusual surroundings, prolonged anticipation of an event and a concomitant increase in psycho-emotional stress.
In children with obsessive-compulsive disorder, vocal and motor tics are combined with compulsive repetition of a movement or activity. Apparently, in children with anxiety disorders, tics are an additional, albeit pathological, form of psychomotor discharge, a way of calming and “processing” accumulated internal discomfort.
Cerebrasthenic syndrome in childhood is a consequence of traumatic brain injuries or neuroinfections. The appearance or intensification of tics in children with cerebrasthenic syndrome is often provoked by external factors: heat, stuffiness, changes in barometric pressure. Typically, tics increase with fatigue, after long-term or repeated somatic and infectious diseases, and increased educational loads.
Let us present our own data. Of the 52 children who complained of tics, there were 44 boys and 7 girls; the ratio “boys: girls” was “6:1” (Table 2).
| Table 2 Distribution of children with tics by age and gender |
So, the largest number of calls for tics was observed in boys aged 5–10 years, with a peak at 7–8 years. The clinical picture of tics is presented in Table. 3.
| Table 3 Types of tics in group patients |
Thus, simple motor tics with localization mainly in the muscles of the face and neck and simple vocal tics imitating physiological actions (coughing, expectoration) were most often observed. Jumping and complex vocal expressions were much less common - only in children with Tourette syndrome.
Temporary (transient) tics lasting less than 1 year were observed more often than chronic (remitting or stationary) tics. Tourette's syndrome (chronic stationary generalized tic) was observed in 7 children (5 boys and 2 girls) (Table 4).
| Table 4 Distribution of patients by type of treatment for tics |
Treatment
The main principle of treatment for tics in children is an integrated and differentiated approach to treatment. Before prescribing medication or other therapy, it is necessary to find out the possible causes of the disease and discuss methods of pedagogical correction with parents. It is necessary to explain the involuntary nature of hyperkinesis, the impossibility of controlling them by willpower and, as a consequence of this, the inadmissibility of comments to a child about tics. Often the severity of tics decreases when the demands on the child from the parents are reduced, attention is not focused on his shortcomings, and his personality is perceived as a whole, without isolating “good” and “bad” qualities. Streamlining the regimen and playing sports, especially in the fresh air, have a therapeutic effect. If induced tics are suspected, the help of a psychotherapist is necessary, since such hyperkinesis can be relieved by suggestion.
When deciding whether to prescribe drug treatment, it is necessary to take into account factors such as etiology, age of the patient, severity and severity of tics, their nature, and concomitant diseases. Drug treatment must be carried out for severe, pronounced, persistent tics, combined with behavioral disorders, poor performance at school, affecting the child’s well-being, complicating his adaptation in the team, limiting his opportunities for self-realization. Drug therapy should not be prescribed if the tics only bother the parents but do not interfere with the child's normal activities.
The main group of drugs prescribed for tics are antipsychotics: haloperidol, pimozide, fluphenazine, tiapride, risperidone. Their effectiveness in the treatment of hyperkinesis reaches 80%. The drugs have analgesic, anticonvulsant, antihistamine, antiemetic, neuroleptic, antipsychotic, and sedative effects. The mechanisms of their action include blockade of postsynaptic dopaminergic receptors of the limbic system, hypothalamus, trigger zone of the gag reflex, extrapyramidal system, inhibition of the reuptake of dopamine by the presynaptic membrane and subsequent deposition, as well as blockade of adrenergic receptors of the reticular formation of the brain. Side effects: headache, drowsiness, difficulty concentrating, dry mouth, increased appetite, agitation, restlessness, anxiety, fear. With prolonged use, extrapyramidal disorders may develop, including increased muscle tone, tremor, and akinesia.
Haloperidol: the initial dose is 0.5 mg at night, then it is increased by 0.5 mg per week until a therapeutic effect is achieved (1-3 mg/day in 2 divided doses).
Pimozide (Orap) is comparable in effectiveness to haloperidol, but has fewer side effects. The initial dose is 2 mg/day in 2 divided doses; if necessary, the dose is increased by 2 mg per week, but not higher than 10 mg/day.
Fluphenazine is prescribed at a dose of 1 mg/day, then the dose is increased by 1 mg per week to 2–6 mg/day.
Risperidone belongs to the group of atypical antipsychotics. Risperidone is known to be effective for tics and related behavioral disorders, especially those of an oppositional defiant nature. The initial dose is 0.5–1 mg/day with a gradual increase until positive dynamics are achieved.
Tiaprid (Tiapridal): children 7–12 years old are recommended 50 mg (1/2 tablet) 1–2 times a day.
When choosing a drug to treat a child with tics, you should consider the dosage form that is most convenient for dosing. Optimal for titration and subsequent treatment in childhood are drop forms (haloperidol, risperidone), which allow you to most accurately select a maintenance dose and avoid an unjustified overdose of the drug, which is especially important when carrying out long courses of treatment. Preference is also given to drugs with a relatively low risk of side effects (risperidone, tiapride).
Metoclopramide (Reglan, Cerucal) is a specific blocker of dopamine and serotonin receptors in the trigger zone of the brain stem. For Tourette's syndrome in children, it is used in a dose of 5–10 mg per day (1/2–1 tablet), in 2–3 doses. Side effects include extrapyramidal disorders that occur when the dose exceeds 0.5 mg/kg/day.
In recent years, valproic acid preparations have been used to treat hyperkinesis. The main mechanism of action of valproate is to enhance the synthesis and release of γ-aminobutyric acid, which is an inhibitory neurotransmitter of the central nervous system. Valproates are the first choice drugs in the treatment of epilepsy, but their thymoleptic effect, manifested in a decrease in hyperactivity, aggressiveness, irritability, as well as a positive effect on the severity of hyperkinesis, is of interest. The therapeutic dose recommended for the treatment of hyperkinesis is significantly lower than for the treatment of epilepsy and is 20 mg/kg/day. Side effects include drowsiness, weight gain, and hair loss.
When hyperkinesis is combined with obsessive-compulsive disorder, antidepressants - clomipramine, fluoxetine - have a positive effect.
Clomipramine (Anafranil, Clominal, Clofranil) is a tricyclic antidepressant whose mechanism of action is inhibition of the reuptake of norepinephrine and serotonin. The recommended dose for children with tics is 3 mg/kg/day. Side effects include transient visual disturbances, dry mouth, nausea, urinary retention, headache, dizziness, insomnia, excitability, extrapyramidal disorders.
Fluoxetine (Prozac) is an antidepressant, a selective serotonin reuptake inhibitor with low activity in relation to the norepinephrine and dopaminergic systems of the brain. In children with Tourette's syndrome, it effectively eliminates restlessness, anxiety, and fear. The initial dose in childhood is 5 mg/day once a day, the effective dose is 10–20 mg/day once in the morning. The drug is generally well tolerated, side effects are relatively rare. Among them, the most significant are anxiety, sleep disturbances, asthenic syndrome, sweating, and weight loss. The drug is also effective in combination with pimozide.
Literature
- Zavadenko N. N. Hyperactivity and attention deficit in childhood. M.: ACADEMA, 2005.
- Mash E., Wolf D. Child mental disorders. SPb.: Prime EUROZNAK; M.: OLMA PRESS, 2003.
- Omelyanenko A., Evtushenko O. S., Kutyakova et al. // International Neurological Journal. Donetsk. 2006. No. 3(7). pp. 81-82.
- Petrukhin A. S. Neurology of childhood. M.: Medicine, 2004.
- Fenichel J.M. Pediatric neurology. Fundamentals of clinical diagnosis. M.: Medicine, 2004.
- L. Bradley, Schlaggar, Jonathan W. Mink. Movement // Disorders in Children Pediatrics in Review. 2003; 24(2).
N. Yu. Suvorinova , Candidate of Medical Sciences, Russian State Medical University, Moscow
Features of speech therapy diagnostics
The presence of involuntary accompanying movements can also be identified during a speech therapy examination. To do this, check the condition of the motor sphere: general, finger, articulatory and facial.
Gross motor assessment
To evaluate it, they offer exercises for statics (holding) of a certain pose and dynamic tasks:
- standing alternately on one leg for a count of 5;
- stretch one leg and arms forward, close your eyes and try to maintain this position for a count of 5;
- jumping in place;
- running in place;
- march to the count while raising your legs and arms.
The specialist pays attention to coordination and the presence of accompanying movements: for example, when raising a leg, the child may stick out his tongue, or when standing on one leg, the other tries to straighten, etc. The child’s condition is also assessed: how quickly he gets tired, how he reacts if the task does not work out . Sometimes children with muscle tone problems may refuse to perform tasks because they experience physical discomfort. For example, there may be pain when straightening a leg or arm. All this is a sign of a violation of the general motor sphere.
Finger motor assessment
Many studies have proven that finger motor skills are associated with the work of speech centers. Therefore, special attention is paid to it in correctional work. If a child has difficulty mastering subtle differentiated movements with his fingers, then he may have difficulty forming sound pronunciation.
All exercises are performed in a certain sequence. First they do it with the right hand, then with the left and with both at the same time. You need to hold the poses for a count of 5.
- Keep your palm straight with your fingers close together in a vertical position.
- A similar task, only the fingers are spread apart.
- Extend your thumb and little finger.
- Make a “bunny” pose - put out your index and middle fingers, gather the rest into a pinch.
- The index and little fingers are straightened, the rest are gathered into a fist.
- Place your middle finger on your index finger.
- Connect all fingers one by one with the thumb (“Ring”). First on one hand, then on the other and on both at the same time.
- The fingers are clenched into a fist and unclenched several times.
- The palm is placed on the table and the fingers are connected and separated.
- Make a ring out of your fingers, then open your palm 5-8 times.
- One hand is in the “open palm” position, the other is clenched into a fist. Then they change places and repeat this several times.
While performing the above exercises, the speech therapist pays attention to the accuracy of their implementation; coordination; difficulties in switching. Synkinesis can manifest itself in conjugal movements of facial muscles (for example, lowering the lower jaw, raising the tongue, etc.) or simultaneous performance of all tests on both hands.
Assessment of facial muscles
Often, with severe speech disorders, there is a violation of facial motor skills. To test it, the child is asked to depict emotions of surprise, anger, sadness, joy. When performing this task, facial and oral synkinesis may appear. Before performing, the child is shown pictures depicting these emotions if he has difficulty understanding the instructions.
Articulatory motor assessment
For testing, they offer tasks to hold a pose and test the dynamic side.
- Make your lips a tube, round them, smile.
- Open your mouth wide and close it several times.
- Place your wide tongue on your lower lip.
- Pull out the narrow tongue.
- Raise and lower your tongue.
- Move your tongue left and right.
- Hold in a “Cup” shape.
- Suck the tip of your tongue to the roof of your mouth (“Mushroom”) and hold it in this position.
- Make a “Mushroom” and raise and lower the lower jaw.
- Make a "Horse".
While performing the exercises, the specialist looks at the accuracy of the movements; switching features; the presence of tongue tremor and the state of its muscle tone. With dysarthria, synkinesis may appear during testing of articulatory motor skills. For example, when the child lowers his tongue, his forehead wrinkles or his upper lip droops; other types of involuntary movements may also occur.
Diagnosis of dysarthria and methodological development in speech therapy on the topic
Diagnosis of motor development disorders1. Examination of general voluntary motor skills Instructions: a) “Stand on one leg: left, right.”
b) “Jump on two legs with progress.”
c) “Throw and catch the ball.”
d) “Walk in one place.”
d) “Go up and down the steps of the stairs.”
Criteria for evaluation:
5 points - all tasks are completed correctly;
4 points - all tasks are completed correctly, but at a slow pace;
3 points - tasks are not performed accurately enough, the child stretches his arms to the sides to maintain balance;
2 points - poorly maintains balance when standing on one leg, quickly stumbles, seeks support; throws the ball very low; does not maintain balance when stopping on command;
1 point - the task is not completed.2. Study of differentiation of spatial concepts (on a sheet of paper)
Instructions: “Show me what is in the center of the picture? What's to the left of the square? What's to the right of the square? What's under the little triangle? What's between a circle and a big square? What are the shapes at the top of the picture? What are the figures at the bottom of the picture?
Criteria for evaluation:
5 points - tasks are completed correctly;
4 points - tasks are completed with errors, but errors are corrected independently;
3 points - tasks are completed with minimal assistance from an adult;
2 points - active assistance from an adult is required to complete the task;
1 point - the task is not completed.
The child is offered a sheet of paper with images of geometric shapes
3. Study of the visual-spatial organization of movements Instructions: “When I raise my right hand, you will also raise your right hand, and when I raise your left hand, you will also raise your left hand.” “Raise your right hand!” “Take your left ear with your right hand.” “Raise your left hand!” “Take your right ear with your left hand.”
Criteria for evaluation:
5 points - all tasks are completed correctly;
4 points - all tasks are completed correctly, but at a slow pace;
3 points - tasks are completed correctly, errors are noticed and corrected independently;
2 points - echopraxia occurs when performing the first task and persists during subsequent tasks; mistakes are noticed independently;
1 point - persistent echopraxia, does not notice errors independently.
The experimenter and the child sit opposite each other.
4. Research on the development of the kinesthetic basis of hand movements
Instructions:
1. “Lower your right hand down. Squeeze all fingers except the thumb, extend the thumb to the left.”
2. “Clench both hands into fists, while extending your thumbs up.”
3. “Clench your right (left) hand into a fist, place the palm of your left (right) hand on it.”
4. “Clench your right (left) hand into a fist, lean the palm of your left (right) hand vertically against it.”
Criteria for evaluation:
5 points - all tasks are completed correctly;
4 points - all tasks are completed correctly, but at a slow pace;
3 points - tasks are performed correctly, synkinesis is observed;
2 points - tasks are completed with the help of an adult;
1 point - tasks are not completed.
5. Study of visual-motor coordination of movements (graphic tests)
Study of movement accuracy.
A drawing on which “Paths” are drawn, at one end of which there are cars, at the other - a house. The car must “drive” along the path to the house. The width of the paths is selected so that it is quite difficult, but accessible to the child. The type of tracks becomes more difficult from first to last.
Instructions: “Cars and paths to the houses are drawn here. You must connect the car to the house with a line without leaving the path."
Criteria for evaluation:
5 points - when completing the task there are no exits from the path, the pencil does not come off the paper;
4 points - there are no exits from the track, the pencil comes off no more than three times; 3 points - there are no exits from the track, the pencil comes off no more than three times, synkinesis is observed;
2 points - no more than three exits from the “track”, an uneven trembling line, very weak, almost invisible, or a line with very strong pressure, synkinesis;
1 point - impossibility of execution, numerous exits from the “track”, repeated execution in the same place.
“Tracks” Draw straight lines in the middle of the path without lifting the pencil or moving off the path.
Draw lines in the middle of the path without lifting your pencil or moving off the path.
6. Examination of kinesthetic oral praxis1. Instructions: “Repeat the sounds after the speech therapist. Tell me what position your lips are in when pronouncing...”
A - ?
AND - ?
ABOUT - ? U - ?
2. Instructions: “Pronounce the sounds [t] and [t] and tell me where the tip of the tongue was when pronouncing them, at the top or bottom?”
3. Instructions: “Say [si] - [su], [ki] - [ku] and tell me how the position of your lips changed when pronouncing them?”
4. Instructions: “Say the sounds [i], [sh] successively in front of the mirror and tell me when pronouncing which sound the tip of the tongue is lowered, and when pronouncing which sound it is raised?”
5. Instructions: “Pronounce the sounds [t], [d], [n] and tell me where the tip of the tongue was when pronouncing them - behind the upper or lower teeth?”
Criteria for evaluation:
5 points - correct answer;
4 points - self-correction or correct answer after stimulating assistance;
3 points - search for articulation, answer with single errors;
2 points - inaccurate answer, inaccurate completion of the task;
1 point – no answer.
7. Examination of kinetic oral praxis
Examination procedure.
The exercises are performed sitting in front of a mirror. The child is asked to perform one or another exercise in response to the speech therapist. The sequence of all exercises is: “fence” - “window” - “bridge” - “sail” - “shovel”, “delicious jam”, etc.
In order to evaluate the performance of an articulation exercise, the child is asked to hold the articulation organs in the desired position for 5-7 seconds.
1. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- open your mouth wide, raise the tip of your tongue up to the upper teeth - “sail”, fix this position, holding it for 5-7 seconds.
2. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “shovel” tongue - wide, spread out, lying motionless on the lower lip, mouth slightly open, fix this position, holding it for 5-7 seconds.
3. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “delicious jam” - the mouth is open, the wide tongue clasps the upper lip and then, with a slow movement from top to bottom, is removed into the oral cavity (hold for 5-7 seconds).
4. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “bridge” - the mouth is open, a wide flat tongue lies at the bottom of the mouth. The tip rests on the lower incisors (hold for 5-7 seconds).
5. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “window” - the mouth is open, the upper and lower teeth are visible (hold for 5-7 seconds).
Evaluated:
— accuracy of movements (exact execution, approximate execution, search for articulation, replacement of one movement with another);
- duration of holding the articulatory posture (sufficient, rapid exhaustion);
- symmetry;
- presence of synkinesis, hyperkinesis, salivation.
Criteria for evaluation:
5 points - correct execution of the movement with exact correspondence of all characteristics to the presented one;
4 points - slow and intense execution, rapid exhaustion;
3 points - the time for fixing the pose is limited to 1-3 seconds;
2 points - execution with errors, long search for a pose, deviations in configuration, synkinesis, hyperkinesis, hypersalivation;
1 point – failure to perform the movement.
8 Examination of dynamic coordination of articulatory movementsExamination procedure.
The exercises are performed sitting in front of a mirror. The child is asked to perform the movements in response to the speech therapist. The child is asked to perform the exercises 4-5 times.
1. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “swing” (raise the tip of the tongue by the upper ones, then lower them by the lower incisors. Repeat this exercise 4-5 times).
2. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “pendulum” (alternately touch the protruding tip of the tongue to the right, then to the left corner of the lips. Repeat this movement 4-5 times).
3. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- raise the tip of the tongue to the upper lip, lower it to the lower lip, alternately touch the protruding tip of the tongue to the right, then to the left corner of the lips. Repeat these movements 4-5 times.
4. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”: - stick your tongue forward, while simultaneously lifting its tip up. Repeat these movements 4-5 times.
5. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- simultaneously move the lower jaw and protruding tongue to the right, then to the left. Repeat these movements 4-5 times.
Evaluated:
— sequence of movements;
— the ability to switch from one movement to another;
— inertia of movement, perseveration;
— pace of movements;
— range of motion (range of motion is sufficient, limited);
— accuracy of movements (exact execution, approximate execution, search for articulation, replacement of one movement with another);
- presence of synkinesis, hyperkinesis, salivation.
Criteria for evaluation:
5 points - relatively accurate execution of movements, all movements are coordinated;
4 points - slow and tense execution of switching from one movement to another;
3 points - the number of correctly performed movements is limited to two or three;
2 points - execution with errors, long search for a pose, replacement of one movement with another, synkinesis, salivation, hyperkinesis;
1 point - failure to perform movements.
9 Examination of facial musclesExamination procedure. Exercises are performed in front of a mirror. The child is asked to perform the movements in response to the speech therapist. It is carried out according to the sample, then according to verbal instructions.
1. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- frown eyebrows
2. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- raise eyebrows
3. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- wrinkle forehead
4. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- puff out your cheeks one by one
5. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- pull in cheeks
Criteria for evaluation:
5 points - accurate completion of tasks, absence of disturbances in muscle tone of facial muscles and other pathological symptoms;
4 points - inaccurate execution of some movements, slight violation of the tone of facial muscles;
3 points—single movements are impaired, single pathological symptoms;
2 points - difficulty performing movements, moderately severe disturbance of muscle tone of facial muscles (hypertonicity, hypotonia, dystonia), smoothness of nasolabial folds, synkinesis;
1 point - grossly expressed pathology of muscle tone of facial muscles, hypomimia.10 Examination of muscle tone and lip mobility Examination procedure: the child is asked to repeat the movements in front of the speech therapist, sitting at a table in front of a mirror.
1. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “tube” (pull your closed lips forward with a tube, hold for 5-7 seconds).
2. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- alternating “fence” - “tube” (up to 5 times).
3. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- raise your upper lip, lower your lower lip, repeat the movements several times.
Criteria for evaluation:
5 points - accurate completion of tasks, normal tone, lips mobile;
4 points - inaccurate execution of movements, slight violation of the tone of the labial muscles (hypertonicity, hypotonia, dystonia);
3 points - the upper lip is tense, its mobility is limited;
2 points—difficulty performing movements, marked impairment of the tone of the labial muscles, lips are inactive;
1 point - failure to complete tasks, severe pathology.
11. Examination of the muscle tone of the tongue and the presence of pathological symptoms. Examination procedure: the child is asked to repeat the movements in front of the mirror behind the speech therapist.
1. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “shovel” - the tongue is wide, spread out, lying motionless on the lower lip.
2. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
— “bridge” — from the “window” position, the tongue rests on the lower incisors, the tongue is wide, flat, and lies quietly in the oral cavity.
3. Instructions: “Look carefully in the mirror and repeat the movements after the speech therapist”:
- “pendulum” - alternately reach the tip of the tongue to the right, then to the left corner of the mouth.
Criteria for evaluation:
5 points - accurate execution of movements, absence of violations of the muscle tone of the tongue, no pathological symptoms;
4 points - inaccurate completion of tasks, slight violation of tongue tone (hypertonicity, hypotonia, dystonia);
3 points—difficulty performing exercises, moderately severe disturbance of the muscle tone of the tongue, salivation, which increases with functional load, deviation of the tongue;
2 points - grossly expressed violation of the muscle tone of the tongue, severe pathological symptoms (constant salivation, hyperkinesis, blue tip of the tongue, deviation);
1 point - does not complete the task.
Diagnosis of motor development disorders in children with erased dysarthria
Profile of the structure of a motor disorder of a child with erased dysarthria. After completing the entire examination, a profile of the structure of a motor disorder of a child with erased dysarthria is compiled. The function score allows you to assess not only the presence of pathological symptoms, but also the degree of its severity.
The graph shows a curve demonstrating the state of motor development (general, manual, articulatory) at the time of the examination. After corrective measures are carried out, the dynamics are reflected in the graph in the form of a second curve. Thus, the results of the correction work can be seen on the graph.
Examination parameters: 1. Examination of general voluntary motor skills.
2. Study of differentiation of spatial concepts.
3. Study of the visual-spatial orientation of movement 4. Study of the development of the kinesthetic basis of hand movements.
5. Study of visual-motor coordination (graphic tests).
6. Examination of kinesthetic oral praxis. 7. Examination of kinetic oral praxis.
8. Examination of dynamic coordination of articulatory movements. 9. Examination of facial muscles. 10. Examination of the labial muscles 11. Examination of the lingual muscles.
conclusions
1. The development of the motor system of children is a factor stimulating the development of speech.
2. The level of development of children's speech depends on the degree of development of fine movements of the fingers. A third of the entire area of the motor projection of the brain is occupied by the projection of the hand, which is located next to the projection of the speech motor zone.
3. Fine motor skills are motor activities that are determined by the coordinated work of the small muscles of the hand and eye.
4. Movements of the fingers are of particular importance, as they influence the development of the child’s higher nervous activity.
5. The motor sphere of children with erased dysarthria is characterized by slow, awkward, constrained, undifferentiated movements.
6. All motor pathological symptoms with erased dysarthria appear in a mildly expressed form.
7. Motor insufficiency manifests itself most clearly when performing complex motor acts that require precise control of movements.
8. In children with erased dysarthria, the kinesthetic and kinetic basis of movements is insufficiently developed.
9. In children with erased dysarthria, pathological symptoms are detected in the articulatory, vocal, and respiratory parts of the peripheral speech apparatus.
10. Diagnosis of motor development disorders is necessary to clarify the structure of the defect.
Corrective work
To overcome synkinesis you need a complex effect. These are exercises to improve general motor skills and relax muscle tone. Therefore, such patients are often recommended to take up swimming, because it has a beneficial effect not only on motor activity, but also on the nervous system.
Children with synkinesis attend exercise therapy classes and undergo courses of therapeutic massages prescribed by the doctor. If they manifest themselves in articulatory and facial motor skills, then a course of speech therapy massage is added. It should only be performed by a speech therapist who has completed special courses. At home, you can do simple self-massage, which also has a beneficial effect on the facial and articulatory muscles.
For dysarthria, drug treatment is prescribed. It not only stimulates the work of speech centers, but also affects the state of muscle tone.
The sooner parents seek advice from a specialist, the more effective the correction work will be. Overcoming synkinesis has a beneficial effect not only on speech activity, but also on the nervous system and muscle tone.
Spasticity
Gavrilkina Oksana Sergeevna Chief rehabilitation doctor, physical therapy and sports medicine doctor,
More about the doctor
Spasticity or muscle hypertonicity as a syndrome signals the progression of central nervous system diseases. It can occur in older people in response to the death of motor neurons or as a consequence of a cerebral stroke, spinal stroke, head or spinal injury . Different severity of spasms can either not interfere with the patient’s life at all or lead to disability. It is noteworthy that at the initial stages of rehabilitation after a stroke, muscle spasticity indicates the possibility of complete restoration of motor activity of the limbs.
Factors causing spasticity
Mildly expressed cramps and spasms are often diagnosed in the elderly due to age-related changes in the nervous regulation of muscles and tendons. This is also facilitated by wearing tight shoes and clothes, frequent hypothermia, bad habits, excess weight, constant stress, and some chronic diseases. Since neurodegenerative diseases develop in genetically predisposed patients, muscle spasticity , which develops due to pathologies of the central nervous system, can also be considered as a syndrome that is inherited. In addition, spasticity occurs against the background of such diseases:
- brain stroke;
- inflammation of the meninges (meningitis);
- varicose veins;
- atherosclerosis;
- arterial hypertension;
- diabetes;
- brain and/or spinal cord injuries.
Often muscle spasticity develops against the background of Parkinson's disease , Alzheimer's disease , senile dementia . Cramps and increased muscle tone can be triggered by any inflammatory diseases, constipation, or infections of the genitourinary system.
Symptoms of spasticity in the elderly
The first thing a specialist pays attention to when diagnosing spasticity is increased muscle tone. In this case, the patient complains of spontaneous cramps, especially at night and after physical activity, pain when flexing/extending the limb. Deformations in the joints are also observed, and posture changes. The reflex response increases. The pathology is aggravated by concomitant inflammatory processes in the joints, and the intensity of pain increases.
Diagnosis and treatment of spasticity in the elderly
When assessing the severity of pathology neurologically, the Ashworth scale . In it, the severity of the disease is divided according to the severity of muscle hypertonicity. The maximum degree of damage is 4, in which the limb under study practically does not bend/extend. Using CT or MRI, the presence of any disorders in the central nervous system or spinal injuries that can cause spasticity is determined.
Treatment is conservative, comprehensive, and includes both the use of medications and physical therapy. Self-medication is contraindicated; all drugs used to treat spasticity are available with a doctor's prescription. Their action is aimed at reducing muscle tone by inhibiting interneurons and blocking nerve impulses. An overdose leads to hallucinations, respiratory arrest, and death.
Local anesthetics may be used to relieve pain. Convulsions can be controlled with magnesium supplements. It is mandatory to take B vitamins to improve the functioning of neurons, activate trophism and blood circulation, and relieve inflammation.
Physiotherapy consists of the use of electrophoresis , acupuncture , therapeutic massage , and exercise therapy .
In case of injuries, tumors, or deforming changes in the joints, surgical intervention may be required. The operation consists of truncation of nerve roots that cause muscle hypertonicity. For the treatment of mild and moderate spasticity in elderly and senile people, surgical intervention is not recommended.
