MOTOORIKA lisa. Kaili Puusepp
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1 MOTOORIKA lisa Kaili Puusepp Autsimispektrihäiretega laste motoorseid oskuseid on hinnatud kasutades erinevaid teste. Antud ülevaatartiklites kajastatuimad testid olid Movement Assessment Battery for Children (M-ABC,1992) ning The Test of Gross Motor Development (TGMD-2, 2000) ja Physical and Neurologycal Examination of Subtle Signs (PANESS; Denckla 1985). 1. PANESS Physical and Neurological Examination of Subtle Signs (PANESS; Denckla 1985). See on laiahaardeline uuring, mis koosneb 4 valdkonnast: kõnd, tasakaal, koordinatsioon, täpsus. Muuhulgas sisaldab ülesannet, kus katsealused sooritavad kiireid patsutamisliigutusi käe- ning jalajalabaga aja peale. Pööratakse suurt rõhku liigutuste kvaliteedile: hinnatakse kaasliigutusi (proksimaalsed, orofastsiaalsed, peegel-liigutused vastasjäsemega), muutuseid kehaasendis ning düsrütmiat. Test on standardiseeritud soo, vanuse ja käelisuse alusel. 2. ZNA The Zurich Neuromotor Assessment (ZNA; Largo et al. 2002). Se lle testiga püütakse eristada puhast motoorset funktsiooni adaptatiivsest funktsioonist. Vanuse normid on määratud lastele 5-18 aastat. Koosneb 11-st peen- ja jämemotoorika testist, muuhulgas võimaldab hinnata didakokineesi. 3. Movement ABC The Movement Assessment Battery for Children (M-ABC; Henderson ja Sugden, 1992) Koosneb kahest hindamiskomponendist: juhendaja täidetavast ankeedist ning standardiseeritud testist. Testi osad: käeline osavus, pallikäsitlusoskused, staatiline- ja dünaamiline tasakaal. Vanuse normid 4-12 aastastele lastele. 4. TOMI-H The Test of Motor Impairment-Henderson Revision (TOMI -H, Stott et al. 1984). Test koosneb samuti kolmest osast: käeline osavus, staatiline- ja dünaamiline tasakaal, pallikäsitlusoskused. Lastele vanuses 5-12 aastat. 5. TGMD-2 The Test of Gross Motor Development (TGMD -2; Ulrich, 2000). See on standardiseeritud test, kus hindamine toimub 12 põhillise liikumisoskuse alusel. Ka selles uuringus pööratakse rõhku liikumiskvaliteedile, hinnatakse liikumiste küpset mustrit. Uuring on jaotatud kaheks alagrupiks: lokomotsioon ning objektikontroll. Vanustele 3-10 eluaastat.
2 Lisaks on autismispektrihäiretega inimeste motoorset võimekust hinnatud testidega: Florida Apraxia Battery (2003), Griffith s test (1989), Bruininks-Oseretsky Sky test (1998), Bruininks-Oseretsky test (1987), Touwen scales (1982) jmt. PEENMOTOORIKA 1. Aeglasem korduvate käe- ja jalaliigutuste sooritus PANESS testi kasutasid: Dowell et al, 2009; Dzuik et al, 2007 ja Jansiewicz et al, 2006; ZNA testi: Freitag et al, Teadustöödes uuriti peamiselt düspraksiat, kuid ka motoorseid baasoskuseid. Mõõdeti käe- ja jalaliigutuse sooritamise kiirust (patsutamisliigutus käe- ja jalalabaga vastavalt ranne- ja kand toetatud) Viidatud on düspraksia esinemise ja aeglasemate käte- ning jala liigutuste positiivsele korrelatsioonile (Dzuik et al, 2007). 2. Aeglasem ja vähemtäpne käeline osavus Käelise osavuse testides kasutati lisaks teistele meetoditele mõõtmiseks sageli spetsiaalset Purdue Pegboard testi. Movement ABC : Green et al, 2002 ja Miyahara et al, 1997; TOMI-H testi: Manjiviona ja Prior, 1995; TGMD-s testi: Staples ja Reid, 2010; Pegboard test: Freitag et al, Diadokokinees. Freitag et al, 2007 kasutasid hindamiseks ZNA testi. Hinnati pronatsioon-supinatsioon liigutuste kiire järjestikuse soorituse sujuvust protokolli alusel 4. Kehvemad pallikäsitlusoskused (täpne viskamine ja püüdmine) Movement ABC testi kasutas Green et al., 2002, kus märgiti, et käteosavuse ja pallikäsitlusoskuste tulemused olid tugevas positiivses korrelatsioonis, kusjuures kehvemad pallikäsitlusoskused oli ka ainsaks parameetriks, mille alusel eristusid autismispektrihäirega ning spetsiifilise arenguhäirega lapsed olulisel määral. Sama testi kasutasid Miyahara et al, 1997, kus spekuleeriti selle üle, et kehvemad
3 pallikäsitlusoskused võivad olla seoses vähese harjutamisega. Pallikäsitlusoskuste harjutamine eeldab sotsiaalset interaktsiooni, koostööd partneriga. TOMI-H testi kasutasid Manjiviona ja Prior, Lapsed pidid viskama tennisepalli vastu seina ning selle kinni püüdma. Esines probleeme liigutuse jõu ja suuna kontrollimisel. Terakotikese viskamisel anumasse märgiti, et lapsed ei vaadanud sageli sihtmärgi poole. TGMD-2 testi kasutasid Staples ja Reid, Selles uuringus hinnati liikumise kvaliteeti ning märgiti, et paljudel ASH lastel esines raskuseid jõu- ja ruumiliste parameetrite täpsel arvestamisel palli viskamise ning löömise funktsioonil. Kokkuvõttes momentumi/jõu ja ajastuse/koordinatsiooni probleemid. Sama testi kasutasid enda uuringus ka Pan et al, Märgiti, et kuigi autismispektrihäirega ning hüperaktiivsetel lastel esineb sageli häireid motoorses soorituses, leidub mõlemas grupis ka lapsi, kelle motoorne sooritus on erisusteta. Autismispektrihäiretega laste sooritus antud testides oli tunduvalt madalam kui hüperaktiivsete laste sooritus, mis jäi omakorda alla tavalastele. Antud artiklis on välja toodud ka TGMD-2 testi kvalitatiivsed hindamiskriteeriumid. 5. Lisaks on leitud, et kognitiivse mahajäämuseta ASH-ga laste käekiri on kehvem kui vanuse ja IQ taseme poolest vastavatel tüüpilise arenguga lastel. Olles sealjuures olulises korrelatsioonis üldise motoorse võimekuse mitte IQ tasemega (Fuentes et al, 2009) JÄMEMOTOORIKA 1. Ebastabiilne tasakaal Green et al, 2002 ja Miyahara et al, 1997 kasutasid uuringus Movment-ABC testi, Manjiviona ja Prior, 1995 TOMI-H testi. Kõik autorid tõid välja, et ASH laste testi tulemused tasakaalufunktsiooni hindamisel olid madalamad, kuid üksikasju artiklites ei täpsustatud. PANESS testi kasutasid Jansiewicz et al Hinnati ühel jalal seismist silmad lahtikinni ning ühel jalal hüppamist.
4 ZNA testi kasutasid Freitag et al, Märgiti, et suuremad erinevused esinesid dünaamilises tasakaalus. Hindamiseks jälgiti küljelt-küljele ning ette hüppamist. Erisusi oli ka staatilises tasakaalus, mille hindamiseks pidid katsealused seisma ühel jalal silmad kinni, hoides samal ajal võimlemiskeppi pea kohal. 2. Häired kõnnimustris Enamikes käsitletud uuringutes on pööratud rõhku erinevate stress-kõndide jälgimisele (tandemkõnd, kannal- ja päkalkõnd). Ülevaateartiklites ei ole välja toodud leide uuringutest, kus on hinnatud kõnnimustri erisusi tavalisel lokomotsioonil. PANESS testi kasutasid Jansiewicz et al, 2006, kus anti kvalitatiivne hinnang erinevatele kõndidele: kannal, päkal, jalalaba külgedel ning tandemkõnd edasi-ja tagasisuunas. Hinnati kaasliikumisi, ebatavalise kehahoiu esinemist. Ming et al, 2007 uurimuses toodi välja, et 19%-l 152-st autismispektrihäirega uuringus osalenud lapsest esines vähemalt 6 kuu jooksul oma elus harjumus kõndida päkkadel, vaid vähestel lastel kaasnes selle harjumusega hüppeliigese liikuvuse piiratus. 3. Vähenenud koordinatsioon lokomotoorsetel oskustel (jooksmine, hüppamine) Staples ja Reid, 2010 kasutasid TGMD-2 testi. Reeglina suutsid kõik lapsed liikumisi sooritada, madalad hinded viitasid erisustele liikumiskvaliteedis. Raskuseid esines kahe kehapoole koordineritud liikumiste sooritamisel või käte-jalgade samaaegsete liigutuste sooritamisel, näiteks horisontaalhüppel esines varieeruvusi liikumise ajastuse ja koordinatsiooni oasas. Kätehoog oli sageli olematu ja veelgi vähesemad lapsed kasutasid käte liikumise abi maandumisel (etteliikumise pidurdamisel). Käte liikumised olid sageli halvasti koordineeritud või mittefunktsionaalsed. Näiteks hüplemise ajal käed jõu genereerimisele kaasa aitamise asemel lihtsalt vehklesid suvaliselt. Pan et al, 2009 kasutasid samuti TGMD-s testi. Suuremaid erinevusi märgiti galopphüppe sooritamisel ja hüplemisel. Allikad:
5 Dowell L R, Mahone E M, Mostofsky S H. Associations of postural knowledge and basic motor skill with dyspraxia in autism: Implication for abnormalities in disturbed connectivity and motor learning. Neuropsychology 2009; 23 (5): Dziuk M A, Gidley Larson J C, Apostu A, Mahone E M, Denkla M B, Mostofsky S H. Dyspraxia in autism: associations with motor, social, and communicative deficitis. Developmental Medicine and Child Neurology 2007; 49: Freitag C M, Kleser C, Schneider M, von Gontard A. Quantitative assessment of neuromotor function in adolescents with high functioning autism and asperger syndrome. Journal of Autism and Developmental Disorders 2007; 37(5): Jansiewicz E M, Golberg M C, Newschaffer C J, Denckla M B, Landa R, Mostofsky S H. Motor signs distinguish children with high functioning autism and Asperger s syndrome from controls. Journal of Autism and Neurodevelopmental Disorders 2006; 36: Green D, Baird G, Barnett A L, Henderson L, Huber J, Henderson S E. The severity and nature of motor impairment in Asperger syndrome: A comparison with specific developmental disorder of motor function. Journal of Child Psychology and Psychiatry 2002; 43: Manjiviona J, Prior M. Comparison of Asperger syndrome and high-functioning autistic children on a test of motor impairment. Journal of Autism and Developmental Disorders 1995; 25:23-39 Miyahara M, Tsujii M, Hori m; Nakanishi K, Kageyama H, Sugiyama T. Brief report: motor incoordination in children with Asperger syndrome and learning disabilities. Journal of Autism and Developmental Disorders 1997; 27: Staples K L, Reid G. Fundamental movement skills and autism spectrum disorders. Journal of autism and Developmental Disorders 2010; 40 (2): Fuentes CT, Mostofsky SH, Bastian AJ. Children with autism show specific handwriting impairments. Neurology 2009; 73: Pan C Y, Tsai CL, Chu CH. Fundamental movement skills in children diagnosed with autism spectrum disorders and attention deficit hyperactivity disorder. Journal of autism and Developmental Disorders 2010; 39(12):
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