Kinesitherapy methods in the medical rehabilitation of children with perinatal lesion of the central nervous system

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Abstract

Nowadays the leading place in the structure of diseases of children in the perinatal period, is occupied by the perinatal lesion of the central nervous system. Special attention should be paid to the issue of minimal use of medicines in children with perinatal pathology, which is why one of the main tasks of medical rehabilitation is still the development and scientific justification of new methods of kinesitherapy.

To study the results of research conducted by Russian and foreign authors on the issues of physical rehabilitation of children with perinatal damage to the central nervous system and to conduct an analysis of the effectiveness of the proposed technologies. The literature review for this article was conducted from the eLibrary, PubMed, Cochrane Library databases with a search depth of 10 years. The selection of publications was carried out using keywords: non-drug technologies; perinatal damage to the central nervous system; perinatal hypoxic-ischemic encephalopathy; kinesotherapy; neurodevelopmental therapy; massage, thin finger training method; dry immersion; fitball gymnastics; V. Voit therapy; Bobat therapy.

It is shown that the motor development of a child in the first year of life is the most important criterion in the formation of further processes of structural and functional maturation of the nervous system. Medical rehabilitation of children with perinatal lesions of the central nervous system is aimed at improving blood supply and metabolic processes in brain tissue, stimulation of neuromuscular conduction and normalization of central and peripheral regulation of muscle tone.

Currently, the issues of substantiating the use of various physical factors in the medical rehabilitation of children with perinatal lesions of the central nervous system from the standpoint of evidence-based medicine remain relevant.

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Results
Nowdays, there are a large number of scientific papers by domestic and foreign authors, which contain data on the effectiveness of various kinesiotherapy technologies in the medical rehabilitation of children with CNS PP. In the materials of these publications, the following methods of kinesiotherapy are leading: therapeutic massage, the method of thin finger training, dry immersion, fitball gymnastics, hydrocolonotherapy, Bobath therapy and Vojta therapy. The main advantage of the above methods of kinesiotherapy is the possibility of their early inclusion in the rehabilitation program of newborns with CNS PP, starting from 2-3 weeks of age.
Numerous studies show different methods of therapeutic massage. Massage applications are possible from the first weeks of life. The authors of publications have established multidirectional clinical effects during various massage techniques, which indicates the need for a differentiated approach when using therapeutic massage in children with CNS PP [11-14]. So, soft stroking, rubbing and kneading calms the nervous system, and such motor techniques can be used with high excitability of the body of a newborn, and tapping and pinching movements, on the contrary, have an exciting effect [11]. In foreign literature, there are publications describing the effectiveness of massage in premature newborns. It has been proven that the use of therapeutic massage increases vagal regulation, stimulates the functions of the gastrointestinal tract, and also harmonizes the level of insulin in the blood serum [14].
A.N. Nalobina analyzed various massage techniques in her research. It was found that when using connective tissue massage, there is a more pronounced improvement in gross motor skills and movements in children with CNS PP at the age of 1-2, 5-6, 10-12 months, and the use of classical massage was more effective at the age of 3-4 and 7 months. -9 months. In case of pathological muscle hypertonicity, greater effectiveness was determined in the case of the use of connective tissue massage, and in case of muscle hypotension, the use of classical massage techniques [11].
In a scientific study by E.I. Current describes the effectiveness of the use of the method of thin finger training in newborns with CNS PP. This method is a tactile stimulating massage of the hands and fingers and can be used in extremely small children in the first weeks of life. The tactile analyzer matures quite early and is already developed by the time the baby is born, a newborn baby has a great sensitivity to touch. By influencing the tactile receptors of the palms and fingers and toes of a newborn, the formation of new neural connections between the cortical sensorimotor centers of the hand and the oral region is stimulated, due to their anatomical proximity, which determines the positive effect of thin finger training on the dynamics of the development of cortical and subcortical structures responsible for the formation of fine motor skills and speech. An improvement in the clinical symptoms of very premature babies was found in the form of: an increase in spontaneous motor activity, the formation of reflexes of oral and spinal automatism, stimulation of self-sucking. [fifteen].
A large number of scientific publications emphasize the positive impact of therapeutic exercises in the formation of motor skills in newborns with perinatal lesions of the central nervous system, including premature ones. Gymnastics courses contribute to the improvement of motor, as well as emotional development [16].
An effective and affordable technology of kinesiotherapy is fitball-gymnastics, which is based on exercises with balls (fitballs) of various sizes, colors, degrees of elasticity and types of surfaces. A.N. Nalobina studied the effect of fitball gymnastics on the physical development of children in the first year of life with CNS PP. Various characteristics of the fitball act as additional tactile stimuli of the nervous system of children with the consequences of CNS PP. There is a harmonious distribution of information coming from all types of analyzers, which stimulates the formation of new functional connections between different parts of the cerebral cortex. In the work of A.N. Nalobina 2013. the dynamics of indicators of the state of the visual system was assessed in children of the first year of life with the consequences of CNS PP - by the middle of the fitball-gymnastics course, an improvement in visual concentration was noted, which persisted by the end of the course; motor development indicators were analyzed - by the middle of the fitball-gymnastics course, the indicator reflecting general movements increased by 1 point, with a further increase to 2.5 points after the course. It has been proven that fitball gymnastics is an effective method of kinesiotherapy in children with dysfunction of the visual sensory system and the vestibular apparatus, with a delay in the formation of adjusting reflexes [17].
According to a number of authors, the most physiological methods of kinesiotherapy in the rehabilitation of children with CNS PP is hydrokinesitherapy. This type of medical rehabilitation is based on the influence of the physical properties of water: the buoyancy force creates conditions for additional support and support for the child's skeletal muscles, facilitating the development of verticalization skills in water, water resistance (frontal, vortex and viscous resistance) contributes to training balance and corset, and hydrostatic pressure improves blood circulation, reduces muscle tension, and stimulates the cardiovascular and respiratory systems [18]. The selection of hydrokinesitherapy modes occurs individually for each patient [18, 19]. Studies have shown that hydrokinesitherapy contributes to mild stimulation of bone mineralization in premature newborns [15]. At the end of the course of hydrotherapy procedures, laboratory parameters of hemodynamics and parameters of gas homeostasis stabilized in premature infants [14]. The advantages of this rehabilitation technology include the possibility of its use in small children.
In scientific publications of domestic authors, the dry immersion method as an effective technology for the rehabilitation of children with CNS PP. The method is based on modeling weightlessness conditions, which provide a positive effect of the aquatic environment on the child's body without direct contact with water - the concept of a newborn's transition from prenatal weightlessness to gravity (a new sense of its weight). Clinical observations carried out by N.P. Bure and co-authors in 500 children with perinatal CNS lesions, aged 7 days to 9 months, showed that improvement in neurological symptoms occurs due to mild stimulation of spontaneous motor activity, improvement of microcirculation and tissue trophism. [20].
To date, great importance is given to scientific publications on the effectiveness of Bobath neurodevelopmental therapy. The technique was developed by British specialists: physiotherapist Berta Bobath and neurophysiologist Karl Bobath in 1943. Bobath therapy is aimed at: normalizing muscle tone, preventing the development of muscle contractures, improving balance, improving coordination, improving the quality and quantity of movements. The principle of the method is to form motor skills by sensory stimulation of proprioreceptors, which changes the sensations that arise during movements and static posture, which creates the possibility of correcting the motor functions of the child. Repeated repetition of stimuli contributes to the formation of new neural connections in the brain and the formation of correct motor stereotypes. The main directions of the therapeutic effect: in Bobath therapy are inhibition (suppression of pathological movements and postures), facilitation (facilitation of performing natural, physiological movements and maintaining a physiological posture), stimulation (to enhance the sense of the position of one's own body in space) [21].
A number of studies have shown the effectiveness of Bobath therapy in CNS PP. The introduction of this method into the rehabilitation treatment of such children occurs at an older age, when persistent motor disorders have already been formed, as well as in patients with an established diagnosis of cerebral palsy [22, 23]. Further in-depth studies are needed to study the effectiveness of Bobath therapy with an increase in the volume of clinical observations of children with the consequences of CNS PP, taking into account the severity of motor disorders, the severity of the disease and the nature of brain damage.
The leading place in the rehabilitation of children with CNS PP, according to Russian and foreign authors, is occupied by Vojta therapy. The Vojta Therapy was developed in the 1950s by the Czech neurologist Vaclav Vojta. This kinesiotherapeutic method is based on the principle of reflex locomotion, which consists in the activation of the main motor complexes of rolling and crawling, through the child's response to external influences in the form of muscle contraction in a specific reflexogenic zone. Repeated repetition of motor complexes of rollover and crawling restores functionally blocked nerve connections between the child's brain and spinal cord. Due to the proximity of sensory and motor areas of the cortex, the stimulation of motor skills indirectly affects the development and recovery of cognitive functions. [24].
In a study by foreign neurophysiologists, the effectiveness of Vojta therapy was established using the neuroimaging method of functional magnetic resonance imaging (fMRI). According to the publication, the effect of Vojta therapy on the brain structures responsible for the regulation of movements (basal ganglia, reticular formation) was described [25].
A number of studies have considered the possibility of including Vojta therapy in a complex of rehabilitation measures in children with severe forms of CNS PP, born at early gestational periods (25-36 weeks) with severe motor impairment, a high risk of developing a persistent neurological deficit, as well as disabling diseases, such as as cerebral palsy, focal epilepsy and mental disorders. The effectiveness of reflex Vojta therapy has been proven in studies by Russian authors. Thus, after the courses of Vojta therapy, the vast majority of children (60%) showed improvements in the form of the formation of new motor skills, a decrease in muscle spasticity, and the extinction of postural reflexes. In 40% of children, positive dynamics was observed 3-4 months after the end of the course [26].
The Center for Neurology in Frankfurt published an article describing a randomized controlled trial on the effectiveness of Vojta therapy in infants with congenital muscular torticollis compared with a group of children who received Bobath therapy. According to published data, with the same duration of rehabilitation measures, neurodevelopmental therapy and Vojta therapy proved to be effective in children's postural asymmetry and were relatively well used by parents. However, a statistically significant improvement in motor function was observed in the group of children treated with Vojta therapy. 

Conclusion
Thus, the motor development of a child in the first year of life is the most important criterion in the formation of further processes of structural and functional maturation of the nervous system. Medical rehabilitation of children with CNS PP sets important tasks: to improve blood circulation and metabolic processes in the brain tissue, to stimulate neuromuscular conduction, to normalize the central and peripheral regulation of muscle tone. Currently, the urgent issue is the need to justify the possibility of using various physical factors in the medical rehabilitation of children with perinatal CNS damage from the standpoint of evidence-based medicine, which is based on the principle of using only methods whose effectiveness and safety have been proven in the course of multicenter clinical trials.

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About the authors

Maya A. Khan

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine; Central state medical academy of department of presidential affairs; Filatov N.F. Children's City Hospital

Email: 6057016@mail.ru
ORCID iD: 0000-0002-1081-1726
SPIN-code: 1070-2800

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow, Moscow, Moscow

Maria G. Degtyareva

The Russian National Research Medical University named after N.I. Pirogov

Email: doctor_masha1@mail.ru
ORCID iD: 0000-0002-1118-7304
SPIN-code: 2877-0800

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Irina I. Ivanova

Central state medical academy of department of presidential affairs

Email: i.ivanova@mail.ru
ORCID iD: 0000-0002-8943-9321
SPIN-code: 6308-1355

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Natalya A. Mikitchenko

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine; Filatov N.F. Children's City Hospital

Email: mikitchenko_nata@mail.ru
ORCID iD: 0000-0002-9886-3810
SPIN-code: 6353-9780

MD, Cand. Sci. (Med.), Senior Research Associate

Russian Federation, Moscow, Moscow

Olga Yu. Smotrina

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine; Filatov N.F. Children's City Hospital

Author for correspondence.
Email: smotrinao@gmail.com
ORCID iD: 0000-0002-2465-3642
SPIN-code: 3527-2746

Junior Research Associate

Russian Federation, Moscow, Moscow

Zareta Kh. Shungarova

Filatov N.F. Children's City Hospital

Email: zareta64@mail.ru
ORCID iD: 0000-0002-3348-2611

MD, Cand. Sci. (Med.)

Russian Federation, Moscow

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