Physiotherapist, PhD student Lithuanian Academy of Physical Education, Human Motorics laboratory, Kaunas, Lithuania¹

Director of Psycho-linguistic centre, Siberian institute for business, management and psychology, Krasnoyarsk, Russia²

In spite of big amount of sport and sanitary actions, designed by traditional medicine, the problem of help, development and education of somatic sick children remains actual.

In security system of health full-grown and childhood the problem of often being ill children remains important not only with physician-social, but also with economic standpoint. The volume of often being ill children among baby population accounts the biggest part at the age of 3 - 4 years. Except this, modern studies show that often being ill children category shares from 25% to 56,9% of all diseases at preschool age. The researchers confirm that often diseases are a factor of the risk to chronic pathology in teenage period and adult life (in 2 times more often cases of anemia, in 5 once more often heart diseases, about 60% - an allergic manifestations).

During the last years there has appeared the tendency to the diseases during more young age. The total amount of the diseases among children, including the preschool age, constantly grows. The volume of children with functional frustration and chronic disease is also increasing. In particular, on territory of Russia children of the first group of health (the absence of functional and morphological deflections) form whole only 16,2%, the second group (functional and morphological deflections with reduced receptivity of the organism) - 82,2%, the third group of health (the chronic diseases in stage of the compensations) form 1,6% of children. Accordingly, group of often being ill children is the most extensive in modern society.

It is accepted to consider that often being ill children - a phenomenon of specific age. This group is formed mainly by children of the preschool age, which are ill the different flue diseases more than four once a year. However studies show that sharp flue diseases to viral infections not the only reason for often diseases. The baby infections, sinusitis and cause of the chronic diseases in phase of the intensification only enter in the number of the reasons.

In study of N.G.Veseloe is specified that in Russian medicine often being ill are considered:

children before 1 if cases of flue diseases - 4 and more per annum;

children from 1 before 3 years - 6 and more ORZ per annum;

children from 3 before 5 years - 5 and more ORZ per annum;

children of 5 years - 4 and more ORZ per annum.

Quite often, the child is ill not only often, but also long (more than 10-14 days).

When we use the term "often being ill child", we mean not diagnosis, since practicing physician deals with clinical sound child, who is seasonly been ill by reason of temporary deflections in defensive system of the organism and has no temporary organic breaches in them.

D.N.Isaev characterizes the general condition of such children by manifestations, which possible mark as before neurotically (the breaches in dreams, teaks, pathological habits, groundless weeping), vegetal (the dizziness, headaches, breaches of the rhythm of the heartbeat, shortness of breath, swoons, the repeated stomachache, skin diseases, belch by air), somatic (the thirst, retching after meal, obesity and so on).

In structure of the chronic diseases this group of children, on studies of N.G.Veseloe, the most significant are: otolaryngology diseases (from 32% to 87,3%), organ of the digestion (from 20% before 25%), supporting-motor device (from 18,3% before 28,7%) and disease of the nervous system (the neurosis -23%, asthenia syndrome - 16,4%, small brain dysfunction - 9,8%, neurotic reactions - 6,5%). The total amount of disease in all age group on sex is higher in groups of boys.

The experience of medical practice allows to make the conclusion about absence of rack result in treatment of such children, since, passing course of the treatment, they soon fall ill once again and have to address again to their therapist physician. Accordingly, life of given categories of children is limited around families, they lose the full-fledged contact with peer that prevents their psychic development.

V.V.Nickolaeva and G.A.Arina confirm that special social situation of the development create for sick child two types of the restrictions: a) restriction motion, b) restriction to cognitive activity. However it is well-known that motor activity is an important form of self-definition of child, as well as the most strong factor of his development. Besides, change in cognitive activity of somatic sick child and insufficiency of the contact with peer change the social situation of the development greatly.

Different from situations of the development of sound child, special objective social situation of the development of often being ill child, which exists in case of existing disease, subjectively is revalued by child and forms the subjective component of the general picture of the somatic disease - an internal picture of disease. The internal picture of disease is a main complex secondary psychological on its nature, symptoms of the disease, and its origin, first of all, is connected with social factor of the life and education of child.

The study and close examination of subjective sides of diseases are an efficient way, which enables to value the internal world sick child objectively and mark the ways of correctional-developing activity with him.

Special, qualitatively other nature of the development to personalities often being ill child is conditioned as well as his personal particularity, which are closely connected with nature of the relations child with parent, his subjective knowledge and attitude to health, rather then only objective gravity of the disease. All this defines the original behavior of a child in situations of disease, which is possible to characterize as adaptive.

The data of psychological literature is pointing to differences of often being ill children from their sound peer on some individually-psychological features. So, they can be characterized by such features as characteristic expressed alarm, timidity, insecurity in itself, quick tiredness, dependency from opinion of surrounding (first of all from opinion of mother). The bad general state, restriction of the motion, heavy and long treatment brings development of emotional anxiety, breach in the dreams, high alarm, depression and regression. All this reflects the social situation of the development, forming in condition disease. The main consequence to this situation is a change to directivities of the personalities, in system of self esteem, in installation on activity.

In parallel with identical and even several up rated realized self confidence often being ill children can have negative emotional self relation. In this case the comparison with mother often exists, revealing in self destruction, impute to itself negative emotion, such, as grief (the sadness), anger (fury) and feeling of the blame.

It is interesting that with standpoint of the subjective picture of disease, for often being ill children have such characteristic as bi - polar attitude to it. So, of majority children understands that disease disturbs them: it is impossible to visit friends and relatives, to go outdoors, it is necessary to take treatment, take the medicine, sometimes it is even possible to get into hospital. But on subconscious level disease is more attractive for them, than health: "disease" most often is linked with red, yellow or violet color, but "health" - with black more often or gray. The disease is even "profitable" for child since it gives him possibility to approach to full-grown, get certain emotional support in the manner of cares and attention. The biggest amount of often being ill children suppose that during disease they will get attention and care of them.

If to speak of behavior the somatic sick child of senior preschool age, that it changes, often becomes "difficult" for surrounding adult. And though disease, in most cases, it does not stop the psychic development of a child, it distorts, burdens and slows its move. The situation of disease, being heavy psychic trauma, can not only actuate its compensational potential of the psyche, but also can destruct upon it.

There are specific particularities of the interpersonal interaction and activity of often being ill child. Here we can name the pertain insufficiency of the circle of the contact for sick child, objective dependency from adult (the parents, teacher), longing to get the help from them.

Exactly at preschool age one of the solving factor, defining lifestyle child, shaping the basis of his personalities, are an example of the nearest adult and particularly parents. Obviously that position of child to correct (sound) lifestyle and his attitude to disease - health defines and bolts the position of the parents. However studies show that parents more prone or exaggerate the condition of a child in situation of disease, or ignore change, occurring in organism and psyche of child. It is also possible to note low efficiency of applicable ways on introduction in lifestyle of the adult people of the firm identical beliefs about value and observance of sound lifestyle. Though it is in the know that personal example of the parents on shaping sound lifestyle is straightly connected with development of the active life position of child.

To the group of social factors, influencing upon development of often somatic diseases pertain the alcoholism, drug addiction and smoking by the parents, as well as usage on the way in crèche-kindergarten and back the public transport.

Besides, there are the studies, which show that in the group of often being ill children basically we can include children, whose parents have a more high social position and level of education.

The important social factor, disposing to often somatic diseases, is a fact of the attending by a child baby preschool institution, which, in turn, is accompanied by such provoking stress factor as long parting with parent and home; the hit in unacquainted, new on organizations and structure subject-spatial ambience; the long contact with strangers, teachers and personnel.

There are also biological reasons for often somatic diseases, among them we can find out genetic predisposition.

So we see that the problem of somatic ill children of pre-school age becomes more and more actual nowadays. The psychological and medical help in this case should be closely connected. The correctional work should spread not only on the group of children itself and be done by psychologists and physiotherapists but touch all people around a child and all spheres of his life.

The basic concepts of chest physiotherapy (CPT) in pediatric patients are identical to those in adults; this applies to the objectives of this therapeutic approach as well as to the mechanical principles applied for the clearance of abundant intrabronchial secretions from the airways [12]. The objectives of CPT are to prevent or reduce the mechanical consequences of obstructing secretions, such as hyperinflation, atelectasis, misdistribution of ventilation, ventilation/perfusion mismatch and increased work of breathing. Another therapeutic concept focuses on removing infective material, inflammatory mediators, and proteolysis and oxidative activity from the airways and in doing so reduces or even prevents host-mediated inflammatory tissue damage [11]. CPT might be seen as the therapeutic application of mechanical interventions based on respiratory physiology. As far as these mechanical approaches to airway clearance are concerned, CPT in pediatric patients and CPT in adult patients share a spectrum of basic principles, for example the upstream migration of compression waves that occurs with an ongoing forced expiration, gas/liquid pumping effected by the rhythmical distension and compression of the airways, and elevation of the lung volume to bring air behind obstructing secretions [10]. The basic difference between CPT for pediatric and for adult patients lies in the techniques by which these mechanical principles are effected.

In contrast to the adult, the pediatric patient presents a spectrum of age-specific physiological differences which are continuously changing during growth and development. Generally, these physiological differences are most striking in the premature and newborn baby, but are also present in infancy although the situation gradually changes into the adult standard during preschool and school ages. Disease-inflicted changes interfere with this growth and development, thus further modifying structure and function. To add further complexity, there is a changing psychological basis to the therapist/ patient interaction throughout childhood, and a voluntary cooperation with therapeutic techniques will generally not be possible before the end of the preschool period. It follows that CPT for mucus clearance in pediatrics must take a physiological and developmental approach that differs substantially from the methodology routinely applied in adults [9].

Physiotherapy should be applied write after the first illness days. Physiotherapy aims and tasks are dependant of operating conditions. During bed regimen, main physical therapy aims are:

Compensate breathing insufficiency.

To decrease an amount of dwelled secret in lungs.

No normalize child emotional conditions.

To activate child vital power.

Physiotherapist should use gymnastic exercises in a slow rate from light weighted positions. Those exercises are lengthening and thinning out breathing. During bed regimen therapeutic breathing exercises should be used, without resistance and forcing (without explosive inhale and exhale), static (during those exercises only main breathing muscles are under workload - diaphragm and m. intercostals ext.) and dynamic (during those exercises back and chest muscles power are improving). During I and II breathing insufficiency, if child can combine breathing with an exercise, it would be very effective to prescribe breathing exercises. It could be useful to perform lower extremities and chest massage [7]. They are performed from such starting positions:

Seating, hands behind the head and rose up (its better lower lungs sections ventilation).

Seating, hands lay down on the hip (its better anterior lungs sections ventilation).

Lying on the back (its better anterior lungs sections ventilation).

Lying on the side (then lower ribs movements are restricted).

Lying with the flexed legs (easier diaphragm breathing).

Seated.

Changing all those positions.

To improve lungs blood circulation, to decrease stasis, different exercises are recommended which are prescribed during ward regiment, and also exercises for upper extremities thus chest. During Ward regiment physical therapy aims are:

Do improve physiotherapy procedures effect.

To improve breathing.

To improve infiltrate emission from lungs tissue.

Cardiac function normalization.

To recover and to improve walking skills.

To adapt child body to a higher intensity workload according ward regiment.

During this illness period it’s very important to use easy exercises for all muscle groups and from all starting positions (laying, standing, sitting), middle intensity games. Thus breathing exercises are also prescribed, in this stage is possible to include breathing exercises with resistance, exercises for upper extremity, chest muscles exercises, and drainage exercises, exercises stimulating pathological secret extraction. During energetic exercises performance breathing rhythm is always more frequent and hyperventilation signs can be noticed. It can affect child health in negative way. Starting position has a huge impact to performed exercises. According to ward regiment, workload intensity is average, physiotherapist can use - short walking, active games, for the school age children individual independent tasks could be organized.

Complete external breathing recovery and normalization

Breathing efficiency amplification. Physical capacity and movement skills recovery

Child physical capacity and motor activity recovery.

To successfully come true those aim, during those periods, physiotherapist can prescribe generic exercise for all muscle groups and from all starting positions. In this term is possible to use sport games moderate and high intensity mobility games. From a special exercises groups breathing, relaxation, drainage exercises can be used. Exercises intensity is moderate and intensive. High intensity can be reached by extending exercise performance time, increasing workload and resistance! Starting positions to perform a task are used such to impede breathing by lying on the stomach, reclined on hands. It’s possible to use an exercises complex taken from adults program. As example:

• Head and neck position correction with a ball. To seat on the chair, with a straight backrest. Between back and backrest a small tennis ball is putted. By repeating this exercise the it possible to achieve the improvement of lumbar lordosis, child has a better breathing skill through the nose, his shoulder which is pathologically raised up during the illness are pulled down in a normal position, breathing becomes more rhythmic and rare.

• Blow through the closed lips, it improves breathing capacity and helps to prevent extra alveolar collapse. Patricianly ill children are doing it spontaneously. By mean time child is getting used to perform this exercise.

• The pressure with hands. For a comfortably lying or seating child, physiotherapist gently with his palms a pressing upper and lower chest segment. During 30-120 s. Thoracic muscles are relaxing, and breathing becomes more rhythmic and slower and deeper in a natural way.

• Rotation. For the half lying child physiotherapist pus his hand on child’s hip, and the other hand goes to his shoulder. During inhale, physiotherapist by holding the hip and pushing the shoulder is rotating a trunk "backwards", by exhale - "forwards". It improves thoracic muscle mobility and breathing becomes deeper.

• Percussion. Physiotherapist slightly with his palm fingers together performing chest percussion in a place of atelectasis and secret accumulation place. In this case the pathological secret removed more quicker.

• Springing. For the supine lying child physiotherapist is putting his hands on the lower part of the child chest and during inspiration the resists to expand of the chest moment. When the physiotherapist felt pressure he suddenly removes his hands. By this moment is possible to recover collapsed lungs sections, and the secret removes in a better way.

• Diaphragm breathing. Physiotherapist is putting his hand in epigastria section when the child is standing or sitting and breathing normally. When the child is making an attempts to exhale physiotherapist hand for a stomach. Inhale should be full according to capacity with closed lips through the nose. By this exercise is possible to recover diaphragm, the intercostals are also trained. It’s very important to monitor the jaw size, to guarantee adequate ventilation.

Those methods are very helpful especially for those children who have a strongly affected breathing muscle and there function is regulated with a nerve apart. Thus during exercising and during rest period it important to teach child not to be tensed, to relax his shoulder griddle muscle, to control thoracic kenosis and compensative lumbar lordosis. Time - frame for exercising for the school age child - 35-40 min; under school age - 25-35 min [8]. After the dismissing from the hospital children are usually sent to sanatorium rehabilitation. If the child is not going to sanatorium, usually his is getting his rehab program in a policlinic. Child is attending physiotherapy program not less then twice in a week and always correcting his program with individual tasks at home [7].

Bibliography:

Came to edition 11.11.2008.