RU2819386C1 - Method of examining a patient before correcting speech disorders - Google Patents

Abstract

FIELD: medicine; speech therapy.

SUBSTANCE: invention can be used when examining a patient before correcting speech disorders. A complex examination of the postural position of the whole body from head to feet, cervical region, thoracic region and craniofacial region is carried out. Examination is carried out by means of visual, palpation, motor-dynamic and static examinations (tests). For examination of postural body position, it is preferable to use photofixation of its image in 4 projections with superimposition of a grid of horizontal and vertical lines. At the same time any deviations from grid lines will be assessed as displacements, which can lead to speech disorders. Similarly, photofixation is used when examining the craniofacial region, when grids of horizontal and vertical lines are superimposed on its images in a frontal projection, and deviations from the norm are examined.

EFFECT: method provides widening and complex examination of the area of speech disorders, reducing the length and increasing efficiency of detecting pathological abnormalities in children at an early stage of development.

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Description

The invention relates to the field of medicine, in particular to speech therapy, and can be used in the diagnosis of speech disorders in children and adults before speech therapy correction.

At the present stage of speech therapy practice, examination is usually carried out using a complex of psychological, medical and pedagogical measures with the preparation of a speech card by a speech therapist. A speech card is one of the main documents of a speech therapist, which reflects all the data of the child from prenatal, postnatal history, his life until the moment the child was brought for consultation with a speech therapist (Volkova G. A Speech Pediatric Rhythmics. M., 1985; Fundamentals of Theory and practices of speech therapy / Ed. M. 1968; Speech therapy M. A.; Textbook for higher education. institutions. - 2nd edition. - M.: Publishing center "Academy", 2nd edition. additional and revised M., “Education”, 1973; Medical and pedagogical characteristics of dysarthric patients. “Essays on the pathology of speech and voice”, ed. ., “Enlightenment”, 1967; and other authors: L.A. Kashe, R.E. Lyapidevsky, R.I. A. Semenova, I.I. Panchenko, M.E. Khvattsev, E.V. The speech card reflects personal data, general and speech anamnesis, early development, checking the state of hearing, the state of general coordination, fine motor skills and mobility of the articulatory apparatus, the state of the organs of the articulatory apparatus and its anatomical structure, examination of the phonetic side of speech and syllabic structure, the state of prosody, functions of phonemic hearing, sound analysis and word synthesis, examination of speech understanding, examination of passive and active vocabulary, grammatical structure, coherent speech, examination of reading and writing.

In speech therapy practice, several types of speech (speech therapy) cards have been developed, which are mostly standard, but also describe some features focused on a specific structure of speech disorder. For example, a speech card for a child with dyslalia, a speech card for a child with a stutter, a speech therapy card for the complex diagnosis of children with systemic speech underdevelopment, a speech therapy card for diagnosing dysarthria, etc. (Trubnikova N.M. Structure and content of a speech card. Educational manual. Ekaterinburg: Ural State Pedagogical University, 1998; Dmitrova, E.D. Speech therapy cards for diagnosing speech disorders. M.: AST: Astrel, 2008; Speech therapy: Textbook for students of pedagogical universities / Ed. L.S. Shakhovskaya. - M.: Humanit Center, 1998; violations / Under the general editorship of Prof. G.V. Chirkina - 3rd ed. - M.: ARCTI: Textbook for higher education. institutions / I.Yu. Levchenko, S.D. Zabramnaya, T.A. Dobrovolskaya, etc.; Ed. G.).

The result of a standard examination by a speech therapist is a speech therapy conclusion, on the basis of which a plan of corrective measures is drawn up, or the patient is referred to further clarification of the nature of the deviations to specialized specialists.

Traditional speech cards belong to pedagogical examination methods and are used in the structure of the methodology for overcoming a specific speech disorder. Speech cards require the speech therapist to describe the identified speech, motor, and psychophysiological disorders of the child. In fact, the speech therapist records the identified symptoms of speech and motor characteristics. Based on this, he determines the structure and severity of the speech defect and draws up a pedagogical (speech therapy) conclusion for the correction route, including referral to specialized medical specialists. A feature of all speech cards are simple muscle motor tests of the facial and intraoral regions for the mobility of facial and linguistic muscles (open-close the mouth, move the lower jaw left-right; raise-lower the eyebrows alternately, simultaneously; wrinkle the nose; close-open the eyes alternately, simultaneously ; inflate and retract the cheeks at the same time, alternately; stretch the lips, stretch the lips with a tube, etc.). The purpose of using samples is to confirm or exclude the presence of dysarthria, the presence of neurological disorders, that is, damage, dysfunction of the cranial nerves that are involved in the speech act.

At the same time, existing speech maps do not take into account the versatility of the causes of speech disorders and, as a consequence, the need to use a combined, interdisciplinary and expanded approach to diagnosis. The main problem is that the objectively observed close relationship between the functioning of the speech system and the biomechanics of the body regarding the primary or secondary occurrence of speech pathology is not analyzed. In particular, speech pathologies can be a consequence of insufficient mass of speech muscles, disturbances in the innervation of their fibers, immobility or inactivity of the articulatory and masticatory apparatus, as well as spasmodic phenomena in the skeletal muscles, muscle-fascial compression. On the other hand, speech disorders may be the result of changes in the nervous system, damage and diseases of the brain with preservation of intelligence or deeper disorders with loss of intelligence that destroy the very ability to speak; may be caused by multiple and interrelated disorders at the neural, bone, blood supply and myofascial level in both the neonatal and postnatal periods. Persons with speech pathology may experience a combination of a number of deviations in the state of motor skills, articulation, phonation, breathing and their synchronization, resulting from damage to various levels of the nervous system of a central and peripheral nature. Thus, the disadvantage of speech cards is the lack of a systematic approach to identifying the source of the disorder and possible ways to correct the speech disorder, especially in combination with identified motor disorders, because they are considered the subject of another field and are corrected in accordance with the practices of these fields separately (neurology, kinesiology, osteopathy , pediatrics).

For example, the prior art contains the “Method for diagnosing and correcting speech disorders associated with natally caused trauma to the cervical spine in children” (RF patent No. 2310373). This invention can be used to diagnose and correct speech disorders associated with such injuries. As a result of an osteopathic examination, vertebrae with abnormal position and pathological mobility are identified at the level of C2-C3, or C3-C4, or C2-C3-C4. Dystonia and asymmetry of muscle tone are detected. The displacement of the position of the hyoid bone relative to the bones of the base of the skull - sphenoid, temporal, occipital - is determined. Detect language deviation and Gothic palate. If the listed deviations are identified, the presence of speech therapy and orthodontic disorders is diagnosed. This approach, on the one hand, assumes that preliminary examinations have already been carried out and the main causes of visible violations have been identified, and on the other hand, a highly specialized approach leads to a delay in the process of diagnosis and corrective measures. Similarly, the known method for early diagnosis of speech therapy, orthodontic and otolaryngological disorders (RF patent No. 2310433) has limitations in the effectiveness of its application due to the narrow range of pathologies examined. It involves only palpation of the cervical vertebrae from bottom to top from C7 to C1 and determining the displacement of the position of the hyoid bone relative to the bones of the base of the skull, identifying deviation of the tongue, disruption of the shape of the upper and lower jaws, deep overlap of the incisors, deviation of the crown of the teeth to the lingual side after their eruption. Examinations are carried out by visual observation and digital examination.

A speech therapist, if he sees signs of a disorder based on symptoms, diagnostic static and dynamic tests, suggests referring the child to specialized specialists - doctors. To a neurologist for the treatment of psychological disorders, to a dentist if there are dentition problems, to an orthodontist if there is a malocclusion, to a physical therapy instructor for physical therapy if there is a posture problem. All activities carried out by other specialists are proposed to be included in the speech therapist’s individual long-term plan. Thus, the corrections carried out are scattered in nature and are aimed primarily at the most visible external symptoms without establishing a complex of root causes of speech disorders, without taking into account the mechanism of the formed defect.

Typically, a speech therapist only carries out pedagogical activities through verbal instructions, showing an action or a method for its implementation, combined, verbal-dynamic support of the child using an arsenal of bright didactic tools (pictures, toys, board games, etc.). At the same time, even the use of the most modern technical means, using visual information images in an interactive environment (RF patent No. 2788132) may not give the expected result precisely due to the lack of an integrated comprehensive methodology for examining and correcting speech disorders. Correction for primary somatic, neurological and secondary dental, postural status is carried out by other specialists without taking into account the speech therapy status of the child. Such a fragmented, highly specialized approach can lead to a distortion of cause-and-effect relationships regarding the formed speech defect and the way out of it, which leads to a delay in the process of speech correction and often does not allow achieving the desired result.

The claimed invention is an original speech therapy method for psychological, pedagogical, visual and palpation diagnostics, built on the principles of a close relationship between the functioning of the speech system and the biomechanics of the body, including a number of static and dynamic studies (tests) in order to best select further paths of correctional support.

The technical result of using the invention is: expansion of the diagnosed area of speech disorders, reduction of time and increase in the efficiency of diagnosis, the ability to identify pathological abnormalities in children at an early stage of development.

The declared technical result is achieved by the fact that the method of speech therapy diagnostics by Sakharovskaya O.P. includes: a comprehensive examination of the postural position of the entire body from head to feet, the cervical region (part of the articulatory apparatus - the suprahyoid zone, the vocal apparatus - the subhyoid zone), the thoracic region (including the respiratory apparatus) and the craniofacial region (the articulatory apparatus, the masticatory apparatus, the temporal -mandibular joint). Typically, the examination is carried out through visual, palpation, motor-dynamic and static studies (tests). To examine the postural position of the body, it is preferable to use photographic recording of its image in 4 projections with a grid of horizontal and vertical lines superimposed on them. In this case, any deviations from the grid lines will be assessed as displacements, which can lead to speech disorders. Similarly, photographic recording is used when examining the craniofacial region, when a grid of horizontal and vertical lines is superimposed on its images in the frontal projection and deviations from the norm are examined.

The proposed method makes it possible to identify muscular, neural, motor (respiratory, voice-producing, sound-reproducing), postural disorders, the mechanisms of their formation, which are the root cause of the formation of a speech defect. It also allows, during repeated diagnostics, to monitor the dynamics at the myofascial, neural, blood supply and bone levels during correction sessions.

The diagnostic method is harmoniously combined with the author's method of correcting speech disorders (RF patent No. 2723221) and can be used to monitor the dynamics of changes occurring in the patient when implementing the specified correction method.

IMPLEMENTATION EXAMPLES

Previously, before implementing the proposed method, a speech therapy (pedagogical) diagnosis of the entire speech system can be carried out using standard speech cards, which allows one to form an initial opinion about speech disorders.

Diagnostics in accordance with the claimed invention is carried out comprehensively, in the manner described above.

Initially, the functional state of the postural position of the body is examined in an upright position, standing. To do this, visual diagnostics are carried out through motor-static, motor-dynamic tests for the presence or absence of altered tone, displacements, shortening in any area of the body, mobility of the TMJ joints, limb joints (wrist, ankle, knee, hip, elbow, shoulder joints), symmetry of the body relative to “top-bottom”, “left-right”, mobility of the soft tissues of the body. A visual diagnosis of the body from head to foot is also carried out, namely postural balance (body position in space: front-back, left-right, top-bottom in the vertical plane and each region in the horizontal plane, relative to the overlying and underlying region - zygomatic region, shoulder girdles, collarbones, shoulder blades, iliums, knees, feet) to identify deviations from the normotypical state. The position of the head and neck should be assessed relative to and in totality with the position of the entire spine, shoulder girdle, pelvis, legs, and feet.

For objective control, it is preferable to use photographic recording of the body in a relaxed position in 4 projections (back, front, side left, side right). The child (patient) should be invited to stand comfortably and relaxed, without additional verbal or manual adjustments to his position. As an approximate norm, the body should be positioned vertically at an angle of 90 degrees relative to the horizontal plane. Body weight is distributed evenly on both feet. The feet are shoulder-width apart, toes forward or slightly outward. Legs straight, without bending at the knees. Arms - relaxed without bending at the elbows or twisting inward at the wrist joints. The correct physiological cervical and lumbar lordosis is visualized. The lower jaw-neck angle should be approximately 90 degrees. The patient should be photographed from the front, back, side (left and right) in full height. The camera should be placed at eye level of the child (or adult), at a distance of 2 meters from the object. To analyze the obtained images, front (front) and counter-face (rear), the following positions are used:

- In the photo, a conventional vertical line should be drawn in the center of the body from the back of the head along the spine and down to the feet inclusive. Both sides, left and right, should be symmetrical relative to it. Any deviation of the left or right side from the center line outward or inward is a local or regional displacement, with compensatory change obligatory in the regions located below and above.

- In the photo, draw conditional vertical lines upward from the center of the base of the foot to the pelvis through the ankle, knee and hip joints. Any deviation of a part of the leg from the center line outward or inward is a displacement (valgus, vargus). The curvatures are directed to the outside (O-shaped legs), the curvatures are directed to the inside (X-shaped legs).

- In the photo from behind, draw five conditional horizontal lines at the level of the shoulder girdle, the lower edge of the shoulder blades, the iliac crests, the center of the popliteal fossa, and the ankles. Any deviation from the horizontal line is a displacement.

- In the front photo, draw five conditional horizontal lines at the level of the shoulder girdle, collarbones, lower edge of the ribs, iliac crests, center of the knee joints, ankles. Any deviation from the horizontal line is a displacement.

To analyze images of lateral projections (left and right), draw a conventional vertical line from the center of the ankle joint to the auditory opening of the ear. The auricle, shoulder joint, hip joint, and ankle joint should be located on the same vertical line. Any deviation of any region of the body from the line back or forward is a displacement, a violation of centering with a mandatory compensatory change in the regions located below and above.

Then, two parallel vertical lines are drawn on the lateral projection image, limiting the object at the edges (passing through protruding landmarks: the back of the head - the heels and the big toe - the nose). Any deviation of the body from the line back or forward is a displacement and a violation of centering. The body should not fall forward, the pose of a “skier” or “ski jumper” (body weight is shifted to the front of the feet). The body should not fall back, as if tipping over (body weight is shifted to the back of the feet, heels). Any deviation of any kind - a region of the body from the line back or forward is a displacement, a violation of centering with a mandatory compensatory change in the regions located below and above.

Simultaneously with photographic recording of the body, photography of the facial part of the skull can be taken, which can be used in the future for objective diagnosis of the craniofacial region.

- To analyze the frontal image, a conventional vertical line is drawn in the center of the face from the crown to the chin. Any deviation of the left or right side of the face from the center line is a displacement.

- On the frontal image, horizontal lines are drawn at the level of the eyebrows, pupils of the eyes, zygomatic arches, corners of the mouth, earlobes. Any deviation from the horizontal in one direction or another is a displacement. At the same time, it is not recommended to evaluate the location of the ears, eyes, eyebrows, cheekbones and their symmetry when the neck is displaced, general alignment is present, or the presence of pelvis-torso twisting is present. This can lead to confusion and prevent a correct and objective assessment of the conditions of the facial skull.

The general requirements for correct photodiagnosis are the correct application of a grid of vertical and horizontal lines, taking into account the general contours of the body and its position in space. When retaking photographs, it is necessary to maintain the same angles and distances for lens placement and subject orientation, and it is also preferable to choose the same lighting conditions. Failure to comply with these requirements can lead to an illusory change in the contours of the body, “swelling”. The image for analysis can be obtained both in color and in grayscale. Moreover, the latter option is preferable for visual analysis.

The next stage of diagnosis is an examination of the cervical region from the occipital-maxillary to the cervicothoracic diaphragm. This also includes an examination of the functional state of the vocal apparatus. Visual diagnosis of the position of the head and neck is carried out in relation to the position of the entire spine, upper shoulder girdle, arms, pelvis and legs. All this is considered together. A visual examination may reveal changes in cervical lordosis, tilt or position of the head in relation to the neck, and malocclusion. During visual inspection and palpation, fascial shortening and stiffness of the neck muscles can be detected, while adjacent tissues can be soft, swollen and, as it were, “extra”, collected in folds that should not be there normally. On the side of dysfunction, fascial shortening will be stiffer and more painful in hypertonicity, on the opposite side in normotonus, or overstretched. The myofascial system of the hypoglossal diaphragm is located in the cervical region. It consists of the hyoid bone, the muscles of the neck of the lower tier and the skeletal muscles of the tongue of the upper tier (bottom of the mouth), which have bony attachments to the skull, collarbones, ribs, and cervical vertebrae. Here it is necessary to take into account that the starting zone for controlling the skeletal muscles of the tongue is the myofascial complex of the sublingual diaphragm, which is involved in the acts of sucking, chewing, swallowing and in the formation of sound pronunciation, both normal and with phonetic distortions. In the case of speech therapy disorders, one has to deal with the absence of speech or disorders of sound pronunciation, such as lateral sigmatism, labiodental sigmatism, interdental sigmatism, softening defect, voicing/deafening defect, violation of physiological breathing as a primary type in the structure of a speech defect and, as a consequence, , impaired speech breathing is already secondary in the structure of the speech defect. With prolonged violations of the position of the neck, all organs located in this region (vertebrae, ligaments, hyoid bone, vocal folds, veins, arteries) and in the underlying region are displaced. Compression of the vertebral artery by articular processes may occur with instability of the cervical spine. Compression of the vertebral arteries is also possible by the neck muscles (scalenus, longus colli, inferior oblique capitis) during their fascial contraction or during certain prolonged positions of the head. Compression of the jugular veins, subclavian and carotid arteries is also possible with the scalene muscles and sternocleidomastoid muscles. Even with a slight displacement, restriction of tissue mobility, the quality of functioning of all organs in a given region, from myofascial structures to vascular structures supplying blood to the upper shoulder girdle, neck and craniofacial region with brain structures, decreases. Myofascial disorders in the cervical region can lead to problems with blood supply to the vertebrobasilar system (VBS). The VBS supplies blood to the following sections: the cervical spinal cord, the brain stem (exit of 12 pairs of cranial nerves), the cerebellum, part of the thalamus opticus and the hypothalamic region, partially the occipital, parietal and mediobasal sections of the temporal lobes of the brain. When there is insufficient blood supply in the vertebrobasilar region, symptoms are observed in various combinations. The cervical region is a conductor to the brain and provides two-way communication between the central parts of the nervous system and the organs and systems of the whole body. The vagus nerve, which innervates breathing, passes through the cervical spine (C3-C5 - innervation of the diaphragm, C1-C3 - auxiliary muscles that are involved in the expansion of the chest and lungs). The neck may be tilted forward, tilted back, and there may be rotation of the head to the left or right (symptoms of torticollis or GCM syndrome). Accordingly, in this position of the head, compensatory changes will occur throughout the body. Overall body centering, support and weight distribution will be balanced according to the dysfunctions created to maintain a balanced posture. For example, forward displacement of the head and neck increases lumbar lordosis. A protruded belly causes a misalignment, causing the body to deviate about 10 degrees backward and the neck to be pulled forward. There may also be mixed postural states, twisted, relative to the torso - pelvis. The whole body is shifted forward with a tilt of 5-10 degrees, and the left side of the body is rotated forward and to the right. In this case, the left side will be shortened in front, and the right side will be shortened in the back. Thus, when an imbalance occurs in any area, visual postural changes are observed at the level of the entire body, and displacements, clamps, compactions, contractions, “glues” in the form of balls, flagella, rigidities, and dips are felt by palpation in the fascial tissue of the body. When diagnosing these areas of the body, touch is usually ticklish, painful, and unpleasant. To carry out diagnostics most effectively in accordance with the proposed method, the author has developed a number of research techniques (tests).

Test No. 1: Visual examination of the position of the torso, head, neck, clavicular-humeral joints, shoulder blades, chest and palpation examination of the muscles of the cervical region, in order to identify deviations from the normal position of the neck relative to the body.

The relevant muscles and their functionality are examined in the following order:

- The sternocleidomastoid muscle, which normally tilts the head in its direction, turns the head in the opposite direction. With bilateral contraction, the cervical spine bends forward and the head straightens. Helps to straighten the head in the area of the 1st and 2nd cervical vertebrae (atlanto-occipital and atlanto-axial joints), and also controls excessive neck extension. Also acts as an accessory muscle for inhalation. With myofascial or neural hypertonicity, it is in a shortened state (bilateral, unilateral). With hypotonia, it is not able to perform its function in full. With dystonia, floating, unstable tone will be observed. An altered state of the myofascial tone of the GCM can lead to an asymmetrical position of the neck in relation to the upper shoulder girdle (right-sided, left-sided torticollis; a persistent or prolonged position with the head tilted forward; with bilateral myofascial shortening, there is a sort of subsidence, retraction of the neck into the body with the chin moving forward, or vice versa, with the head and chin down). The stoop increases, the clavicular-humeral joints are brought inward.

- The digastric muscle, the posterior belly, normally pulls the hyoid bone up and back, lifts the larynx upward, and is involved in swallowing and pronunciation of sounds. With myofascial or neural hypertonicity, it is in a shortened state. With hypotonicity, it does not participate in the upward and backward movement of the larynx and hyoid bone. With dystonia, floating, unstable tone will be observed. An altered state of myofascial tone can lead to a persistent or prolonged position of the hyoid bone in a retracted state. Accordingly, the root of the tongue will be pulled back and raised by a slide, which leads to the formation of the lower structure of the tongue and the lower structure of the sounds Ш, Ж, Х; formation of the throat sound R; lack of formation of the front-lingual sounds T, D, N with their possible replacement by the back-lingual sounds K, G, X; softening of consonant sounds, impaired swallowing or impaired formation of sound pronunciation.

- The stylohyoid muscle normally pulls the hyoid bone upward and backward. Participates in fixation of the hyoid bone. With myofascial or neural hypertonicity, it is in a shortened state. With hypotonicity, it does not participate in fixation and stabilization of the hyoid bone. With dystonia, floating, unstable tone will be observed. An altered state of myofascial tone can lead to a persistent or long-term position of the hyoid bone in a pushed position back; accordingly, the root of the tongue will be pulled back and raised by a slide. This leads to the formation of the lower structure of the language and the lower structure of the sounds Ш, Ж, Х; formation of the throat sound R; the absence of formation of the anterior lingual sounds T, D, N with their possible replacement by the posterior lingual sounds K, G, X.

- The mylohyoid muscle forms the floor of the oral cavity and is involved in raising the hyoid bone with the larynx and lowering the lower jaw.

- The scapulohyoid muscle, with the scapula fixed, pulls the hyoid bone back and down.

- The sternohyoid muscle pulls the hyoid bone down.

- The sternothyroid muscle pulls the larynx down.

- The thyrohyoid muscle pulls the hyoid bone down and raises the larynx (with a fixed hyoid bone).

- The anterior and middle scalene muscles tilt the head to their side; with bilateral contraction, tilt the head forward; with the head in a fixed position, the upper ribs (1st rib) are raised, participating in inhalation; lower the ribs when exhaling.

- The posterior scalene muscle tilts the head to its side. With bilateral contraction, the muscles tilt the head forward. With the head fixed, the second ribs (II rib) are raised, participating in inhalation. The ribs lower when exhaling.

- The longus colli muscle tilts the head to its side. With bilateral muscle contraction, the head is tilted forward.

- The longus capitis muscle tilts the head forward.

- The anterior and lateral rectus capitis muscles tilt the head forward and to the sides.

- The posterior rectus capitis muscles and the oblique muscles of the capitis, with unilateral contraction, tilt the head in their direction, with bilateral contraction, they throw back the head.

For speech therapy examination, the following examples of functional disorders in the cervical region can be given: torticollis, short neck, “grown” into the shoulders; head thrown back; head tilted forward and down; horizontal folds on the front and side of the neck - “necklace”; folds behind the ears; difficulty turning the head to the sides and throwing it back; arched clavicles; shoulders pulled forward; one shoulder is higher than the other; slouch; deformed chest.

Displacement and change in muscle-fascial tension in any region can affect postural changes in an ascending or descending manner, depending on the location of the disorder, and lead to changes throughout the body. These changes are forced compensation, which subsequently leads to secondary forced compensation in the area of the respiratory, vocal, and articulatory apparatus. In the described case, this can lead to a decrease in the quality of physiological breathing (inhalation, exhalation, smoothness, uniformity), defects in voice formation, sound production and the quality of the syllabic structure of words.

The next stage of diagnosis is an examination of the thoracic region, from the cervicothoracic to the thoraco-abdominal and pelvic diaphragm. This stage also includes an examination of the functional state of the respiratory apparatus.

To carry out diagnostics, the type of breathing is determined. Typically, the following types of physiological breathing are distinguished: thoracic or costal, diaphragmatic or abdominal, thoraco-abdominal (combined, mixed), additionally, the upper thoracic or clavicular type of breathing is distinguished. Breathing carried out by the movement of the entire chest is called thoracic, produced with the help of the diaphragm and abdominal muscles - diaphragmatic or abdominal. The combined thoraco-abdominal type of breathing is the most beneficial for speech and beneficial for health (as the lightest, most economical, smooth and rich in the amount of inhaled and exhaled air). A normal calm inhalation is associated with the activity of the muscles of the diaphragm and the external intercostal muscles that lift the ribs. If the inhalation is intense, for example, during active speech training, then the auxiliary muscles of the torso and neck are activated, such as the sternocleidomastoid muscle, the anterior, middle and posterior scalene muscles. All of these muscles are inspiratory muscles and have a fulcrum in the cervical spine, which is made rigid by the action of other muscles: the pectoralis major and pectoralis minor muscles, when they act on the area of the shoulder blades and upper limbs in an abducted position; the lower fibers of the serratus anterior muscle and the latissimus dorsi muscle when the latter acts on the upper limb in the adduction-abduction position; serratus posterior superior; the upper fibers of the iliocostalis muscle, which are attached above to the transverse processes of the last five cervical vertebrae, and below to the arches of the six upper ribs. When you inhale, the diaphragm lowers, the ribs rise, and the distance between them increases. Normal calm exhalation is a passive process of returning the chest to its original position and is carried out by the internal intercostal muscles. In a standing position, the ribs lower under the influence of their own gravity. If the exhalation is intense, for example, during active speech training, then the auxiliary muscles of exhalation are activated, such as the muscles of the abdominal wall, rectus abdominis, external, oblique muscles; The internal oblique muscle strongly lowers the lower thoracic outlet. In the lumbar-thoracic region, additional muscles of exhalation are connected: the lower fibers of the sacrolumbar muscle, the longissimus dorsi muscle, the posterior inferior serratus muscle and the quadratus lumborum muscle. When exhaling, the diaphragm rises, the ribs move down, the distance between them decreases (Mikhailov S.S. Respiratory muscles // Great Medical Encyclopedia: in 30 volumes / chief editor B.V. Petrovsky. - 3rd ed. - M .: Soviet Encyclopedia, 1977. - T. 7: Dehydrases - Dyadkovsky - P. 529. – 548 pp.).

In the children being examined, upper thoracic, or clavicular, breathing is often observed (the shoulder girdle is raised when inhaling). Due to the slight excitability of the respiratory center in the child’s brain, underdevelopment of regulation, any physical, psychological stress or emotional reactions further contribute to increased breathing, the breathing rhythm is disrupted, and, consequently, the imperfection of speech increases and the prosodic side of speech is disrupted. This type of breathing is caused by shortening of the sternocleidomastoid muscles, scalene muscles, longus colli and inferior oblique muscles of the capitis, shortening of the pectoralis major and minor muscles. With the clavicular type of breathing, compensatory, there is no sufficient opening or movement of the ribs, myofascial stretching and sliding of fibers, the apices of the lungs and bronchi are not fully saturated with oxygen. This entails disruption of innervation and blood circulation in the organs of the respiratory system.

There is also an oral-nasal type of breathing. In a state of rest and silence, breathing should be through the nose with the mouth closed. In the state of performing a speech act (short phrase, monologue, dialogue), breathing is carried out in the oral-nasal manner. The inability to breathe oro-nasally also causes disorganization in pronunciation: omissions of sounds, hesitations in speech, “stuckness”, gasping for air in the middle of a phrase, in the middle of a word, phonetic distortions, etc.

The physiological type of breathing is primary and the basis for the speech act. During it, a combined, thoraco-abdominal type of breathing is preferred. With it, the chest evenly expands when inhaling and narrows when exhaling (uniform horizontal movement of the chest and abdominal muscles, back in all planes). The more complete the amplitude of the thoraco-abdominal inhalation, the smoother, stronger and longer the exhalation during the speech act. (Lungs // Las Tunas-Lomonos. - M.: Great Russian Encyclopedia, 2010. - P. 147. - (Big Russian Encyclopedia: [in 35 volumes] / chief editor Yu.S. Osipov; 2004 -2017, v. 17; Pyatin V. F. Chapter 8. Breathing // Human physiology / V. M. Pokrovsky, G. F. Korotko. - M.: Medicine, 1998. - T. 1. - P. 401 -442. - 448 p.) The person breathes fully - all systems work well. With dysfunctional breathing, disruptions and compensations begin (only the abdominal muscles work); sections of the chest - clavicular view), as a result - hypoxia of the tissues of the body and brain.

The speech act, namely, sound production and reproduction, voice production and reproduction, fluency of speech, tempo, length of a phrase with logical pauses directly depends on the quality of physiological breathing. With postural changes and postural disturbances, the speech system and the quality of the speech system will almost always suffer. From this point of view, in speech therapy, such an issue is not sufficiently covered; accordingly, at this level, diagnostics are not carried out, and the ways of correction are reduced to pedagogical training in starting only diaphragmatic breathing through the development of speech breathing, its duration and exhalation force.

Diagnosis of physiological respiration in children and adults, in accordance with the claimed method, begins with a visual and motor assessment of the quality of inhalation and exhalation at the point of expansion and contraction of the respiratory apparatus: synchrony, smoothness and consistency; the presence or absence of myofascial tension, shortening, limitation of mobility of bone and connective tissue structures. The nature of physiological breathing at rest and in silent mode is determined. Then it is suggested to take a deep breath and exhale smoothly in several cycles. The results of studies (tests) at rest and during forced breathing are recorded. When diagnosing, the following types of breathing are distinguished:

- Thoracic or costal. When inhaling, the chest rises and expands (from the upper to the lower section, synchronously). The collarbones and shoulder girdles coordinately follow the opening of the chest. The abdominal muscles remain in place. The central part of the lungs, external and internal intercostal muscles take a predominant part in breathing.

- Abdominal (compensated, forced type). When you inhale, the stomach inflates and expands. In the area of the lower thoracic region, the ribs do not expand in a horizontal vector. Pits or depressions are observed in the lateral area (landmark: area of the 12th intercostal space, diaphragm). As a rule, there is a hole or depression in the solar plexus area. The upper part of the chest is narrowed. In the area of the solar plexus, transverse folds are visualized on the skin of the abdomen. The myofascial structures of the lumbar and cervical spine are in a state of tension. The abdominal and lower back muscles take a predominant part in breathing.

- Diaphragmatic-abdominal (this type of breathing prevails among singers and athletes). When you inhale, the lower thoracic region expands, the lower ribs protrude slightly (area of the 12th intercostal space), and the abdomen rises in front and on the sides. Expansion during inspiration is synchronous, volumetric and horizontal. When you exhale, the opposite happens. The diaphragm takes a predominant part in breathing, with auxiliary muscles of the abdomen, lower back, and back.

- Thoraco-abdominal, or combined, most beneficial for speech and good for health. When you inhale, the entire thoracic region expands, the lower ribs protrude slightly, and the abdomen rises in front and on the sides. Expansion during inspiration is synchronous, volumetric and horizontal. As you exhale, the opposite happens - the abdomen and thoracic region descend, and the chest becomes smaller. This is normal breathing. The muscles of the abdomen, lower back, torso, neck, central part of the lungs, and diaphragm take a predominant part in breathing.

- Clavicular (forced, compensated type). When you inhale, the shoulder girdles rise, the collarbones are brought inwards, the neck is pulled into the shoulder girdles. When inhaling, a person throws his head back. With this type of inhalation, the stomach is drawn in. The upper part of the respiratory tract and the scalene muscles of the neck take a predominant part in breathing.

- Wavy (forced, compensated type). The abdominal type of breathing predominates. When you inhale, your stomach first inflates. Then, with effort, the chest rises up without expansion in the horizontal vector (landmark: the area of the 12th and 5th intercostal spaces). Raising, opening and expansion of the upper chest is minimal.

For the most effective implementation of the diagnostic method, the author proposes his own procedure for research (tests).

Test No. 2. Breathing in a standing position in order to determine the type of breathing (thoracic, abdominal, diaphragmatic-abdominal, thoraco-abdominal, clavicular, wavy). The examination of physiological respiration begins with a visual assessment and observation of the act of inhalation and exhalation at rest and during speech load. The child is in a standing position. The speech therapist (carrying out the diagnostics) is located to the right of the child during the test. He places his right hand on the child's belly, his left on the upper thoracic region. Asks the child to inhale and exhale several times.

Test No. 3. Breathing in a sitting position in order to confirm or exclude the clavicular type of breathing. The examination of physiological respiration begins with a visual assessment and observation of the act of inhalation and exhalation at rest and during speech load. The child sits on a chair in front of the speech therapist. The speech therapist is behind the child’s back and places the palms of his hands on his shoulder girdles, the phalanges of the 2, 3, 4, 5 fingers touch the collarbones, at the same time the second finger (index) touches the side surface of the neck, the first (thumb) finger is laid back and touches the back surface and base of the neck . The speech therapist asks the child to inhale and exhale several times. With the clavicular type of breathing, tension in the neck muscles, a clear raising of the shoulders and an accompanying movement with throwing back the head will be felt.

Test No. 4. Breathing in a lying position in order to determine the type of breathing (thoracic, abdominal, diaphragmatic-abdominal, thoraco-abdominal, clavicular, wavy). The examination of physiological respiration begins with a visual assessment and observation of the act of inhalation and exhalation only at rest and in silent mode. The child lies on the couch, with the speech therapist located to the right of the child. He places his right hand under the child's lower back, his left hand under the neck. Asks the child to inhale and exhale several times. If breathing is abdominal or wave-like, tension in the neck muscles and obvious tension in the shoulders and lower back will be felt. May be accompanied by a slight tilting of the head.

Based on personal practical experience over 25 years, the author in most cases encounters speech disorders in people with dysfunctional breathing patterns. The breathing apparatus operates with a smaller opening amplitude than it should be. Accordingly, the air supply to the vocal apparatus arrives with less volume, pressure and force. The vocal cords receive less stress. The vocal apparatus is involved in the formation of modulation, voice timbre, vowel sounds, consonant voiced and voiceless sounds. Various variations of phonetic disturbances in sound production are observed, from the absence of sounds to phonetic distortions. If the position of the neck, its inclination or bend changes and accordingly the position of organs, muscles, ligaments, bones in a given region changes (vocal cords, hyoid bone, skeletal and proper muscles of the tongue), then the quality of pronunciation is disrupted, the tongue changes its position in the oral cavity and does not provide adequate load on the dental arches, on the hard and soft palate, and does not provide support to the bone structures in the oral cavity. In turn, they begin to sag, narrow and change their position, and then another type of growth of the facial skeleton is formed according to the vertical type or “adenoid type”. With this formation of facial skeleton growth, children experience frequent otitis, laryngitis, tonsillitis, hearing loss, hypoxia of peripheral tissues and brain structures. With this condition, children may develop dysfunctional growth of the brain and facial skeleton with forced malocclusion.

The next stage of diagnosis is an examination of the craniofacial region with a study of the functional state of facial and speech motor skills. Persons with speech impairments (from the absence of one sound to a severe form of speech impairment) may experience a number of deviations in the state of motor skills, articulation, phonation, speech breathing and their synchronization. These deviations arise as a result of damage to various levels of the nervous system (central and peripheral, including all types of manifestations of dysarthria from minimal to severe forms) or the development of postural changes in the musculoskeletal system (consequences of birth trauma of the skull, sacrum and upper cervical spine, cesarean section) . To select means of differentiated corrective action, it is necessary to determine mobility in the articulatory and facial muscles, to assess the quality of voluntary motor skills in static and dynamic tests. To do this, carry out:

- Study of the state of facial motor skills (quality and volume of movements of the muscles of the forehead, eyes, lips, cheeks, chin).

- Study of the function of masticatory motor skills (quality and volume of movements of the temporal and masticatory muscles, condition of the temporomandibular joints-TMJ).

- Study of speech motor skills (quality, strength, accuracy, volume, switchability of movements of the lips, cheeks, tongue).

Test No. 5. Raise your eyebrows at the same time (“Surprise”). Move your eyebrows alternately. In this case, the following are involved: the occipitofrontal muscle and the frontal belly, which pull the eyebrow upward; occipital abdomen, which pulls the skin of the scalp back. In this case, the following assessments of functional impairments are used: full, clear implementation (absence of impairment); partial, not clear enough; sample failure.

Sample No. 6. Frown your eyebrows. In this case, the muscle that corrugates the eyebrow is involved, bringing the eyebrows together, forming vertical folds above the bridge of the nose. Assessments of functional impairments are made in the same way: full, clear implementation (absence of impairment); partial, not clear enough; sample failure.

Test No. 7: Squint your eyes. Close your eyelids tightly and close your eyes. In this case, the following are involved: the orbicularis oculi muscle, the sphincter of the palpebral fissure, which closes the eyelids and expands the lacrimal sac. Assessments of functional impairment are made in a similar manner.

Sample No. 8. "Window". Open your mouth wide (as when pronouncing the sound “A”) and close your mouth (as when pronouncing the “Fence”). When performing the test, the upper and lower front teeth are visible, the lips do not close. Everything is done slowly. Repeat 4-6 times.

When performing the test, the following muscles are involved: digastric muscle, anterior abdomen, which lower the lower jaw; the masticatory temporalis muscle, which lifts the lower jaw and pulls it back; the masticatory muscle, which lifts the lower jaw and pulls it forward; the lateral pterygoid muscle, which, with bilateral contraction, pushes the jaw forward, and with unilateral contraction, moves the lower jaw to the opposite side. In this case, the following assessments of functional impairments are used: full implementation (absence of impairment); partial, not clear enough; sample failure; jaw deviation to the left, jaw deviation to the right; uneven mouth opening; two-stage mouth opening.

Sample No. 9. “Comb” (top). Grab your upper lip with your teeth and pull it through, “combing” it between your teeth. When performing the test, the following muscles are involved: the mentalis muscle, which pulls the skin of the chin up and protrudes the lower lip; the masticatory temporal muscle, which lifts the lower jaw and pulls it back; the masticatory muscle, which lifts the lower jaw and pulls it forward; The medial pterygoid muscle, which lifts the lower jaw, pushes it forward. In this case, the following assessments of functional impairments are used: full implementation (absence of impairment); partial, not clear enough; sample failure; deviation of the jaw to the left, right; impaired mobility of the orbicularis oris muscle and the muscles intertwined with it (depressors and levators).

Test No. 10: “Comb” (bottom). Grab your lower lip with your teeth and pull it through, “combing” it between your teeth. When performing the test, the following muscles are involved: digastric muscle, anterior abdomen, which lower the lower jaw; the masticatory temporal muscle, which lifts the lower jaw and pulls it back; the masticatory muscle, which elevates the lower jaw, pulls it forward. Assessments of functional impairment are made in the same way as the previous test.

Sample No. 11. “Fence”. Smile, show your upper and lower teeth. The corners of the lips are stretched to the sides as much as possible and symmetrically. The teeth are aligned end-to-end, without “overlapping.” Hold in this position for a count of five. When performing the test, the following muscles are involved: the muscle depressing the angle of the mouth, which pulls the angle of the mouth laterally down; the subcutaneous muscle of the neck, which pulls the corner of the mouth down; the depressor labii inferioris muscle, which pulls the lower lip downward and laterally; the buccal muscle, which pulls the corner of the mouth back, presses the cheek against the teeth; muscle that lifts the upper lip and the wing of the nose; zygomatic minor muscle, which raises the corner of the mouth; the zygomaticus major muscle, which pulls the corner of the mouth outward and upward; the laughter muscle, which pulls the corner of the mouth laterally; the masticatory muscle (priprognathia), which raises the lower jaw and pulls it forward; the masticatory temporal muscle (priprogenium), which raises the lower jaw and pulls it back. In this case, the following assessments of functional impairments are used: full, clear implementation (absence of impairment); partial, not clear enough; sample failure; bilateral or unilateral drooping of the corner of the mouth; inability to expose the lower teeth; inability to expose the upper teeth; labial-dental sigmatism of whistling sounds (s, z, ts) and hissing sounds (sh, zh, ch, shch).

Sample No. 12. “Tube”. The teeth are closed. Pull your lips forward like a tube. The front four teeth are visible. The oval of the lips is smooth and symmetrical. Hold in this position for a count of five. (Similarly, tests and movements are used that change the size and shape of the vestibule of the mouth, thereby influencing the resonance of the entire oral cavity: “Elephant”, “Speaker”, “Rabbit”, “Proboscis”, etc.). When performing the test, the following muscles are involved: the orbicularis oris muscle, which pulls the lips forward and closes the oral fissure; the mentalis muscle, which protrudes the lower lip; muscle that lifts the upper lip and the wing of the nose; the zygomaticus major muscle, which pulls the corner of the mouth outward and upward; the laughter muscle, which pulls the corner of the mouth laterally. In this case, the following assessments of functional impairments are used: full implementation (absence of impairment); partial, not clear enough; sample failure; when trying to pull the lips forward, the jaws unclench and the mouth opens; the pronunciation of labial sounds p, b, m, f, v, o, u suffers.

Sample No. 13. “Smile.” Smile, don't show your teeth. The lips are tightly closed and stretched as far as possible to the sides. The smile is symmetrical. Hold in this position for a count of five. When performing the test, the following muscles are involved: the muscle depressing the angle of the mouth, which pulls the angle of the mouth laterally down; the subcutaneous muscle of the neck, which pulls the corner of the mouth down; the orbicularis oris muscle, which closes the oral fissure; the cheek muscle, which pulls the corner of the mouth back and presses the cheek against the teeth; levator anguli oris muscle; zygomatic minor muscle, which raises the corner of the mouth; the zygomaticus major muscle, which pulls the corner of the mouth outward and upward; the laughter muscle, which pulls the corner of the mouth laterally. Assessments of functional impairment are made in the same way as the previous test.

Sample No. 14. “Fence” - “Pipe” - “Smile” - “Pipe”

See above for the muscles involved when performing the test. In this case, an assessment of the switchability of movements is used. The evaluation criteria are similar to those described earlier.

Test No. 15 includes the “spatula” exercise, when the mouth is open without tension, the orbicularis oris muscle is relaxed, a wide, relaxed tongue must be placed on the lower lip, held in this position for a count of five. Another exercise is “brushing your teeth” (lower ones). In this case, you need to open your mouth and brush your lower teeth with the tip of your tongue. Movements should be performed with the tip of the tongue behind the teeth, along the alveoli left and right. When performing the test, the following muscles are involved: the sternohyoid muscle, which pulls the hyoid bone down; the thyrohyoid muscle, which pulls the hyoid bone down and raises the larynx (with a fixed hyoid bone); the mylohyoid muscle, which forms the floor of the oral cavity and is involved in raising the hyoid bone with the larynx and lowering the lower jaw; the genioglossus muscle, which pulls the tongue up and forward; digastric muscle, posterior belly, which pulls the hyoid bone upward and backward; styloglossus muscle, which pulls the tongue upward and medially; the tongue's own muscles, which change its shape. In this case, the following assessments of functional impairments are used: full, clear implementation (absence of impairment); partial, not clear enough; sample failure; tremor, tongue twitching; inability to hold the tongue in this position; the tongue is pulled deep into the mouth; insufficient downward movement of the tongue; involuntary raising of the tip of the tongue or individual parts of the tongue; lateral contraction of the tongue; lateral unilateral or bilateral sigmatism of whistling (s, z, c) or hissing (sh, zh, h, sch) sounds; changes in the tone of the muscles of the tongue, accompanied by its lengthening, protrusion, shortening, pulling back and raising its individual parts, curvature, and various lateral movements. The pronunciation of some vowel sounds (e, i) may also be affected.

Sample No. 16. “Candy”, “Cup”, “Brushing teeth” (upper). When performing the test, the following muscles are involved: the stylohyoid muscle, which pulls the hyoid bone up and back; digastric muscle, posterior belly, which pulls the hyoid bone upward and backward; the hyoglossus muscle, which pulls the root of the tongue back and down; the mylohyoid muscle, which forms the floor of the oral cavity and is involved in raising the hyoid bone with the larynx and lowering the lower jaw; the velopharyngeal muscle, which lowers the velum palatine, reducing the opening of the pharynx; styloglossus muscle, which pulls the tongue upward and medially; palatoglossus muscle, which lowers the velum palatine down, reducing the opening of the pharynx; the tongue's own muscles, which change its shape. In this case, the following assessments of functional disorders are used: insufficiency of lifting the tongue upward in the oral cavity; involuntary friendly movement following the tongue of the lower lip and lower jaw; throwing the head back; limited mobility of the tongue backwards; when the muscle tone of the tongue changes, lengthening, protrusion, shortening, pulling back and lifting of its individual parts, curvature, and various lateral movements can be observed; the pronunciation of sounds of the upper instep is distorted, as well as sounds that require the combined action of the indicated muscles of the tongue for their reproduction (l, l, r, r, w, w, h, sch, t, d); the articulation of vowels (a, e, o, y), as well as consonant sounds (g, k, x) is impaired; Possible lateral unilateral or bilateral sigmatism of whistling (s, z, c) or hissing (sh, zh, h, sch) sounds, kappacism (k, g, x), thetism (t, d).

The described tests can be used as diagnostic ones before implementing a method for correcting speech disorders - sessions of logofascial massage (LFM). During LFM sessions, they can be used to monitor the course of correctional measures and, as the innervation of muscle tone is restored during the sessions, they can be used as an articulatory load for the purpose of retraining and reloading the facial and articulatory muscles at the fourth and fifth stages of the described system (LFM).

If, during the initial diagnosis, the patient has difficulties in performing articulatory, respiratory, finger test tests, there are limitations or difficulties associated with general and fine coordination, this means that there is a possibility that there is a violation of the blood supply and innervation of the muscles of the face, tongue, neck, underlying sections and limbs (all types of dysarthria, dyspraxia, dysphonia, impaired swallowing, chewing; paresis, paralysis) at the central or peripheral level of the systems.

If, during visual diagnosis, there is asymmetry in the facial skeleton, in the cranial skeleton and in the brain-facial relationship, there is a malocclusion or dysfunction of the TMJ, there is a violation of posture, the neck is pulled into the shoulders or torticollis, one shoulder is turned anteriorly, the shoulder blades are at different levels, there is kyphosis, lordosis in any part of the spine - this means that there is a possibility that there is a violation already at four levels, namely: bone, innervating, myofascial and blood supply to the tissues of the craniofacial region (brain, face, tongue), and the cervical region, which provides neurotrophic regulation of the cervical region and head as a whole, and the underlying parts of the trunk and limbs (all types of dysarthria, dyspraxia, dysphonia, swallowing, chewing disorders; paresis, paralysis; valgus of the knee and ankle joints) at the central or peripheral level of the nervous system .

If there is instability of the spinal cord or impaired blood supply to the brain (VBB, venous outflow, arterial inflow), then the brain does not have enough resources for timely functional maturation (the blood supply to the brain stem is impaired - 12 pairs of cranial nerves, the medulla oblongata, the cerebellum and a third of the brain) .

If TMJ dysfunction is detected alone or in combination with malocclusion, then regional and cerebral blood supply and innervation may also be impaired in the joint area. As a result, developmental delays may be observed in varying degrees of manifestation (speech, intelligence, emotions, behavior, performance, learning material, cognitive interest, eating habits, etc.).

After implementing the methods of speech therapy diagnostics and before the start of speech correction sessions, logo-fascial massage, the speech therapist may recommend referring the child to a functional diagnostics doctor for screening to study the vessels of the neck and brain: duplex (triplex), ultrasound doppler (Doppler), TCD, ultrasound cervical spine and to conduct an EEG to study the functional maturity of the brain. If malocclusion and dysfunction of the temporomandibular joint are detected, the speech therapist recommends sending the child for an ultrasound of the TMJ.

It is important for a speech therapist to take into account the mechanisms of speech pathology described above, relying on anatomical biomechanics and, going to speech through the body, create favorable conditions for the disclosure of the patient’s own biological resources, which were given to him at birth. It is necessary to create conditions for centering, balancing, self-regulation, self-healing and harmonization. One specialist can, as quickly and efficiently as possible, relying on the proposed method of speech therapy diagnostics by Sakharovskaya and the method for correcting speech disorders described in RF patent No. 2723221, carry out integrated, comprehensive measures in order to identify and correct speech, functional and musculofascial disorders. And if necessary, he can refer the patient to doctors for an extensive examination, in order to confirm the identified abnormalities and prescribe additional treatment.

Claims (5)

1. A method of examining a patient before correcting speech disorders, including a comprehensive examination of the postural position of the entire body from head to feet, cervical region, thoracic region, craniofacial region, in which the functional state of the postural position of the body in an upright standing position is initially examined by visual examination of the presence of altered tone, displacements, shortening in any area of the body, mobility of the temporomandibular joint, limb joints, symmetry of the body relative to “top-bottom”, “left-right”, mobility of soft tissues of the body to identify deviations from the normotypical state; the next stage is an examination of the cervical region from the occipital-maxillary to the cervicothoracic diaphragm by visual inspection and palpation to identify displacements and muscle-fascial tensions, at the same stage the functional state of the vocal apparatus is examined by performing tests; the next stage is an examination of the thoracic region, from the cervicothoracic to the thoraco-abdominal and pelvic diaphragm; this same stage includes an examination of the functional state of the respiratory apparatus, including determining the type of breathing; the next stage is an examination of the craniofacial region with a study of the functional state of facial motor skills, including determination of the quality and volume of movements of the muscles of the forehead, eyes, lips, cheeks, chin; chewing motility, including determination of the quality and volume of movements of the temporal and masticatory muscles, the condition of the temporomandibular joints; speech motor skills, including determination of the quality, strength, accuracy, volume, switchability of movements of the lips, cheeks, and tongue. 2. The method according to claim 1, characterized in that during visual examination they use photographic recording of the body in a relaxed position in 4 projections, namely back, front, side left, side right, overlaying a grid of horizontal and vertical lines on the image and evaluating displacement of body parts relative to these lines, while in the photo from the front and back a conventional vertical line is drawn from the back of the head along the spine and down to the feet inclusive, assessing the symmetry of the left and right sides; draw conditional vertical lines upward from the center of the base of the foot to the pelvis through the ankle, knee and hip joints and evaluate the deviation of the leg from the center line outward or inward; in the photo from behind, five conventional horizontal lines are drawn at the level of the shoulder girdle, the lower edge of the shoulder blades, the iliac crests, the center of the popliteal fossa, the ankles and the deviation relative to them is assessed; in the front photo, five conventional horizontal lines are drawn at the level of the shoulder girdle, collarbones, lower edge of the ribs, iliac crests, center of the knee joints, ankles and the deviation relative to them is assessed; in the photo of the lateral projections, draw a conventional vertical line from the center of the ankle joint to the auditory opening of the ear and evaluate the location of the auricle, shoulder joint, hip joint, and ankle joint relative to it; then two parallel vertical lines are drawn, one of which passes through the back of the head and heels, the other passes through the big toe and nose, the deviation of the body from these lines forward and backward is assessed, then photographs are taken of the front part of the skull and in the photo a conventional vertical line is drawn from crown to chin, assessing the symmetry of the left and right sides of the face, draw horizontal lines at the level of the eyebrows, pupils of the eyes, zygomatic arches, corners of the mouth, earlobes, assessing the deviation from the horizontal in one direction or another.