 Wysłany: Śro 0:21, 18 Kwi 2007 Temat postu: |
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| Wysłany: Nie 11:15, 15 Kwi 2007 Temat postu: |
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| Wysłany: Nie 18:59, 08 Kwi 2007 Temat postu: |
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| Wysłany: Sob 19:45, 07 Kwi 2007 Temat postu: |
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| Wysłany: Czw 3:28, 05 Kwi 2007 Temat postu: cizbbdb |
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| Wysłany: Pią 7:16, 30 Mar 2007 Temat postu: rbctqwn |
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| Wysłany: Pią 7:15, 30 Mar 2007 Temat postu: qfjepjx |
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| Wysłany: Sob 12:27, 17 Mar 2007 Temat postu: upjxffg |
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| Wysłany: Sob 12:27, 17 Mar 2007 Temat postu: akalntz |
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| Wysłany: Pon 4:09, 05 Mar 2007 Temat postu: ltfcuzp |
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| Wysłany: Pon 4:09, 05 Mar 2007 Temat postu: qdqaqpe |
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| Wysłany: Pon 18:46, 10 Lip 2006 Temat postu: Neurologopedia |
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| Neurologopedia
Dział logopedii zajmujący się diagnozowaniem i terapią osób z uszkodzeniami neurologicznymi Układ nerwowy Układ nerwowy składa się z łańcuchów połączonych ze sobą komórek nerwowych zwanych neuronami. Każda komórka nerwowa składa się z ciała komórki, od którego odchodzą liczne dendryty (przyjmujące bodźce) i pojedynczy akson, czyli neuryt (przekazujący bodźce). Rodzaje neuronów: a) receptorowe (dośrodkowe, czuciowe) przekazujące podniety z obwodu do ośrodków nerwowych; b) efektorowe (odśrodkowe, ruchowe) przewodzące bodźce z ośrodków do obwodu; c) kojarzeniowe, przekształcające podniety odbierane przez ośrod. ner. na określone reakcje, np. ruchowe. Podziały układu nerwowego: 1. pod wzgl. anatomicznym: -centralny (mózg, rdzeń kręgowy); -obwodowy (12 par nerwów czaszkowych i 31 par nerwów rdzeniowych). 2. pod wzgl. funkcjonalnym: - somatyczny- unerwiający mięśnie poprzecznie prążkowane szkieletu i niektórych narządów wewnętrznych, np. krtani oraz zawierający ośrodki wyższych czynności nerwowych (psychicznych); - autonomiczny(wegetatywny)- unerwiający mięśnie gładkie i poprzecznie prążkowane narządów wewnętrznych, kierujący czynnościami układu krwionośnego, pokarmowego, oddechowego i innych. Układ pozapiramidowy (wzgórze wzrokowe i ciało prążkowane)- utrzymuje napięcie mięśni i reguluje automatycznie ich pracę. Uszkodzenie układu pozapiramidowego powoduje wzmożenie napięcia mięśni artykulacyjnych, zaburzenia natężenia głosu, rytmu i melodii mowy. Układ piramidowy kieruje ruchami b. precyzyjnymi, zależnymi od woli człowieka, uświadamianymi sobie. Uszkodzenie powoduje zaburzenia funkcjonowania ruchowego aparatu mowy, brak koordynacji między oddychaniem i fonacją. Kora mózgowa Świadomymi czynnościami człowieka kieruje kora mózgowa, stanowiąca ośrodek wyższych czynności psychicznych. Wyodrębnia się dwie części mózgu: półkula lewa i półkula prawa. Każda półkula zawiera: płaty: - czołowy, skroniowy, ciemieniowy, potyliczny; okolice: - ruchową, kinestetyczną (czucie ułożenia), słuchową, wzrokową; ośrodki: -węchowy, smakowy. W korze mózgowej wyodrębniane bywają zwykle: - ośrodki ruchowe- wysyłające bodźce do poszczególnych narządów ciała; - ośrodki czuciowe- odbierające bodźce z poszczególnych narządów; - ośrodki kojarzeniowe- pełniące funkcje scalające różnych czynności kory mózgowej. Niektóre czynności w trakcie mowy są automatyczne i nieświadome, np. oddychanie, inne są nabyte, zmechanizowane, np. ruchy artykulacyjne narządów jamy ustnej, są też czynności dowolne i świadome. Tak więc w procesie mowy zaangażowane są różne ośrodki centralnego układu nerwowego. Najważniejsze z nich tzw. ośrodki mowy- mieszczą się w korze mózgowej. Są to: - ośrodek Wernickego, zwany też słuchowym ośrodkiem mowy, obejmuje tylne części górnego zawoju skroniowego w lewej pólkuli; - ośrodek Broca- okolica ruchowa mowy, pole nr 44 w lewym płacie czołowym; - ośrodek Dejerina, tzw. wzrokowy ośrodek mowy (i pisma), w płacie potylicznym w pobliżu centrum wzrokowego. Nerwy czaszkowe I nerwy węchowe- charakter czuciowy, unerwiają nos; II nerwy wzrokowe- charakter czuciowy, unerwiają siatkówkę oka; III nerwy okoruchowe- charakter ruchowy, odpowiadają za ruchy gałki ocznej; IV nerwy bloczkowe- charakter ruchowy, odpowiadają za ruchy gałki ocznej; VI nerwy odwodzące- charakter ruchowy, odpowiadają za ruchy gałki ocznej; V nerw trójdzielny- charakter czuciowo- ruchowy, unerwia czuciowo powierzchnię twarzy, nosa i jamy ustnej, a ruchowo mięśnie żwaczy; VII nerw twarzowy- charakter ruchowy, unerwia mięśnie mimiczne twarzy; VIII nerwy statyczno- słuchowe- charakter czuciowy, unerwiają ucho wewnętrzne, odpowiadają za przewodzenie bodźców słuchowych oraz z narządu równowagi; IX nerwy językowo- gardłowe- charakter ruchowo- czuciowy, przewodzą unerwienie dla tylnej części gardła oraz bodźce smakowe, unerwiają czuciowo struktury ucha środkowego; X nerwy błędne- charakter czuciowo- ruchowy, unerwiają narządy szyji, klatki piersiowej, jamy brzusznej, unerwiają ruchowo całą mięśniówkę krtani; XI nerwy dodatkowe- charakter ruchowy, unerwiają mięśnie karku (zginanie głowy); XII nerwy podjęzykowe- charakter ruchowy, unerwiają mięśnie języka i szyji; XIII nerwy rdzeniowe (31par)- tworzą sploty szyjny, ramienny (8 par), krzyżowy (5 par), lędźwiowy (5 par), piersiowy(12par), guziczny (1 para). Badanie nerwów czaszkowych I Nerw węchowy - nie wykonuje się II Nerw wzrokowy: - odruch oczno-powiekowy (zamykanie oczu na bodziec świetlny) - odruch oczno-karkowy - wodzenie za przedmiotem (koniec 2 m.), siąga w 3 m. rozległość ok. 180 stopni - zamykanie powiek na zbliżanie do oczu jakiegoś przedmiotu (4 m.) Nerwy: (ściśle ze sobą współdziałają, unerwiają zewn. i wewn. mięśnie oczu) III okoruchowy IV bloczkowy VI odwodzący - objaw oczu lalki (reakcja pozostawiania oczu w ustawieniu niezgodnym z ruchem głowy) - ocena szerokości szpar powiekowych - badanie źrenic - badanie ustawienia i ruchów gałek ocznych - objaw zachodzącego słońca (w formie nasilanej u dzieci z wodogłowiem) - oczopląs V Nerw trójdzielny (czuciowo-ruchowy): - odruch rogówkowy (dmuchamy w oko powietrzem z gumowej gruszki - w odpowiedzi następuje zamknięcie oka) - odruch żuchwowy VII Nerw twarzowy: - obserwacja mięśni twarzy podczas spontanicznej aktywności ruchowej. Uszkodzenie powoduje zniesienie ruchomości mięśni twarzy. Przy uszkodzeniu jednostronnym twarz staje się niesymetryczna. Oceniamy charakter porażenia: 1. nadjądrowy (ośrodkowy) - dolne mięśnie są zajęte w stopniu znacznie większym niż górne 2. obwodowy - porażone równomiernie wszystkie mięśnie VIII Nerw przedsionkowo- ślimakowy: - odruch Moro, uszno-powiekowy - unieruchomienie na bodziec dźwiękowy (3-6 m.) - zwrot głowy w kierunku źródła dźwięku (4-6 m.) IX Nerw językowo- gardłowy X Nerw błędny: - sprawdzamy ustawienie i napinanie podniebienia oraz mięśni gardła i krtani - uszkodzenie prowadzi do zespołu opuszkowego - oceniamy jak przebiega ssanie (odruch ssania, cały proces ssania i połykania) Przy obustronnym porażeniu podniebienie nie unosi się przy fonacji, towarzyszy zaburzenie połykania (dysfagia) XI Nerw dodatkowy -unerwia mięsień mostko-obojczykowy - w rutynowym badaniu nerw ten jest pomijany (b. rzadkie uszkodzenia) XII Nerw podjęzykowy - unerwia ruchowo wszystkie mięśnie języka i mięsień brudkowo-gnykowy - uszkodzenie obwodowe powoduje jednostronny lub obustronny zanik mięśni języka z obecnością drgań pęczkowych. Encefalopatia Encefalopatią określa się jedną z form zespołu psychoorganicznego, która charakteryzuje się współistnieniem zaburzeń rozwoju psychoruchowego i zaburzeń neurologicznych. Rozróżnia się encefalopatię statyczną (stan nie ulega pogorszeniu) i encefalopatię postępującą (objawy postępują). Jej przyczynami mogą być: - uszkodzenia okołoporodowe, - choroby infekcyjne, - stany zapalne układu nerwowego, - udary mózgowe, - urazy wewnątrzczaszkowe, - choroby genetyczne, np. Down, - mózgowe porażenie dziecięce Do oceny encefalopatii konieczna jest: a. znajomość prawidłowego fizjologicznego wzorca rozwoju psycho – ruchowego dziecka. b. ocena stanu neurologicznego, c. obserwacja dziecka (generalnie ważniejsza niż badanie), d. wywiad (zazwyczaj rodzice plus książeczka zdrowia), który pozwala ustalić: - historię choroby, - stan ostry, czy przewlekły, - rozwój dziecka (kiedy osiągało kolejne etapy rozwoju), - stan postępujący, czy statyczny, - objawy ogniskowe, czy uogólnione. Ocena rozwoju psychoruchowego obejmuje cztery sfery: 1. Lokomocję i kontrolę postawy. 2. Koordynację wzrokowo – ruchową. 3. Kontakty społeczne. 4. Mowę. Badanie neurologiczne niemowlęcia przeprowadzamy w pozycjach: 1. W leżeniu na plecach (pozycja supinacyjna) – badanie głowy i nerwów czaszkowych, ruchy spontaniczne dziecka, ułożenie, napięcie mięśniowe, odruchy głębokie, automatyzmy ruchowe (odruch toniczny szyjny asymetryczny, odruch skrzyżowanego wyprostu, odruch Moro, odruchy chwytne). 2. W pozycji pionowej – ujmujemy niemowlę za nadgarstki i podciągamy do pozycji siedzącej, następnie chwytamy pod pachy i podnosimy do pozycji pionowej. Oceniamy: - ustawienie głowy przy pociąganiu (głowa opada 1 m. ż., w osi tułowia 4 m.ż, unosi wyżej 5 m.), - ustawienie tułowia i kończyn (obecność odruchu podparcia do 4 m.), - odruch błędnikowy prostujący głowę (linia ust równoległa do podłoża, szczyt głowy układa najwyżej). 3. W leżeniu na brzuchu (pozycja pronacyjna) – oceniamy sposób ustawienia ciała i ruchy lokomocyjne (odruch toniczny szyjny symetryczny, odruch Galanta, można sprawdzić odruchy skokowe). 4. W pozycji poziomej skierowanej twarzą do dołu – sprawdzamy, jak dziecko utrzymuje głowę, tułów i kończyny (odruch Landaua), odruch spadochronowy. Badanie głowy ma ustalić prawidłowości wzrastania głowy. Zaburzenia mogą się przejawiać zmniejszonymi wymiarami (małogłowie), jak i zwiększonymi (wielkogłowie) – obwód głowy jest mniejszy, większy niż trzy odchylenia standardowe Mózgowe porażenie dziecięce Mózgowe porażenie dziecięce nie stanowi odrębnej jednostki chorobowej, a jest różnorodnym etiologicznie zespołem objawów chorobowych, głównie zaburzeń ruchowych. Wczesnymi objawami są zaburzenia podstawowych czynności fizjologicznych – ssanie, połykanie, zaburzenia rozwoju psychoruchowego. Definicje w literaturze przedmiotu: Wg prof. E. Marszał mózgowe porażenie dziecięce to wieloetiologiczny zespół wyrażający się poprzez zaburzenia ruchu i postawy, którego obraz kliniczny zmienia się z wiekiem w zależności od kolejnych etapów dojrzewania struktury i funkcji OUN. Z kolei K. Szymańska określa mózgowe porażenie dziecięce jako pojęcie obejmujące grupę nie postępujących lecz często zmieniających się zespołów ruchowych będących następstwem uszkodzenia lub zaburzenia rozwojowego mózgu we wczesnym stadium jego rozwoju. J. Czochańska pisze, że mózgowe porażenie dziecięce to różnorodne zaburzenia czynności i postawy, będące następstwem uszkodzenia mózgu znajdującego się w stadium niezakończonego rozwoju lub nieprawidłowościami w jego rozwoju nabytymi przed urodzeniem, w okresie okołoporodowym, lub po urodzeniu we wczesnym dzieciństwie. M. Michałowicz stoi na stanowisku, że pod pojęciem mózgowego porażenia dziecięcego należy rozumieć powstałe w czasie ciąży, porodu lub w okresie okołoporodowym nie postępujące zaburzenia czynności będącego w rozwoju ośrodkowego układu nerwowego, za szczególnym uwzględnieniem ośrodkowego neuronu ruchowego. Etiologia: – krytyczny okres między 26-34 tygodniem ciąży, – u wcześniaków jest pourodzeniowe (ciężkie niedotlenienie i krwawienie do i/lub okołokomorowe), – wraz ze wzrostem masy ciała noworodka większą rolę odgrywają czynniki prenatalne, – czynniki genetyczne (rodzinne zgodnie z prawem Mendla), – chromosopatie, – zakażenia wewnątrzmaciczne, – małogłowie, wielkogłowie, – czynniki prawdopodobne (niska punktacja Apgar, odma opłucnowa – powikłana, machaniczna wentylacja powyżej 7 dni). Podział kliniczny: Do dominujących w obrazie klinicznym objawów zaburzeń ruchowych należą: – zaburzenia napięcia mięśniowego – niedowłady kończyn – ruchy mimowolne – zaburzenia zborności ruchów i równowagi I Porażenie lub niedowład mięśni jednej połowy ciała – PORAŻENI KURCZOWE POŁOWICZE – HEMIPLEGIA SPASTIKA II Porażenie lub niedowład mięśni obu stron ciała – PARAPLEGIA W zależności od rozległości zaburzeń ruchowych wyróżnia się zespoły: – niedowład jednej połowy ciała – HEMIPLEGIA – obu kończyn dolnych – DIPLEGIA – obu kończyn górnych i dolnych – QUADRIPLEGIA – kończyny górnej i obu kończyn dolnych – TRIPLEGIA – niedowład jednej kończyny dolnej – MONOPLEGIA Podział mózgowego porażenia dziecięcego wg Hagberga 1. Zespoły spastyczne (uszkodzenie układu piramidowego) - napięcie mięśniowe jest większe niż prawidłowe (hipertonia) 2. Zespoły dyskinetyczne, atetotyczne (uszkodzenie struktur i dróg pozapiramidowych) – napięcie jest na przemian zbyt duże i zbyt małe, nagle zmieniające się, ruchy mimowolne (postać hipertoniczna-hipokinetyczna lub hipotoniczna-hiperkinetyzna) 3. Zespoły ataktyczne (uskodzenie móżdzku i jego połączeń) – napięcie mięśniowe jest zbyt niskie (hipotonia), bezład ruchowy, niezborność, dyskoordynacja ruchów, zaburzenia równowagi, niemożność wykonywania ruchów celowych, mowa skandowana 4. Formy mieszane – występują objawy wszystkich trzech wymienionych zespołów Nieprawidłowości towarzyszące mózgowemu porażeniu dziecięcemu: – napady padaczkowe, – opóźnienie rozwoju umysłowego, – zaburzenia mowy (nieprawidłowości w zakresie oddychania, fonacji, artykulacji), – zaburzenia słuchu i wzroku, – zaburzenia połykania, – zaburzenia wchłaniania, – reflux żołądkowo-przełykowy, – upośledzenie wzrastania, – zaparcia, – przykurcze, skolioza. Literatura: Mierzejewska H., Przybysz-Piwkowa M. red., Mózgowe porażenie dziecięce. Problemy mowy, Warszawa 1997 Charakterystyka mowy dzieci z mózgowym porażeniem dziecięcym Według Z. Kułakowskiej rozwój mowy dzieci z mózgowym porażeniem dziecięcym zależy od poziomu umysłowego dziecka oraz postaci klinicznej mózgowego porażenia dziecięcego. Autorka posługując się badaniami Tardieu podaje, że liczbę dzieci z mózgowym porażeniem dziecięcym mających trudności mowy ocenia się na 50-80%. Trudności te występują u 50% dzieci z normą intelektualną i aż u 94% opóźnionych umysłowo. Podstawowe czynniki etiologiczne wywołujące zaburzenia mowy (wg Z. Kułakowskiej): 1. Opóźnienie umysłowe z okołoporodowym uszkodzeniem mózgu (75% przypadków). 2. Zaburzenia słuchu (występują u 25% dzieci z mózgowym porażeniem dziecięcym w normie intelektualnej, wskaźnik ten wzrasta wraz ze wzrostem stopnia opóźnienia umysłowego). 3. Zaburzenia ruchowe zależne od lokalizacji uszkodzenia ośrodkowego układu nerwowego: - lokalizacje specyficzne odpowiedzialne za mechanizmy mowy (u dzieci spastycznych zaburzenia mowy mają związek z zaburzeniami napięcia mięśniowego w zakresie jamy ustnej, języka i krtani, co prowadzi zawsze do zwolnienia wypowiadania i do dyzartrii; - lokalizacje związane ze strukturami asocjacyjnymi, które są odpowiedzialne za praksje i gnozje. Zaburzenie to polega na braku poczucia „schematu ciała” w obrębie twarzy i jamy ustnej, przejawia się nieadekwatnością schematów ruchów związanych z mową, powoduje trudności integracji żucia i organizacji ruchu. 4. Czynniki psychiczne i emocjonalne (np. brak stymulacji mowy, odrzucające zachowania rodziców, niecierpliwość, ograniczanie kontaktów werbalnych). Mowa dzieci z mózgowym porażeniem dziecięcym jest monotonna, a jej tempo mniej lub bardziej zwolnione (bradylalia) – w znacznym stopniu taki stan zależny jest od sprawności ruchowej mięśni narządów mowy. U dzieci tych obserwuje się, jak podaje A. Otrębowski i B. Woźnica, agnozję akustyczną, dyslalię centralną, opóźniony rozwój mowy, jąkanie organiczne, dysgramatyzm i zaburzenia prozodii mowy (monotonia, monodynamia i bradylalia), poza tym zaburzeniom mowy towarzyszą zaburzenia połykania (dysfagia), głosu (afonia) i żucia. Zaburzenia czynności mówienia – nadawania u dzieci z mózgowym porażeniem dziecięcym to głównie zniekształcenia wyrazów spowodowane opuszczaniem lub dodawaniem głosek przez inne zaburzenia artykulacji oraz nieprawidłowe używanie form gramatycznych. Zaburzeniom rozumienia mowy towarzyszy upośledzenie umysłowe. Zaburzenia ekspresji słownej, zaburzenia rozumienia (wypowiadanie słów bez sensu), mały zasób słów przeważają u dzieci z niedowładem połowicznym lewostronnym. Z kolei u dzieci z niedowładem połowicznym prawostronnym przeważa nieprawidłowa motoryka narządów mowy, zaburzenia rozumienia sensu słów, ubogi słownik. Niezależnie od strony porażenia mózgowego występują u dzieci zaburzenia ekspresji słownej i stosunkowa niski zasób słów, natomiast dominująca strona niedowładu determinuje rozumienie (przy lewostronnym niedowładzie rozumienie gorsze). Głębokie zaburzenia mowy a nawet jej brak występuje u dzieci z postacią niedowładu trój- i czterokończynowego. Zaburzenia artykulacji obserwuje się najczęściej u dzieci z pozapiramidową postacią mózgowego porażenia dziecięcego, a nieco rzadziej u dzieci z niedowładem obu kończyn dolnych. Literatura: Kułakowska Z., Zaburzenia rozwoju mowy w mózgowym porażeniu dziecięcym, w: Mózgowe porażenie dziecięce. Problemy mowy, red H. Mierzejewska, M. Przybysz-Piwkowa, Warszawa 1997. Otrębowski A., Woźnica B., Zaburzenia dysartryczne u dzieci z mózgowym porażeniem dzieciecym, w: Mózgowe porażenie dziecięce. Problemy mowy, red H. Mierzejewska, M. Przybysz-Piwkowa, Warszawa 1997 Afazja w literaturze przedmiotu Terminem fazja (łac. phasia) określa się zespół czynności neurofizjologicznych, odbywających się w ośrodkowym układzie nerwowym, odpowiedzialnych za mówienie i rozumienia. Przedrostek a- świadczy o braku w danym układzie określonej czynności, z kolei przedrostek dys- oznacza, że dana czynność została zniekształcona. W związku z tym pojęcie afazja oznacza całkowity brak mowy (mówienia lub/i rozumienia), natomiast dysfazja oznacza częściową utratę mowy spowodowaną uszkodzeniem struktur korowych odpowiedzialnych za czynności nadawczo – odbiorcze. Istotą afazji (dysfazji) jest dezintegracja mowy, wynikająca z zaburzeń mechanizmów programujących mowę, przy nie naruszonych mechanizmach wykonawczych, prowadząca do częściowej lub całkowitej utraty zdolności porozumiewania się jednostki, która wcześniej umiejętność tę już opanowała (Jastrzębowska 2001). Definicje afazji Afazja to: - spowodowane organicznym uszkodzeniem odpowiednich struktur mózgowych częściowe lub całkowite zaburzenie mechanizmów programujących czynności mowy (nadawanie i odbiór) u człowieka, który uprzednio już opanował te czynności (Maruszewski 1970); - częściowa lub całkowita utrata umiejętności posługiwania się językiem (systemem znaków i reguł gramatycznych), spowodowana uszkodzeniem odpowiednich struktur mózgowych (Styczek 1980); - zaburzenie dowolnego posługiwania się strukturami językowymi (nadawanie i odbiór mowy) na skutek rozchwiania ich korowych wzorców ruchowo-brzmieniowych, czyli artykulacyjno-słuchowych (Mierzejewska 1977); - w ujęciu lingwistycznym – częściowa lub całkowita utrata umiejętności budowania i percypowania tekstów słownych, czyli niemożność wyboru z magazynu językowego symboli (zazwyczaj leksykalnych i fonologicznych), wiązania ich w całość, użycia we właściwej kolejności, produkowania zgodnej z normą społeczną substancji (Kaczmarek 1982). Na podstawie literatury przedmiotu afazję (dysfazję) można określić jako: - zaburzenia zdolności używania symboli językowych, - zaburzenia symbolicznej funkcji mowy (rozumienia i wyrażania znaczeń przy pomocy słów, - niemożność rozumienia mowy lub wyrażania słowami myśli, mimo prawidłowego aparatu wykonawczego mowy (Jakimowicz 1987), - zaburzenia mowy powstałe wskutek uszkodzenia ośrodków mowy w korze mózgu (Prusiński 1989); - zaburzenia w językowym słownym porozumiewaniu się (Kaczmarek 1995 a). Literatura: JakimowiczW., Neurologia kliniczna w zarysie, Warszawa 1987. Jastrzębowska G., Kozołub A., Zburzenia sprawności komunikacji u osób dorosłych, w: Logopedia, red. T. Gałkowski, G .Jastrzębowska, Opole 2001. Kaczmarek L., Nasze dziecko uczy się mówić, Lublin 1982. Kaczmarek B. L. J., Mózg, język, zachowanie, Lublin1995 (a). Maruszewski M., Mowa a mózg. Zagadnienia neuropsychologiczne, Warszawa 1977 Mierzejewska H., Afatyczna dezintegracja fonetycznej postaci wyrazów, Wrocław 1977. Prusiński A., Podstawy neurologii klinicznej, Warszawa 1989. Styczek I., Logopedia, Warszawa 1980. |
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