RU2428161C2 - Method of restoring motor and cognitive activity in children at early stage of rehabilitation of severe craniocerebral trauma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to rehabilitative medicine, exercise therapy (ET) in rehabilitation of children after severe craniocerebral trauma. Method includes successive doing by child of seven specific exercises of adaptive-sensomotor complex, given in invention formula, with assistance of ET methodologist and verbal instructions of teacher-speech pathologist, which makes it possible to create main motor qualities in combination of biomechanical connection of muscles and joints, activate child's cognitive activity and adapt them socially.

EFFECT: method ensures early step-by-step recovery of physical and cognitive potential through creating in child of reflex-motor stereotype, activation of psychic activity through induction of orientation reactions, restoration of methods of adoption of social experience, understanding of speech.

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Description

The invention relates to medicine, to the section of restorative medicine, more specifically, to physiotherapy exercises and can be used for the rehabilitation of children who have suffered a severe traumatic brain injury.

Most effectively, this invention can be used in neurosurgical hospitals and in rehabilitation centers to restore the physical sphere, cognitive activity and social orientation of children with severe traumatic brain injury.

Children who have suffered severe traumatic brain injury have paresis (paralysis) of central origin, as well as severe cognitive impairment associated with a lack of interest in the surrounding subject world and adequate interaction skills in it.

There is a method of normalizing muscle tone and raising normalized motor skills in patients with cerebral palsy (B. Bobat and K. Bobat, M. Weiss, A. Zembaty // Physiotherapy. M: Medicine, 1986, p.114-131), according who use the ball to relax, suppress pathological reflexes, primarily for the development of the stages of physical development for patients: to teach them how to sit and still maintain balance, to stand on their knees, improve support on their hands, etc.

The disadvantage of this method is that when the child is already moving on his own, but he has problems - increased tone, contractures begin to form, or have not yet moved and do not show a reaction (due to the severity of the injury), 2-3 methodologists and correction methods are needed his already formed posture and walk.

There is a method of normalizing muscle tone in children with spastic forms of cerebral palsy (RF Patent No. 2289381 - Kozhevnikova V.T.), which includes stretching exercises of the muscles and joint-ligamentous apparatus of the arms, legs, spine, using methodologists, the difference of which is the exercise stretching on an incompletely inflated ball with a diameter of 120 cm after general relaxation of spastic muscles and combining them with training the vestibular apparatus, which has a positive effect on spastic muscle tone.

The disadvantage of this method is its focus solely on the stabilization of motor functions through the formation of reflex acts: extension and rotation of the head, "exit" to all fours, crawling on all fours, walking on knees, etc.

There is a method of treating the long-term effects of a traumatic brain injury by applying sequential methods of cranial manual therapy, which eliminate pathobiomechanical disturbances in the skull area, normalize cerebrospinal fluid flow and cerebrospinal fluid dynamics, and improve cerebral blood circulation. When implementing the method, a strict sequence of performing the therapeutic complex of techniques is mandatory (RF Patent No. 2305535).

The disadvantage of this method is its clinical focus, imposing a limitation on the cognitive potential of the child’s mental sphere.

There is a method of psychophysiological rehabilitation of patients with traumatic brain injury in the postcomatose period, including the formulation of tasks for the patient to perform psychomotor exercises, repeated repetition of psychomotor exercises to patients taking into account changes in the values of intensity and speed of movements corresponding to psychomotor exercises, even before the possibility of understanding and performing psychomotor exercises for patients, stimuli and stimuli begin to show him to cause ele physiological sensations, these stimuli - tactile, auditory, gustatory, olfactory, visual - alternate, changing the intensity and location of the source of influence, and by re-presenting they achieve a stable unconscious reflex and then conditioned reflex reaction of the patient, alternately present familiar to the patient stimuli and those unfamiliar to him, after that they analyze the patient’s reactions to this complex of stimuli and evaluate the patient’s response level, the correspondence of his condition to one of stages of exit from coma (opening the eyes, fixing the gaze, emotional reactions, understanding speech, own speech, answers to questions, orientation, effectiveness of cognitive processes, emotional and personal adequacy), stimuli and stimuli give a multi-polar emotional coloring, taking them into account when modeling real conditions of life, check by observing the presence and adequacy of the reaction to them from the patient, then, in accordance with the answers received, instruct relatives and friends of the patient to release ying with the patient the above activities and exercises in a real environment, after which provide joint work of the patient and the family, of which the patients evaluated for transition to the next output stage from coma (RF Patent №2073532).

By presenting stimuli and stimuli of different modality, elementary physiological sensations are called up, which gradually have an activating effect on the psyche, translating it from unconscious into conscious activity. This method is selected as a prototype.

The disadvantage of this method is its focus on adult victims.

The objective of the invention is the creation of a set of exercises for the consistent restoration of motor activity and cognitive activity of children in the early stages of rehabilitation in children with severe traumatic brain injury.

The technical result aimed at solving this problem is the early restoration of physical and cognitive potential through the establishment of a reflex-motor stereotype in a child, the activation of his mental activity through inducing orientational reactions, the restoration of ways to assimilate public experience, and understanding speech.

The specified technical result is achieved by the fact that for a method of restoring motor activity and cognitive activity of children at an early stage of rehabilitation of severe traumatic brain injury, a set of exercises for adaptive-sensorimotor recovery is developed.

The adaptive-sensorimotor complex (ASA) is presented in a triad of interaction: a methodologist, teacher and a child who has suffered a severe traumatic brain injury. ASA is aimed at restoring the functions of the child’s body and psyche through the educational effects of adults, which increase the quality of life at an early stage of rehabilitation.

The method is carried out by conducting a joint lesson of a physiotherapy exercises practitioner (exercise therapy) and a defectologist using a complex of exercises performed in strict sequence.

The essence of the invention lies in the fact that with the hands of a physical therapy practitioner, a child forms the trajectory of the "correct" movement of the limb towards the object to call the eye-arm-object interfunctional connection through external influences of "reflex-locomotion", then they work out external influences, changing the intensity of external efforts using a physical therapy method and explaining with the help of verbal instructions the “path” of limb movement to the object or to the place of its fixation, forming a short-term memory, then the defectologist educates the patient alternately a toy bench taking into account his age, after this the LFK methodologist, together with the defectologist, analyzes the child’s actions using objects and toys, taking into account their gun-everyday orientation, assesses the quality of performance, the state of the child’s mental activity, the level of her activity with respect to understanding speech addressed to him and worked-out movements, check by observing the presence and adequacy of their use with a change in muscle strength and assessing the stability of the posture by the child.

A set of exercises for adaptive-sensorimotor recovery.

Exercise 1 (Fig. 1, Fig. 2, Fig. 3).

Purpose: inducing a child's reflex turn of the head and restoration of active turn through bending; evoking fixation of the gaze on the subject.

Starting position: the child lies on a flat surface, on his back; hands are located along the body (if contractures are noted, a verticalizer fixing tape is used); the head is in the midline, face up on a roller 20 cm long, 10 cm in diameter or a warm heating pad; legs are straightened and fixed (shoes are required).

Description of the exercise: The methodologist turns the child’s head to the right side, the teacher presents an object for focusing the gaze. A speech instruction is pronounced, the child makes an active turn of the head to the left behind a moving object and fixes a look at it (up to 3 accounts). The methodologist controls the rotation of the head through its bending. Next, the teacher puts a new toy into the child’s right hand (the methodologist helps to bend the arm in the shoulder joint, palm up), the speech instruction is pronounced and the head is turned actively towards the subject. Then the teacher rings the subject and the child makes a head turn to the sound, but without a speech command.

Dosage: each movement is repeated 3-4 times.

Exercise 2 (Fig. 4, Fig. 5, Fig. 6).

Objective: to increase the support function of the upper shoulder girdle, intensify the work of the muscles of the upper and lower extremities (homo- and controlally), the formation of visual-motor coordination.

Starting position: the child lies on his back, hands along the body, head in the midline, the methodologist changes the angle of the verticalizer (45, 65, 80 °). (Except 1 p., All elements are performed by command and verbal stimulation).

Description of the exercise: The methodologist turns the child’s head to the right and takes his right hand to an angle of 45-60 °, the teacher puts an object into the child’s hand, and he fixes a look at it for 30 seconds. Then the child brings the arm (to the midline of the body), the methodologist smoothly bends the right leg in the knee joint and the child touches the object to the knee. At the command of the teacher, the child looks directly, the head is motionless, the methodologist helps to lead the arm to the right and the child actively extends the leg in the knee joint (bringing in / limbs in supination, abduction in pronation). Dosage: 2-4 leads in each position of the verticalizer.

Exercise 3 (Fig. 7, Fig. 8, Fig. 9).

Objective: to achieve a reflex connection between the cervical reflex, sequential extension of the back and the work of the lower extremities, the formation of support function in the elbow joints; improvement of sensorimotor coordination, fulfillment of objective action.

I.p .: lies on the stomach, under the chest, the roller, arms are bent at the elbow joints in support in front of the roller, on the elbows (shoulder and elbow joints in the same plane).

Description of the exercise: The teacher draws the child’s attention to the subject, the methodologist controls the extension of the spine in the cervical spine, the child fixes the look on the subject. According to the teacher’s instructions, the child stretches his right hand forward and up to the sound object, at this moment the methodologist bends his left leg into a “frog”. The position is fixed up to 4-6 accounts. Then the child actively unbends his leg and puts his hand in the support. Dosage: 3-4 times.

Exercise 4 (Fig. 10, Fig. 11).

Goal: achieving a reflex “exit” to all fours and resting on the elbows, building strength and activating the flexibility of the back muscles, strengthening the gluteal muscles (which are anti-gravity); stabilization of the function of smooth tracking of the subject (up).

I.p .: the child lies on his stomach, there is a roller under his chest, support on arms bent at the elbows, forearms parallel to each other, fingers extended.

Description of the exercise: The teacher attracts the attention of the child with an object, the methodologist controls the extension of the spine in the cervical spine, the child traces with a look behind the moving object up. The methodologist unbends the left lower limb and guides the child to the starting position - sed on the right ankle joint, the back is in an unbent position, the gaze is fixed up to 5 accounts. Then the teacher moves the subject down and the methodologist directs the sequential flexion in the knee and hip joints with access to the support on the knees and elbows.

Dosage: 3-5 times with each foot.

Exercise 5 (Fig. 12).

Purpose: achieving a child's reflex coordination of the muscles of the back and upper limbs (one side in the support, the other in motion); increased back muscle strength; improvement of hand-eye coordination, objective action.

I.p .: lies on the stomach, the right hand is bent at the shoulder, elbow joints and raised (in the hand, an object), the head is turned towards the bent arm. The left lower limb is bent into a “frog”. The left upper limb is lowered along the trunk.

Description of the exercise: According to the verbal command, the child raises his head, looks forward (rests on the right forearm) and with his left hand stretches forward to the subject, the methodologist helps the child to maintain this position up to 5-7 accounts. Then the teacher moves the subject from the left side back and the methodologist directs the extension of the left hand in the shoulder and elbow joints, which contributes to the active rotation of the head by the child. Dosage: 3-4 times.

Exercise 6 (Fig. 13, Fig. 14).

Purpose: restoration of the active rotation of the child’s body on its side (through a reflex turn); fixing sensorimotor coordination.

I.p .: the child lies on his back, hands along the torso, head in the midline.

Description of the exercise: The teacher asks the child to take an object that is in front of his face at a distance of 40-50 cm and pass it to the methodologist standing to the left of the child. The methodologist with his right hand takes the subject and directs the flexion in the right lower limb, followed by turning the body to the left. The teacher stands to the right of the child and attracts the attention of the child, making an active turn of the head to the right side, the methodologist helps to turn the body to its original position. Dosage: 3-4 times in each direction.

Exercise 7 (Fig. 15, Fig. 16).

Purpose: the formation of the prerequisites for static upright holding: development of strength and endurance of the back muscles, stabilization of support on the feet; consolidation of cervical reflex, oculomotor and labyrinth-tonic reflexes; the formation of interest in the implementation of substantive actions.

I.p .: lies on his stomach, on a ball (not fully inflated) with a diameter of 120 cm, his head is turned to the right side, his hands are supported on the forearms on the ball.

Description of the exercise: The methodologist sets the child’s feet on the floor, the teacher draws the child’s attention to the subject moving up, the child unbends his head and back, resting on the feet. The teacher moves the subject to the right, left at eye level, the methodologist helps to maintain the adopted position for 10-15 seconds. Next, the methodologist directs the flexion in the cervical spine and the child makes an active return to its original position.

Dosage: 3-4 times in each direction.

The invention is new, since it is not known from the prior art in the field of physiotherapy for sick children who have had BMI and the consequences associated with this trauma.

ASA is indicated for children with severe traumatic brain injury who are in an early rehabilitation period. Characteristic of these children are pronounced psychophysical disorders in the social, cognitive and physical spheres. Children have a reduced interest in the environment, they do not have self-care skills, there is no speech, which makes them dependent on adults.

In the proposed method, adaptive-sensorimotor complex means are used: table - verticalizer, fitball with a diameter of 120 cm (not fully inflated), a roller with a diameter of 20-25 cm; educational items: sets of items and toys to activate sensorimotor.

Before the start of classes, which use the adaptive-sensorimotor complex, all children undergo functional tests: semi-orthostasis or orthostasis on the verticalizer.

The child is placed in an upright position slowly, on the basis of monitoring the activity of the cardiovascular and vestibular systems.

All exercises of the technique are performed smoothly, with adequate efforts at the moment of passive-active manifestation of movement and correction of the child at the time of the installation reaction at active points, a clear short instruction is used.

After fixing in the final position for 2-3 seconds, the return of the trunk and limbs to the starting position should be performed slowly, after which its relaxation and verbal encouragement are controlled. The fixation of movement is made strictly with the involvement of the oculomotor, cervicotonic and labyrinth reflex.

An absolute contraindication for the use of the ASA complex is the presence of organic contractures and joint deformities, congenital and acquired diseases and spinal deformities in a sick child, and increased body temperature.

A relative contraindication is a feeling of fear of body movements, sharp crying, autonomic manifestations from the cardiovascular and respiratory systems.

A significant difference of the proposed method is the understanding that motor acts, being the main group of processes where the body not only interacts with the outside world, but also actively influences it, made it possible to single out a significant component of their construction - achieving a result that is associated with the model of the required future, namely, the prerequisites that are created in the human brain for the implementation of motor functions. In principle, the ripening of motor activity from primitive tropisms to complex forms of directed action is realized by the organism’s purposefulness, in which the mobilization of the central tuning systems of the brain serves to program the strategy of the movement that is being performed, and the conscious and verbalized codes act as representatives of its highly developed forms. Adaptive movements of the child are controlled by the hands of a methodologist who is guided by the interaction of three levels of the body: head - eyes, shoulder girdle - upper limbs, pelvic girdle - lower limbs. Moving in space of each of the installation parts allows you to call the desired installation reflexes. With everyday exercises and stimulation to repeat, these reflexes are fixed, the effect of pathological tonic reflexes is reduced, a purposeful action is built.

Clinical examples of the method using the adaptive-sensorimotor complex (ASA).

Example 1. Patient Rustam K., 8 years old. Diagnosis: PMTCT, spastic tetraparesis, condition of spastic subluxation of the right clavicle. Upon admission to the gymnastics room, no independent movements were noted, muscle tone in the right upper limb - 3 points, the right lower limb in the equinus setting, the head turned to the right. The presence of a pathological cervical reflex, a decrease in the oculomotor reflex was noted. Mental activity at the level of fuzzy manifestation of sensorimotor reactions, fixation of the gaze - short-term, did not follow the subject.

The treatment was carried out according to the ASK method of 2 courses (10 lessons each).

Tasks of the 1st course were aimed: to reduce the pathological cervicotonia reflex, strengthen the oculomotor muscles and stimulate the muscles of the back, perception of the extremities in supporting function; restoration of indicative reactions and the formation of stable sensorimotor activity.

Tasks of the 2nd course included: strengthening the muscles of the back and the formation of supporting function of the lower extremities, increasing overall motor activity; consolidation of sensorimotor activity; the formation of visual-motor coordination and voluntary reactions to speech.

As a result of treatment, a positive dynamics of the restoration of mental activity was recorded. The boy began to understand the addressed speech, to fulfill elementary requests (shake hands, say goodbye with a gesture, wipe his nose with a handkerchief, etc.). Along with this, there was a clear eye-tracking following the subject, head turning toward the stimulus on command without help (through bending the head), reliance on the forearms, on the command active flexion in the knee and hip joints; improving biomechanical work in the right hip joint and reducing the equinus of the foot. The child has improved supporting function of the lower extremities, reliance on the feet; recorded an increase in muscle strength of the lower extremities (right: flexion 3 points, extension 3 points, left lower limb: 4 points. Upright position with help and slow walking (only with help).

Example 2. Violetta Ch., 10 years. Diagnosis: PMTCT with prolonged coma, gross psycho-organic syndrome, tetraparesis, more pronounced in the left limbs. Received treatment of exercise therapy for 123 days of hospital stay. In the history of the disease, the following were noted: a formed pathological cervical reflex, decreased oculomotor reflex, muscle strength in the left upper limb - flexion 2b, extension 4b, abduction, adduction without restriction, flexion contracture in the left wrist joint; in the right upper limb, muscle strength is 4-5 points, the range of movements is full. Gross violations of statics, coordination and stability (can stand on spread legs for 5-10 seconds). Mental activity at the level of understanding of elementary instructions with severe violations in the cognitive sphere: decreased perception, thinking, there was no active phrasal speech, etc.

The treatment was carried out according to the ASK method of 2 courses (15 lessons each).

During the first course, an improvement in the oculomotor and labyrinth reflexes, static retention of the head and strengthening of the back muscles, the formation of reflex biomechanical connections and support on the elbows, hands, knees were recorded. An active desire for movement appeared. In the cognitive sphere, orientations on the properties of objects, active speech “vocalizations”, and object actions were noted (I began to eat myself, wipe my hands with a towel, and tried to write with a pen).

After the second course: the girl became statically stable and hardy. When assessing erectness, she was able to stand on spread legs for more than 30 seconds with support on a stick (in her right hand), walk with support on a stick - more than 10 m.

In the cognitive sphere, the restoration of active speech, substantive actions, and some teaching skills (reading tasks (5-6 lines), solving simple examples, interest in productive activities - circling the outline of objects, modeling from plasticine, designing from sticks according to the pattern) was noted.

Example 3. Valeria K., 14 years old. Diagnosis: BMI, diffuse axonal brain damage, post-traumatic hydrocephalus, post-traumatic encephalopathy, right-sided hemiparesis.

She was admitted for treatment of exercise therapy on the 84th day of hospital stay, muscle tone in the right extremities up to 3 points (expressed in the upper limb), tremor of the right upper limb, and in motor actions formed compensation due to the left upper limb were noted. In bed, she turned over on her right and left sides, sitting down with help. I didn’t stand on my own.

Mental activity at the level of understanding a simple speech instruction, reducing cognitive activity, difficulties in the communicative sphere and social skills.

The treatment was carried out according to the ASK method of 2 courses (15 lessons each).

During treatment, there was a positive dynamics in the restoration of mental activity. In the motor sphere, straight sitting skills (on a chair with a back and armrests) with support on the elbows with a significant decrease in tremor in the upper limbs) were stabilized; independent uprightness and slow walking with support on a stick (1-2 min). In the cognitive and social sphere, there appeared an interest in household items, a desire to use them (toothbrush, cup, spoon, towel); to cosmetics and accessories (hairpin, jewelry, etc.); active speech in response to a call (question-answer).

Example 4. Sasha L., 5.5 years. Diagnosis: Gunshot blind penetrating head wound in the frontoparietal region. Right hemiplegia. The boy entered the physical therapy classes (46 days after the injury): there was a decreased motor and cognitive activity, pain, voluntary actions with the left hand, lack of active movements in both lower limbs and the right hand; lack of active speech. 1 course was conducted (5 lessons). Positive dynamics of recovery of mental activity was noted. In the motor sphere mobility of the limbs was restored, the boy began to sit in the stroller, the support function of the feet became more active. Active movements of the upper limbs (stronger in the left hand) appeared: the boy began to take various objects, play with them. Attempts were made to perform objective actions with the right hand. When using fitball, there was an activation of the movements of the entire body with active turns of the head towards objects and toys; directed actions of the hands on the functional purpose of the object (knocking with a hammer, rattling a tambourine, banging with a metalophone stick, etc.), there was an interest in environmental objects (he began to independently make turns on the bed; asking with a gesture and a word to give an object from the table (typewriter, ball).

Example 5. Seryozha K., 10 years old. Diagnosis: Severe concomitant injury, Severe brain contusion, Epidural hematoma of the left temporal region. He entered the exercise therapy on the 15th day after the injury. The state of moderate severity, there were reactions to touch and speech, fuzzy fixation of the gaze, selective execution of simple instructions (shook hands), limited eye movement up and to the right, movements in the left extremities are reduced (muscle strength 2 points), in bed turned on the left side independently and spontaneously, upright was not noted. 1 course was conducted according to the ASK technique (8 lessons). Positive dynamics were noted on the part of the ODA, coordination abilities, oculomotor reactions; cognitive sphere.

The boy quickly mastered positional attitudes (support on elbows, all fours, knees and motor acts of walking on his knees, normal walking) (on a stability scale - 4 points). There was active speech, slow, with hesitations. Communicative means were restored (he began to greet with a gesture and a word, began to ask for help). The appearance of gun actions was noted (he began to eat, dress and undress, use a toothbrush); interest in educational activities appeared (he began to read short poems, short stories, etc.). In general, there was a restoration of adequate ways of interacting with adults: it answers questions, performs “homework” (articulation exercises, etc.). Tries to show independence in everyday life.

The complex, which includes the sequential execution of seven exercises, allows you to create basic motor qualities in a combination of biomechanical communication of muscles and joints; to intensify the cognitive activity of the child and socially adapt it.

The claimed method of restoring motor activity does not pretend to quickly solve the problems associated with the consequences of DST in children, however, it is proposed by the authors as the leading method of active functional therapy based on the creation of a fundamental relationship between adaptive physical culture and restoration of sensorimotor capabilities of the body.

Only a comprehensive pathogenetic approach to treatment provides positive clinical dynamics and can effectively improve the quality of life of children in the studied category.

The adaptive-sensorimotor complex, reflecting the interaction of the methodologist and teacher, helps to restore the body and psyche of a child who has suffered a severe head injury, thereby improving the quality of his life.

Claims (1)

A method of restoring motor activity and cognitive activity of children at an early stage of rehabilitation of severe traumatic brain injury, characterized in that they formulate instructions for the child to perform psychomotor exercises of the adaptive-sensorimotor recovery complex with the child repeating these exercises repeatedly and forming his path of correct limb movement to the side subject: for the first exercise, the starting position (PI) - lying on your back, on a flat surface, arms along the body, th fishing along the midline, legs are straight, fixed, the methodologist turns the child’s head to the side, the defectologist with speech instructions presents the object from the other side to focus the child’s gaze, the child actively turns his head behind a moving object and fixes his gaze on it up to 3 accounts , the methodologist controls the rotation of the head through its bending, then the same way to the other side, then the teacher rings the subject, and the child makes head turns to sound, without a speech command, repeat 3-4 times; for the second exercise, the IP is the same, the methodologist changes the angle of the verticalizer, turns the child’s head in one direction and takes the arm of the same name to an angle of 45-60 °, then the child performs techniques according to verbal instructions: the teacher puts an object into the child’s hand and he fixes his gaze on it for 30 s, then the child brings the hand to the midline of the body, the methodologist smoothly bends the same foot in the knee joint, and the child touches the knee with the object, on the command of the teacher the child looks straight, his head is motionless, the methodologist helps bends in the lead of the same name arm, and the child actively unbends the leg in the knee joint, repeat 2-4 leads in each position of the verticalizer; for the third exercise, the FE is lying on his stomach, under the chest, the roller, arms bent at the elbow joints in support in front of the roller, at the elbows, shoulder and elbow joints in the same plane, the teacher draws the child’s attention with the object, the methodologist controls the extension of the spine in the cervical region, the child fixes the look on the subject, according to the instruction of the teacher, the child stretches his hand forward and up to the sound subject, at the same time the methodologist bends the opposite leg of the child into a “frog”, fixes the position up to 4-6 accounts, then the child actively extends foot and puts his hand on a pedestal, repeat 3-4 times; for the fourth exercise, the IP is the same, the forearms are parallel to each other, the fingers are extended, the teacher attracts the attention of the child with an object, the methodologist controls the extension of the spine in the cervical region, the child monitors the object moving upside down, the methodologist extends one leg and directs the child to the IP - sedan the ankle joint of the other leg, the back in an unbent position, the child’s gaze is fixed up to 5 accounts, then the teacher moves the subject down, the methodologist directs the sequential flexion in the knee and hip charters with access to support on his knees and elbows, by 3-5 times on each leg; for the fifth exercise IP - lying on the stomach, one arm is bent at the shoulder, elbow joints and raised, in the hand - an object, the head is turned towards the bent arm, the opposite leg is bent into a “frog”, the other arm is along the torso, according to the verbal instruction the child raises his head, looks forward, rests on the forearm of a bent arm and reaches with the other hand forward to the subject, the methodologist helps the child hold this position for 5-7 accounts, then the teacher moves the subject back, the methodologist directs the extension of the outstretched arm in the shoulder and elbow joints with active head rotation, 3-4 times; for the sixth exercise IP - lying on your back, hands along the torso, head in the midline, the teacher asks the child to take an object that is in front of the person at a distance of 40-50 cm and pass it to the methodologist standing to the left of the child, the methodologist with his right hand takes the object and directs the bending in the child’s right leg, with the subsequent turn of the torso to the left, the teacher stands to the right of the child and draws his attention to perform an active turn of the head to the right side, the methodologist helps to turn the torso in the IP, repeating 3-4 times in each direction; for the seventh IP exercise - lying on his stomach, on a not fully inflated ball with a diameter of 120 cm, his head turned to the right, his hands resting on his forearms on the ball, the methodologist sets the child’s feet on the floor, the teacher draws the child’s attention to the object moving up, the child unbends his head and the back, relying on the feet, the teacher moves the subject to the right, left at eye level, the methodologist helps to maintain the adopted position for 10-15 seconds, then directs the flexion in the cervical spine, and the child actively returns to PI, 3-4 times each blowing side.

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