RU2714213C1 - Method of medical rehabilitation of working age patients in early and late recovery periods of ischemic stroke - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to rehabilitation, restorative medicine, medical equipment, neurology and physiotherapy and can be used both in sanatorium-and-spa conditions, and outpatient in recovery of motor functions of patients after ischemic stroke (IS). Complex physiotherapy, exercise therapy and drug therapy are performed. Latter is Cortexin 10 mg IM, 10 daily injections. Parallel: (i) a transcranial electrotherapy with a feedback from the TETOS apparatus (TETOS-therapy), which is performed through electrodes oriented taking into account the international classification "10-20". During the first session, TETOS is sequentially: 1 – recording of initial brain bioelectric activity (BEA) for 1.5–2 minutes and its analysis, 2 – expert exposure: in the form of electric stimulation by bitemporal action using two-phase exponential current, exposure time 15 s, current intensity – by 20 % below threshold of patient's pain sensitivity, 3 – compensatory pause – 20 minutes. One of three types of patient's BEA reaction is recorded for exposure: a) diagnostic – in the form of changes in a number of BEA parameters; b) corrective, in case of which expert exposure is considered sufficient for BEA normalization; c) excessive, in which expert exposure causes EEG inversion to stimulation; (ii) performing exposure to dry carbonic baths (DCB) at temperature of 32–34 °C, flow rate – 20 l/min; (iii) low-frequency magnetotherapy (LfMT) is performed. DCB is carried out gradually increasing the concentration of carbon dioxide and reducing the exposure time according to the claim. LfMT is presented in the form of general magnetotherapy in the mode according to the invention formula. During TETOS-therapy in case of corrective and excessive reaction further exposure is postponed to the next session, where said sequence of first session receptions is repeated. In case of diagnostic reaction to expert exposure: a) if BEA parameters are changed by at least 75 %, further TETOS procedure length is 0.5–3.0 min; b) if the BEA parameters vary from 30 to 75 %, the following TETOS procedures – 3.1–6.0 min; c) if the BEA parameters change by less than 30 %, the following TETOS procedures are 6.1 to 8.0 min. TETOS-therapy sessions are performed every second day – 2-3 times a week, 2 weeks. Additionally, in the course of the course, the patient performs the exercises of the exercise therapy corresponding to existing motor disturbances, for example, functional training on the REO GO and C-mill devices.

EFFECT: method provides reducing the length of rehabilitation, prolonging the period of preservation of results achieved in rehabilitation – absence of repeated strokes for 2 years, possibility of individualizing physiotherapeutic exposure parameters, absence of polypharmacy and side effects when implementing complex rehabilitation actions.

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Description

The invention relates to rehabilitation, restorative medicine, medical equipment, neurology and physiotherapy and can be used both in a spa and outpatient setting when restoring the motor functions of patients after ischemic stroke.

In the Russian Federation, 500-550 thousand stroke patients are registered annually. Mortality after severe strokes is 30-40%. The level of disability a year after acute cerebrovascular accident (stroke) in Russia ranges from 76 to 85%, while in Western Europe it is no more than 25-30%.

In accordance with current pan-European recommendations, the main goal of rehabilitation is to achieve a level at which, after 3 months after a stroke, more than 70% of surviving patients would be independent in their daily activities.

It is proved that physical factors increase the functional reserves of organs and systems of the body due to compensation and adaptation of impaired functions, regulate neurohumoral and neuroreflex processes, stimulate intraorgan blood flow, the activity of adaptive systems and restore the balance between the sympathetic and parasympathetic parts of the autonomic nervous system and change immunoreactivity.

Despite the variety of rehabilitation programs after stroke, there are not enough clinical studies that substantiate the timing and extent of rehabilitation measures using physical factors, neurostimulation and biocontrol methods, and robotic mechanotherapy. There are no full-fledged pathophysiologically substantiated data on factors determining an individual rehabilitation prognosis for patients with stroke at different stages of rehabilitation, on the basis of which patients are assigned to a particular rehabilitation group, including taking into account their associated disorders.

Studies show that physiobalneotherapy methods included in medical rehabilitation programs allow differentially and directionally acting on pathogenesis links, increasing patient adaptive and reserve capabilities with minimal risk of adverse and allergic reactions. Comprehensive, combined methods of physiotherapy are preferred, leading to optimization of treatment, increased efficiency, and reduced rehabilitation time.

Recently, transcranial stimulation methods have been successfully used in the rehabilitation of patients after stroke. Positive effects on the dynamics of neurological symptoms, stabilization of cerebral blood flow were obtained with transcranial electrical stimulation (L. Tsukurova, 2008). Transcranial magnetic stimulation in a mode of increasing cortical excitability has a beneficial effect on learning and memory processes, attention and language skills, improving cognitive functions in patients with various neurological disorders, including stroke and neurodegenerative diseases (Venkatakrishnan A. et al., Langhorne P. et al. , 2011, Hamilton RH. Et al., 2011, Koch G., 2010).

The introduction of high-tech, computerized rehabilitation complexes operating in the biofeedback mode (BFB) is a priority area of motor rehabilitation of patients with central nervous system damage (Kochetkov A.V., 2008; Burridge J., 2009). The high-tech methods that have appeared in recent years make it possible to optimize and significantly increase the effectiveness of the motor rehabilitation of these patients. A modern technological development of domestic scientists is a feedback transcranial electrotherapy apparatus (TETOS-therapy), which uses pulsed electric currents of an individual nature under the control of the bioelectrical activity (BEA) of the brain.

A fundamentally important point in the operation of the TETOS diagnostic and treatment complex is the continuous recording and automatic analysis of brain BEA by removing the EEG, which ensures high quality diagnostics and assessment of the body's reactions to electrical effects to select the optimal parameters of the treatment current individually for each patient and increase the effectiveness of therapy.

In the rehabilitation of patients with cardiovascular, neurological disorders, it is known to carry out air-carbon dioxide and air-radon treatment procedures using the "REABOX" unit (see, for example, RU 2567827 C1, publ. 10.11.2015, FSBI "RSC MP and K" Ministry of Health of Russia). This is a multifunctional automated treatment unit in which the patient is placed in an air environment with a controlled temperature (25-42 ° C), while the patient’s head is located outside the chamber. Dry baths are used for patients with severe pathology, for whom water baths, as more stressful for the cardiovascular system, are contraindicated.

Dry carbon dioxide bath is intended for patients who are contraindicated in mineral carbon baths and can use the action of carbon dioxide, excluding the mechanical (hydrostatic) and temperature effects of water, which is a contraindication in a number of pathological conditions. Excluded inhaled intake of carbon dioxide in the body (Fig. 1). Gas acts, forming a depot in the skin, causing a constant and lasting effect on the vessels and nerve endings.

Gas concentration, temperature and humidity, flow times and procedures are set and maintained automatically. The required concentration of carbon dioxide (15-30%) is achieved instantly.

When performing SUV, there is a decrease in heart rate and blood pressure, accelerated blood flow and improved ventilation function of the lungs. Carbon dioxide, penetrating the body through the skin, provides a significant expansion of its blood vessels, which leads to an acceleration of blood flow, a decrease in its viscosity and the elimination of stagnation in the vessels.

Therefore, indications for the use of SUV are diseases of the cardiovascular, respiratory systems, metabolic disorders and endocrine diseases, diseases of the musculoskeletal system, skin and nervous system. SUV is contraindicated in unstable angina pectoris, recurrent myocardial infarction, any acute conditions, cancer, pregnancy, stroke (in the acute period), renal failure.

SUV can also be carried out in a conventional therapeutic bath suitable for such a procedure; the presence of the Reabox installation is not necessary.

It is known that TETOS is used in patients with neurocirculatory dystonia (EV Maysak et al. An improved TETOS technique in patients with vegetative-vascular dystonia // Uchenye Zapiski Oryol State University. No. 3 (59), 2014, pp. 223-227). In this case, 4 forms of stimulating currents were used:

1. unipolar exponential impulse (has a strong annoying effect, the duration of the corrective action is up to 30 seconds);

2. unipolar rectangular pulse with a high-frequency filling (has increased energy impact, stimulation duration of 0.5-7 minutes);

3. unipolar rectangular impulse (used for minor functional impairments, stimulation duration 0.5-7 min);

4. bipolar-exponential impulse (recommended for varying degrees of functional disorders in patients of all ages, exposure duration 0.5-15 minutes).

The uniqueness of TETOS lies in its double meaning: the 1st stage is always diagnostic - registration and analysis of brain BEA to monitor the subsequent exposure regimen, its personification; The 2nd stage of treatment is aimed at normalizing the activity and distribution of slow and fast rhythms, eliminating interhemispheric asymmetry and, therefore, stabilizing the central mechanisms of microcirculation.

Although the aforementioned known method indicates the performance of TETOS procedures in two patients in the early recovery period after cerebral infarction, however, specific effective regimens for using TETOS for rehabilitation in the early and late recovery periods of ischemic stroke have not been developed.

It is known that TETOS is carried out in the rehabilitation treatment of patients with dorsopathy with neurological manifestations (RU 2355439 C2, publ. 05/20/2009, Federal State Institution "Scientific Center for Health and Safety of Roszdrav"). In this case, BEA is recorded and analyzed, and then a preliminary transcranial electrotherapeutic effect is performed. After a compensatory pause, BEA parameters are removed and, with a decrease in interhemispheric asymmetry of BEA by 5-15%, a course of transcranial electrotherapy is performed. The exposure is carried out through electrodes located around the head circumference similarly to points FP1, T3, O1, O2, T4, FP2 (Fig. 2), the neutral electrode is located at the point Fpz, and the reference electrodes A1 and A2 are located on the earlobes, the polarity of the electrodes is determined by the principle of reaction of nerve tissue to electric current: under the cathode, depression of activity, under the anode its activation. The impact is carried out by a two-phase exponential current with a frequency of 60-90 Hz, the current strength is determined individually and varies from 0.1 to 3.0 mA with a duration of exposure from 0.5 to 8 minutes. The course is 6-8 sessions. The procedures are carried out in the morning, before other physiological and balneotherapy procedures. The method provides the most pronounced anti-inflammatory, analgesic effect, improves the neurotrophic functions of the central nervous system, the psycho-emotional state of the patient, reduces treatment time and helps to restore working capacity.

However, for this regimen of exposure to TETOS, there is no data on its effectiveness in the rehabilitation of post-stroke patients.

A diagnostic and therapeutic complex of transcranial electrostimulation with feedback (TETOS) restores impaired functions of the human body by acting on the brain structures responsible for regulating homeostasis (neurophysiological and neurohumoral regulation) (http://eegeasy.ru/products/EEG-Tetos.php , circulation date 09/11/2019, online placement date 09/09/2019 at https://web.archive.org/web/20181109125029/http://eegeasy.ru/products/EEG-Tetos.php). Continuous registration and automatic analysis of EEG and ECG ensures a high quality of diagnosis and allows you to evaluate the body's response to electrical effects, optimize the parameters of the treatment current individually for each patient, ensuring the effectiveness of therapy.

As a result of THETOS-therapy, neurophysiological and neurohumoral regulation is normalized, stress resistance and working capacity increase. The production of regulatory peptides (beta-endorphin, STH) in the cerebrospinal fluid and plasma changes, and the cortical-subcortical and interhemispheric interactions normalize, improving the body's adaptation and self-regulation. Adverse reactions and complications are not observed. The quality of the development of practical skills is increased by 25-40%, the clarity and coordination of actions, as well as the effectiveness of professional tasks by 1.5-2.0 times. The length of hospital stay is reduced by 30-50% and the total number of drugs used is 50-80% for psychosomatic and somatic diseases.

A well-known publication of the co-authors of this invention, which discusses the use of THETOS therapy in the early recovery period after an ischemic stroke (Rachin A.P., Nuvakhova M. B. et al. Non-invasive neuromodulation in the rehabilitation of patients with cerebrovascular pathology // Physiotherapist, 2017, 3, p. 50-55). However, it does not show how quantitatively more effective the inclusion of TETOS in the complex of physiotherapeutic influences in such patients can be to accelerate and complete their rehabilitation.

It is known to carry out magnetostimulation (MS) in the late recovery period after a stroke of 20 min 2 r / day for 2 weeks (Magnetotherapy in treatment and rehabilitation and preventive programs: wedge, recommendations. M., 2015, 47 pp.). After the course of MT, a short-term decrease in the spasticity of the flexors of the wrist, long-term effects for the elbow extensor was established. However, no significant changes in motor functions were detected. In the early recovery period of AI with the duration of the disease from 1 to 5 months. in patients with clinical improvement, a significant positive dynamics of BEA was revealed after a course of transcranial MT: the asymmetry coefficient decreased, the B / A indicator, reflecting the state of vascular tone of small and medium caliber, significantly decreased by 1.3 times. A significant part of patients receiving MT showed a regression of spastic muscle hypertonicity (31%), a decrease in the degree of paresis (37%) of patients. Initially, disorders of orientation, speech perception, writing and reading in the examined patients using the MMSE scale corresponded to mild dementia. Against the background of TKMT, the test index significantly increased in 41% (p <0.05) of the patients of the main group, reaching the level of mild cognitive impairment.

Despite the small number of studies of the effects of MT in rehabilitation programs after ischemic stroke, we can talk about the effectiveness of some methods of MT (TKMT, MS) in such patients. So, the above clinical recommendations (see recommendations Nos. 11 and 12, pp. 32-33) suggest that BIMP be applied in the horizontal plane or by a rotating pulsed MP in the direction from right to left or left to right on the cervicothoracic spine using four magnetic inductors , with magnetic induction 20 mT, intermittent mode, pulse frequency MP 5 Hz, a duration of 20 minutes, a course of 10 daily procedures. It is also possible to carry out MT on the lower extremities with “running” pulsed magnetic fluids in a “cylinder” configuration with a pulse frequency of 100 Hz and a magnetic induction of 3.5 mT in I mode for 10 minutes for the first 3 procedures, then to the upper body with rotating pulsed MP in the “prism” configuration with a frequency of 100 Hz and a magnitude of magnetic induction of 3.5 mT in I mode for 15 minutes Course - 10 daily procedures.

The following modes of exposure to a low-frequency magnetic field (LFMP) for vascular disorders are also offered (https://medbe.ru/materials/kadiologicheskaya-reabilitatsiya/fizioterapiya-v-reabilitatsii-bolnykh-s-ibs-i-posle-kardiokhirurgicheskikh-vmeshatelst Date of contact 09/13/2019):

- impact on the projection zone of the lower cervical and upper thoracic autonomic ganglia of the borderline chain (at the level of CV-TIV), on the zone of projection of the heart along the front surface of the chest. The inductor is placed contact in the corresponding zone, the direction of the lines of force is vertical, the induction of the magnetic field is 25 mT, the duration of the procedure is 10-15 minutes, daily, the course is 10-15 procedures;

- for autonomic-correcting effects, NPMs are applied on the thoracic spine paravertebrally or on the collar region with an induction of 15-20 mT at an exposure of 10-15 minutes, daily or every other day depending on individual tolerance, course of 8-15 procedures.

The use of various modes of electro- and magnetotherapy at different periods of rehabilitation after AI is widely known (see, for example, RU 2365388 C2, publ. 08/27/2009, GOUDPO RMAPE Roszdrav; RU 2500441 C1, publ. 10.12.2013, GBOU VPO Altai State Medical University ”of the Ministry of Health and Social Development of the Russian Federation; RU 2303952 C2, published on 08/10/2007, State Research Institute of Neurology of the Russian Academy of Medical Sciences; RU 2157265 C1, published on 10.10.2000, State Research Center for the Protection of Miners' Health; RU 2365387 C1, published on 27.08 .2009, FGU “RSCVMiK Roszdrav”; RU 2513418 C1, publ. 04/20/2014, Solonets I.L .; RU 2284836 C1, publ. 10.10.2006, State Research Institute of Neurology, Russian Academy of Medical Sciences; RU 2284198 C1, publ. 09.27.2006, M. Shchukin; RU 2157259 C2, 10.10.2000, Institute of Evolutionary Physiology and Biochemistry Sechenov I.M. RAS; RU 2355440 C2, 05.20.2009, Fedorov A.B. et al .; Verkhlyutov V.M.EEG transfusions and moving waves of the alpha rhythm of the human cerebral cortex: diss. M., 1999, 113 pp.)

It is known to use the magneto-therapeutic low-frequency installation “EOL-Magnitoturbotron” ® for a system-wide MT (http://www.vita-technika.ru/price/magnit_ter/magnititurbotron/opis.html, accessed September 18, 2019). The installation (Fig. 1) creates a rotating magnetic field (VMP) with maximum values of magnetic induction up to 3 mT around the entire patient’s body at the same time.

General magnetotherapy (OMT), i.e. the effect of a magnetic field (MP) on the whole body at the same time due to the placement of the whole patient inside a large-diameter inductor, provided by Magnetoturbotron installations, allows you to simultaneously affect all body systems, including the nervous, endocrine, cardiovascular and lymphatic, on metabolism and oxidatively - restoration processes, etc. It has an anti-oncological effect.

Indications for the appointment of OMT, in particular, are, along with impaired functions of many body systems, diseases of the nervous system: consequences of injuries and circulatory disorders of the brain and spinal cord, initial manifestations of insufficient blood supply to the brain, circulatory encephalopathy, cranial and peripheral nerve neuropathies, epilepsy, consequences neuroinfections, minor cerebral dysfunctions in children. OMT is recommended at all stages of rehabilitation treatment (hospital, clinic, rehabilitation center, sanatorium, etc.)

The EOL-Magnitoturbotron ® units are also successfully used in cases of combined diseases, and the usual medical practice involves the appointment of several types of effects. The installation uses several types of fields: electromagnetic, variable, low-frequency, uniform, rotating (vortex). The applicable modulation laws are: plateau - PLAT, sinusoidal (3 types - sin A, B, C), triangular (linear) - trnL, trapezoid - trPd, rectangular rectified - rCtL. The maximum induction is 3 mT with a control range from 0 to 3 mT, the frequency of the magnetic field is 50-150 Hz. The direction of rotation of the field is forward and reverse (reverse). The duration of the exposure cycle (field reversal cycle) 30-120 sec. Use procedures lasting 5-60 minutes, depending on the pathology.

In our proposed method, this known installation for OMT can also be used.

However, the disadvantages of the known methods listed are the lack of complexity while the possibility of individualizing the effects, the possible development of side effects, the absence of a confirmed possibility of long-term prophylaxis of repeated strokes, and the duration of rehabilitation.

Known combined transcranial electrical and magnetostimulation in patients with chronic vascular pathology of the brain, taking into account the individual characteristics of neurodynamics and the pathogenesis of diseases (Rachin A.P., Vygovskaya S.N. and others. Non-invasive neuromodulation in the rehabilitation of patients with chronic vertebrobasilar insufficiency // Physiotherapist , 2016, 1, p. 8-14). However, it does not allow to sufficiently reduce the rehabilitation time for patients in the early and late recovery periods after IS, does not provide an individual approach to rehabilitation.

The need for an integrated approach is discussed in several publications by the co-authors of this invention, in particular, Nuvakhova MB in collaboration with Vygovskaya S.N., Odarushchenko O.I. and others, in the form of a number of textbooks on various medical residency programs (neurology, radiology, physiotherapy, etc.) “Medical rehabilitation of patients with motor and cognitive impairment after a stroke in the early recovery period”, M., 2019, and in the publications: Vygovskaya S.N., Nuvakhova M.B. and other Possibilities of complex physiobalneotherapy for circulatory failure in the vertebro-basilar system // Issues of balneology, physiotherapy and physiotherapy, 2011, 4, p. 3-7; Rachin A.P., Vygovskaya S.N., Nuvakhova M.B. et al. Chronic cerebral ischemia - from proper diagnosis to adequate therapy // breast cancer, 2015, v. 23, 12, p. 694-698; Rachin A.P., Nuvakhova M.B., Tynterova A.M., Rachin S.A. Neuropeptide therapy of conitive disorders against the background of chronic cerebral ischemia // Breast cancer, Honey. Review, 2019, vol. 3, No. 4-2, p. 87-90.

Numerous methods of motor rehabilitation of patients with strokes are known, including using various innovative devices, including computerized use of exoskeletons, stabilometric trainings with biofeedback with simultaneous physical impact (e.g., electrical stimulation) (see, e.g., RU 2688723 C1, 05.22.2019, GBUZ MO MONICA named after M.F. Vladimirsky; RU 2642950 C1, 01.29.2018, GBUZ MO MONICA named after M.F. Vladimirsky).

In the publication of Nuvakhova MB (Medical rehabilitation of stroke patients // NovaUm.Ru - No. 17, 2019, p. 387-389) it is noted that for the rehabilitation of stroke patients, it is important to include balneotherapy, therapeutic gymnastics and massage, which have a wide range of actions during rehabilitation. At the same time, exercise therapy is a means of correlation with all the above methods of patient rehabilitation, both in the early and late stages of the post-stroke state. Classes are possible in small groups or individually. Exercise therapy in the form of a systematic and well-chosen rehabilitation program through physical exercises will, like physiotherapy, reduce spasticity, improve coordination and body statics. Before exercise therapy, preparatory measures are taken to prevent stagnation of blood by flexion-extension of the limbs, improving the respiratory function of a person, restoring muscle memory, etc. Only in this case, all exercises will benefit at all stages of rehabilitation.

One of the achievements of modern rehabilitation for stroke patients is the use of robotic mechanotherapy, and the role of robotics in the rehabilitation of patients after a stroke is being intensively studied in the global medical community. Robotic systems are used both for creating simple and repetitive movements, as well as for more complex, controlled multisensory stimulation of the patient, while increasing the element of activity and participation, which subsequently favorably affects the condition of patients. It is proposed, along with mechanized systems to maintain and improve physical activity, to use the virtual reality component (VR), where the patient must control the created 3D objects, which contributes to the implementation of active actions. There is evidence that patients in the process of comprehensive early rehabilitation after a stroke, who were offered the use of the MOTOmed letto 2 simulator, showed such results as a partial decrease in the development of embolism-dangerous thrombosis, a better restoration of lost neurological functions, a lower parameter of multiple organ failure.

A complete comprehensive rehabilitation of post-stroke patients cannot be imagined without drug support. As a rule, such patients are prescribed a number of drugs aimed at improving the condition of blood vessels, brain functions, functions of other organs and systems, i.e. most often there is polypharmacy, which is fraught with the development of side effects.

So, the use of neurotrophic drug therapy is known in the complex of rehabilitation means (Principles for the diagnosis and treatment of patients with acute cerebrovascular accident. Method. Recommendations, M., 2000, 16 pp., See p. 14: Neurotrophic drug therapy) for correcting speech disorders cognitive impairment, decreased mental and motor activity:

- cerebrolysin 5 ml IM or 10-15 ml iv in a drop of 200 ml of isotonic sodium chloride solution No. 20-30 daily 2-3 times during the first year,

- piracetam 2.4-4.8 g per day for several months,

- Semax 0.1%, 2 drops in each nasal passage 3-6 times a day for 2 months.

However, such long courses cause significant discomfort for patients, are associated with the development of intolerance to long-term, difficult treatment, side effects that are incompatible with a number of concomitant diseases that may occur in a patient (for example, prolonged intake of nootropil can cause gastrointestinal disturbances, is practically unacceptable in patients with ulcerative lesions of the stomach / duodenum).

One of the most effective drugs in the class of peptide bioregulators is Cortexin, isolated from the cerebral cortex of calves or pigs, which is a complex of balanced neuropeptides, vitamins, and trace elements with a molecular weight of up to 10 thousand. Yes (Komarov F.I., 1996, Rybnikov Yu.V. , 2000, Skoromets L.A., 2005). Cortexin is effective for cerebral ischemia (Fisun Yu.A., 1996, Skorokhodov A.P., 2004; Gerasimova M.M., 2005; Skoromets A.A. et al., 2007), because it has a complex tissue-specific, antioxidant, neuroprotective, nootropic, neurometabolic effect. Thus, it is possible to use Cortexin in combination with physiotherapeutic methods in patients with rehabilitation after AI.

As the closest analogue of the claimed method, a method of the same purpose developed by the co-authors in the framework of their own scientific research (Rachin A.P., Datiy A.V., Ayrapetova N.S., Kiyatkin V.A., Vygovskaya S.N. ., Nuvakhova MB, Kuzyukova AA, Voropaev AA, Tarasova L.Yu. Personalized neurorehabilitation programs (results of their own research). Monograph. - Moscow, 2019. 71 p.) In this method, an integrated and simultaneously individualized approach to patients after AI is used to achieve recovery I have their motor skills, cognitive functions, inclusion in labor activity in a fairly short time - about 3 weeks.

The use of a complex of effects leads to improved tolerance to the load, the patient gets tired more slowly, indicators of emotional status (mood, anxiety, depression) improve, the time for rehabilitation and therapeutic effect is reduced by ensuring the simultaneous operation of several subsystems of the nervous system, for example, the sensory (visual, auditory vestibular, somatosensory) and musculoskeletal, with the adjustment of the motor act, cognitive training, activation of the cerebral cortex, neuropl asticity.

Moreover, the well-known complex includes both exercise therapy (including using robotic devices) and daily injections of cortexin in / muscle, No. 10, as well as a comprehensive physiotherapeutic effect in the form of a combination of TETOS-therapy of 6-8 procedures, SUV and magnetotherapy of LMP in the lower extremities .

SUV were released at a concentration of carbon dioxide - 1 g / l-1.2-1.4 g / l., Temperature - 32-34 ° C, flow rate - 20 l / min, exposure - 15-20 min., 3- 4 times a week, course - 10-12 procedures.

TETOS-exposure was carried out through electrodes oriented along the head circumference similarly to the points FP1, T3, O1, O2, T4, FP2 of the international classification “10-20”. The neutral electrode (N) is located at Fpz, and the reference electrodes A1 and A2 are located on the earlobes. The polarity of the electrodes was determined by the principle of reaction of nerve tissue to an electric current: under the cathode, there is a depression of activity, under the anode its activation. During the first TETOS session, one to three cycles of a strict sequence of actions were carried out: 1 - registration for 1.5-2 minutes and analysis of the initial bioelectrical activity of the brain (BEA), 2 - electrical pulse therapeutic stimulation of brain structures, 3 - compensatory pause. THETOS therapy began with bitemporal expert exposure. A two-phase exponential current was used, the exposure time was 15 seconds, the current strength was 20% less than the threshold of pain sensitivity. Three types of reactions — changes in BEA parameters — are recorded: a) diagnostic — a decrease in interhemispheric asymmetry in the analyzed BAM points by 5–15%, equalization of asynchrony in the activity of the main rhythms and the tendency of the amplitude gradient along the alpha rhythm to normal distribution; b) corrective - expert impact is enough to normalize the recorded potentials of BEA, characteristic of the optimal, functional state; c) excessive (one observation) - an expert effect causes an inverted neurophysiological reaction of BEA parameters. With a corrective and excessive reaction, further exposure was not carried out. The duration of exposure is determined by the reaction of the BEA to the expert signal: a) with a pronounced reaction (high efficiency in almost all parameters of the BEA), it is minimal and amounts to 0.5-3.0 minutes; b) with a significant response to an expert signal (high efficiency in more than half of the BEA parameters) - from 2.0 to 6.5 minutes; c) with a slight reaction to an expert signal (efficiency is observed in less than 30% of the recorded BEA parameters) - from 5.0 to 8.0 minutes. The arrangement of the electrodes and the shape of the current for the corrective signal are similar to the expert signal. Compensatory belly after corrective signal 20 min. The removal and analysis of BEA is similar to the study of the effectiveness of an expert signal. Further tactics of course treatment is determined by the effectiveness of the first session and the preservation of positive changes a day after the session TETOS-therapy. On the course - 6-8 sessions.

A positive effect of rehabilitation measures on the restoration of focal neurological symptoms, motor functions of the limb, the psycho-emotional state and quality of life of patients after stroke was found.

At the same time, new challenges arise in accelerating rehabilitation with maintaining or enhancing quantitative positive effects in restoring various body functions after AI, both in its early and late recovery periods, as well as preserving these effects for as long as possible period after undergoing rehabilitation. According to the authors, this can be achieved by the development of certain modes of exposure, as well as the sequence of their application. So, in our proposed method, a gradual decrease in the duration of the SUV sessions is used with a gradual increase in the concentration of carbon dioxide when taking a dry bath, which causes a training effect. In addition, a certain procedure procedure allowed to reduce the total rehabilitation time to no more than 2 weeks (in the closest analogue - from 2 to 3 weeks, taking into account the conduct of a series of exposures every other day), while the terms for which the positive impact of the rehabilitation course persists, which is important for the prevention of repeated AI.

The technical result of the proposed method of medical rehabilitation of patients of working age in the early and late recovery periods of AI is to increase its effectiveness in the form of:

- reduction of rehabilitation periods,

- increase the period of preservation of the results achieved during the rehabilitation process - the absence of repeated strokes for 2 years,

- the ability to individualize the parameters of physiotherapeutic effects,

- the absence of polypharmacy and side effects in the implementation of complex rehabilitation effects.

To achieve these aspects of the technical result, the proposed method of medical rehabilitation of patients of working age in the early and late recovery periods of ischemic stroke (II), including complex physiotherapeutic effects, exercise therapy and drug therapy.

As drug therapy, cortexin is administered at 10 mg IM, 10 daily injections. In parallel with the start of the course of administration of cortexin as a complex of physiotherapeutic influences, they begin:

(i) Transcranial electrotherapy with feedback from the TETOS apparatus (TETOS therapy), which is carried out through electrodes oriented along the head circumference at points FP1, T3, O1, O2, T4, FP2 of the international classification “10-20”, In this case, the neutral electrode (N) is located at the Fpz point, and the reference electrodes A1 and A2 are located on the earlobes, the polarity of the electrodes, taking into account the reaction of the nervous tissue to electric current: under the cathode is the depression of activity, under the anode is its activation.

At the same time, during the first TETOS session, the following techniques are carried out sequentially:

1 - registration of the initial bioelectric activity of the brain (BEA) for 1.5-2 minutes and its analysis,

2 - expert impact: in the form of electropulse medical stimulation of brain structures by bitemporal exposure using two-phase exponential current, exposure time of 15 seconds, the value of the current strength is 20% lower than the threshold of pain sensitivity of the patient,

3 - compensatory pause - 20 minutes

In this case, one of the three types of BEA reaction of the patient to the effect is recorded:

a) diagnostic - in the form of changes in BEA parameters: a decrease in interhemispheric asymmetry in the analyzed points of the BEA of the brain by 5-15% compared with the initial BEA, alignment of asynchrony in the activity of the main EEG rhythms and the tendency of the amplitude gradient in alpha rhythm to normal distribution;

b) corrective, in the case of which the expert impact is considered sufficient to normalize the recorded potentials of the BEA of the brain;

c) excessive, in which the expert effect causes the inversion of the neurophysiological response of the EEG to stimulation.

(ii) Carry out exposure to dry carbon dioxide baths (SUV) with a temperature of 32-34 ° C, with a flow rate of 20 l / min.

(iii) Low-frequency magnetotherapy (LFMT) is also performed.

The claimed method differs from the closest analogue in that the SUV is carried out starting from a carbon dioxide concentration of 0.7 g / l, bringing to the last procedure to 1.4 g / l, with an exposure starting from 12 minutes in the first procedure to 5 minutes last, only - 7 procedures every other day for 2 weeks.

In addition, NPhMTs are carried out in the form of general magnetotherapy - on the entire body of the patient, except for the head area, by exposure to a rotating magnetic field with magnetic induction of 2 mT with trapezoidal pulses modulated at a frequency of 100 Hz, a procedure duration of 25 minutes, and a field rotation cycle of 60 sec, total per course - 5 procedures every other day on the days of the SUV, free of THETOS-therapy.

Moreover, when conducting THETOS therapy in the case of a corrective and excessive reaction, further action is postponed until the next session, at which the mentioned sequence of methods of the first session is repeated.

In the case of a diagnostic reaction to expert impact, the duration of further TETOS sessions is determined in accordance with the BEA's response to expert impact:

a) when the mentioned BEA parameters are changed by at least 75%, the duration of further TETOS procedures is 0.5-3.0 min;

b) when changing in response to the expert impact of the mentioned BEA parameters from 30 to 75%, the duration of subsequent TETOS procedures is 3.1-6.0 min;

c) when changing in response to the expert impact of the mentioned BEA parameters by less than 30%, the duration of subsequent TETOS procedures is 6.1 to 8.0 minutes.

Moreover, in subsequent TETOS procedures, the arrangement of the electrodes, the shape, current value for the corrective signal are identical to the expert impact,

Sessions of THETOS-therapy are carried out every other day - 2-3 times a week for 2 weeks.

Additionally, in the course of the course, the patient performs exercise therapy exercises corresponding to existing motor disorders.

As exercise therapy, functional training on the REO GO device can be used for 20 minutes daily, 10 days, aimed at improving movements in the shoulder, elbow and wrist joints, as well as the actions of the daily activity of the hand and the whole arm, and functional training on the C-mill device 5 days a week for 20 minutes, a total of 10 days, aimed at improving walking skills.

Examples of the method.

For the period 2016-2019, 72 patients were monitored at various times after suffering a cerebrovascular accident of hemispheric localization (ischemic stroke), aged 30 to 65 years.

The stroke duration in 60% of patients ranged from 2 to 6 months. (early recovery period), in 40% - from 6 to 12 months (late recovery period). Their distribution into groups was random.

The main reasons for the development of stroke in patients were arterial hypertension (AH) (32 patients), a combination of AH and atherosclerosis (16 patients), heart disease, etc.

According to the localization of the lesion focus, no statistically significant differences were observed between the parties (59.7% of cases - left hemisphere stroke, 40.3% - right hemisphere).

Criteria for inclusion in the study:

- Patients in the early and late recovery period after verified AI, age 30-65 years.

- The presence of motor and vascular cognitive disorders.

The study did not include patients according to the following criteria:

- Age over 65 years old, and with hemiplegia.

- Severe restrictions on movement and self-service.

- Joint contractures, severe spasticity, epiprises (with the exception of rare partial).

- A stroke with hypertensive intracerebral hematomas.

- Patients with severe dementia.

- Patients with cognitive impairment of non-vascular (endocrinopathies, toxic effects, hyponutritic and deficiency states) or combined (vascular, non-vascular) genesis, psycho-organic syndrome.

- Hemorrhagic stroke.

- The stroke duration is more than 1 year and less than 2 months.

- Decompensation of hemodynamics or concomitant diseases.

- General contraindications to physiotherapy.

To assess the dynamics of the condition of patients (before, during the rehabilitation process and after its completion), a clinical neurological study using functional tests and scales was used; neuropsychological extended study with a qualitative and quantitative assessment of the results; neurophysiological studies: EEG, stabilometry, a study of cerebral hemodynamics (rheovasography, doppleroscintigraphy); study of locomotion; laboratory diagnostic techniques: electrolytes Na, K, P, Ca, Mg, hemorheology, blood lipids, etc.

All patients using simple randomization, depending on the complex used, were divided into 6 groups - 12 patients each, with a random distribution by gender, age and post-stroke period.

Exercise therapy aimed at appropriate motor impairment was conducted with patients of all groups. Including, 7 people in each group received physical therapy classes using functional training, robotic devices, and the rest received classical physical therapy in the form of appropriate physical exercises. Functional training was carried out on the REO GO device for 20 minutes daily, 10 days, to improve motions in the shoulder, elbow and wrist joints, motivated patient actions were carried out. In the process of training, tasks were performed in real life situations, as well as video games with various difficulty levels in accordance with the capabilities of patients. During the procedure, several tasks were carried out, one after another. In the course of training, the strength of resistance, the complexity of tasks and time changed.

Functional training was also performed on the C-mill device 5 days a week for 20 minutes, a total of 10 days, to improve walking skills. In the process of training, tasks were performed in real life situations, as well as video games with various difficulty levels in accordance with the capabilities of patients. During the procedure, several tasks were carried out, which followed one after another.

In addition to the aforementioned exercise therapy, patients of the 1st group received complex drug therapy, in accordance with the above recommendations (cerebrolysin, nootropil and semax), as well as a full range of physiotherapeutic effects according to our proposed method, in the proposed modes (TETOS, LChMP and SUV), but with an increase in the total duration of the rehabilitation course to 3 weeks (taking into account the procedures carried out every other day).

Patients of the 2nd group, in addition to exercise therapy, received cortexin, as in our proposed method, as well as a complex of TETOS and NchMP in the proposed modes, without performing an SUV.

Patients of the 3rd group, in addition to exercise therapy, received cortexin according to the proposed method, as well as a complex of SUV and NchMP in the proposed modes, without THETOS therapy.

Patients of the 4th group, in addition to exercise therapy, received cortexin according to the proposed method, as well as a complex of SUV and TETOS in the proposed modes, without conducting OMT.

Patients of the 5th group, in addition to exercise therapy, received cortexin and a full range of physiotherapeutic effects (TETOS, SUV and NchMP) in the regimes we proposed, that is, this group was an experience group, the total course of exposure was 2 weeks (10 working days).

Patients of the 6th group received a complex according to the prototype method — intramuscular cortexin, No. 10, 10 mg daily, SUV in the mode according to the prototype method (without changing the duration of the sessions and carbon dioxide concentration), low-frequency LMP in the lower limbs and THETOS therapy in the specified mode, the course for this group lasted for 3 weeks, taking into account the procedures every other day.

Statistical data processing was carried out using the software package Statistica 6.0 and SPSS Statistics 19.0, MS Exell. Quantitative data, depending on the type of distribution, were represented by the mean or median, standard deviation (SD), or 25% and 75% quartiles. For qualitative signs, their relative frequencies were calculated. To test the hypotheses about the difference within the groups - the Wilcoxon sign test of rank and the Student test, the Mann-Whitney U-test, criterion χ2, two-sided Fisher exact test were used between the groups; Kraskel-Wallace criterion, one-way analysis of variance, and the Spearman correlation coefficient was also determined. Differences between the two average values were considered significant at p <0.05. Determining the effectiveness of rehabilitation was carried out using correlation and discriminant analysis.

It was established that the severity of focal neurological deficit at the time of the beginning of rehabilitation in patients was:

- small (17.3%),

- medium (77.5%),

- severe (5.2%).

Almost all patients (87.5%) in the clinical picture had motor disorders in the form of hemiparesis of varying severity and cognitive post-stroke disorders in the form of moderate cognitive impairment syndrome (93.2%).

The spasticity in the muscles of the paretic arm (on the Ashworth scale) averaged 2.5 [1.6-4.3], in the proximal section 2.7 [1.6-3.3], and in the distal 3.3 [ 1.9-4.4] points. The presence of spasticity was the reason for the decrease in the active function of the upper limb, which was confirmed by the data from the French test, indicating that the performance of the task on this test was on average 2.6 times lower in patients than normal. On a Fugl-Mayer scale, separately for the hand, the score was 32.7 ± 11.6 points.

Violation of the function of the upper limb in patients after IS was also manifested by a significant decrease in the motor function of the arm according to the RMA 6.4 test [4.6-8.9], as well as a limitation of daily activity and self-care by the FIM test 24.4 [23-29 ].

In patients with post-stroke spasticity of the arm, an important role in limiting movements was played by pain, more often in the shoulder joint (49%).

The type of lesion, localization of the focus, and other neuromorphometric parameters of brain damage in all cases were verified using CT or MRI.

Against the background of the ongoing rehabilitation, in general, good tolerability of the procedures was noted in all patients with almost complete absence of side effects. However, in the first group, against the background of polypharmacy, 45% of patients showed undesirable effects from the gastrointestinal tract (nausea, heartburn, decreased appetite).

The study found a positive effect of rehabilitation measures on the restoration of focal neurological symptoms, motor functions of the limb, on the psycho-emotional state and quality of life of patients after stroke.

With a long history of the disease, a decrease in spasticity was more pronounced in group 5, which received comprehensive rehabilitation according to the claimed method, which, according to the authors, is associated with its greater effectiveness due to the mutual potentiation of the effects of all the rehabilitation factors used when using the proposed exposure modes and their sequence, even despite a decrease in the total duration of the rehabilitation course.

The decrease in spasticity was accompanied by an increase in range of motion, especially in large joints of the affected arm, also most pronounced in group 5, with no statistically significant differences at the end of the course of treatment (indicators of flexion in the shoulder joint increased from 42.70 to 64.10, movements in the elbow joint in the direction of flexion, extension increased by 200, in the wrist - by 100 deg.). At the same time, although the increase in the range of movements was revealed in the patients of the other five groups, the positive changes were less pronounced.

A comparative analysis of the effect of various treatment complexes on the state of motor function of the upper limb according to the Rivermead scale after treatment also noted the advantage of the claimed method, and it was statistically significant (p <0.05).

After completion of the rehabilitation course, active movements increased on average 1.65 times in group 5, and in other groups - 1.54-1.48 times. At the same time, there was a slight increase (improvement) in the indicators in assessing long-term results (by the end of the year after a stroke) only in patients of group 5 who received rehabilitation according to the claimed method.

With a comparable degree of neurological deficit, patients with lesions of the right hemisphere in all groups (1, 2, 3, 4, and 6) had the worst rates of recovery of motor functions, which is probably due to the greater severity of psychopathological syndromes in these patients.

Against the background of treatment, most pronounced in group 5, patients noted positive results in the form of improved mood, sleep, increased activity, positive mood. In this case, patients of groups 1-4 and 6 indicated periodic headaches and joint pains statistically significantly more often than in the 5th group, which may be due to the non-optimal physiotherapy regimes in these groups, and in the 1st group, along with with this, also with polypharmacy.

The test "10 words", conducted before the start of rehabilitation measures, showed a reduced mnestic potential in all examined. The nature of the “memory curve” indicated a weakening, instability and exhaustion of attention, pronounced fatigue of patients with cerebral infarction. After the rehabilitation course, the number of reproduced words significantly increased in both direct and delayed reproduction. However, in patients of groups 1-4 and 6, these changes were not significant.

Assessment of psychoemotional disorders after a course of medical rehabilitation revealed a reduction in depressive symptoms in all groups with a predominance of a positive effect in group 5. Analysis of situational anxiety (ST) using the Spilberger-Khanin test after complex rehabilitation showed a significant decrease in the value of ST and personal anxiety (RT) (p <0.05): 64.0% with high ST transferred to the group with moderate ST and 70.0% of patients with high RT to the group with moderate RT.

During the rehabilitation process, an improvement in all characteristics was recorded during the SAN technique (Health, Activity, Mood), however, only in group 5 did they reach normal values. This provision indicates the antidepressant effects of the combined use of cortexin and a complex of physiotherapeutic effects according to the claimed method.

The visual analogue scale (VAS) score for headache statistically significantly decreased in the 5th group (p <0.05), both in the early and late recovery period. In all other groups, the decrease in the VAS score for headache was less significant, and in patients in the late recovery period it was not statistically significant at all.

Neurophysiological data indicated the absence of negative changes in brain BEA after a course of medical rehabilitation in all patients. Moreover, the most pronounced positive effects were observed in patients of the 5th group: in 80% of patients, the phenomena of interhemispheric asymmetry decreased, and in 75% of the pathological slow-wave reduced and alpha rhythm increased (p <0.01). The data obtained indicate the predominant influence of the complex of methods according to the claimed method on the synchronizing systems of the brain, primarily on amocortical.

It should be noted that for 2 years after the rehabilitation course in all patients of group 5, repeated ONMKs were absent.

In patients of groups 1-4 and 6, repeated rehabilitation courses were carried out 1-1.5 years after the first stroke. However, in these groups, on average, 34.2% of patients (the average age of this sample was 53.0 years) had repeated ischemic type ONMK disorders both in the form of microstrokes and in the form of strokes in the next 2 years after a stroke.

Thus, in patients of working age in the early and late recovery period after ischemic stroke, the complex of drug and physiotherapeutic influences according to the claimed method helps to restore motor and cognitive functions, normalize the psycho-emotional state, reduce the phenomena of interhemispheric asymmetry, reduce slow-wave activity and activate alpha rhythm .

Claims (26)

1. A method of medical rehabilitation of patients of working age in the early and late recovery periods of ischemic stroke, including complex physiotherapeutic effects, exercise therapy and drug therapy, Cortexin 10 mg IM, 10 daily injections are administered as drug therapy in parallel with the start of the course of the introduction of cortexin as a complex of physiotherapeutic influences begin: (i) transcranial electrotherapy with feedback from the TETOS apparatus (TETOS therapy), which is carried out through electrodes oriented along the head circumference at points FP1, T3, O1, O2, T4, FP2 of the international classification “10-20”, In this case, the neutral electrode (N) is located at the Fpz point, and the reference electrodes A1 and A2 are located on the earlobes, the polarity of the electrodes, taking into account the reaction of the nervous tissue to electric current: under the cathode is the depression of activity, under the anode is its activation, at the same time, during the first TETOS session, the following techniques are carried out sequentially: 1 - registration of the initial bioelectric activity of the brain (BEA) for 1.5-2 minutes and its analysis, 2 - expert impact: in the form of electropulse therapeutic stimulation of brain structures by bitemporal exposure using a two-phase exponential current, exposure time of 15 s, the value of the current strength is 20% lower than the threshold of pain sensitivity of the patient, 3 - compensatory pause - 20 min, at the same time, one of the three types of BEA reaction of the patient to the effect is recorded: a) diagnostic - in the form of changes in BEA parameters: a decrease in interhemispheric asymmetry in the analyzed points of the BEA of the brain by 5-15% compared with the initial BEA, alignment of asynchrony in the activity of the main EEG rhythms and the tendency of the amplitude gradient in alpha rhythm to normal distribution; b) corrective, in the case of which the expert impact is considered sufficient to normalize the recorded potentials of the BEA of the brain; c) excessive, in which the expert effect causes an inversion of the neurophysiological response of the EEG to stimulation; (ii) exposure to dry carbonic baths (SUV) with a temperature of 32-34 ° C, with a flow rate of 20 l / min; (iii) as well as low-frequency magnetotherapy (NPMT), characterized in that SUV is carried out starting from a carbon dioxide concentration of 0.7 g / l, bringing to the last procedure to 1.4 g / l, with an exposure ranging from 12 minutes in the first procedure to 5 minutes in the last, a total of 7 procedures every other day for 2 weeks .; NLMTs are carried out in the form of general magnetotherapy - on the entire patient’s body, except for the head region, by exposure to a 2 mTl rotating magnetic field with trapezoidal pulses modulated at a frequency of 100 Hz, a procedure duration of 25 minutes, a field rotation cycle of 60 s, total on the course - 5 procedures every other day on the days of SUV, free of THETOS-therapy, moreover, when conducting THETOS therapy in the case of a corrective and excessive reaction, further action is postponed until the next session, at which the mentioned sequence of methods of the first session is repeated, in the case of a diagnostic reaction to expert impact, the duration of further TETOS sessions is determined in accordance with the BEA's response to expert impact: a) when the mentioned BEA parameters are changed by at least 75%, the duration of further TETOS procedures is 0.5-3.0 min; b) when changing in response to the expert impact of the mentioned BEA parameters from 30 to 75%, the duration of subsequent TETOS procedures is 3.1-6.0 min; c) when changing in response to the expert impact of the mentioned BEA parameters by less than 30%, the duration of subsequent TETOS procedures is 6.1 to 8.0 minutes, in the following TETOS procedures, the arrangement of the electrodes, the shape, current value for the corrective signal are identical to the expert impact, TETOS-therapy sessions are carried out every other day - 2-3 times a week for 2 weeks; Additionally, during the course of the course, the patient performs exercise therapy exercises corresponding to existing motor disorders. 2. The method according to p. 1, characterized in that the exercise therapy uses functional training on the REO GO device for 20 minutes daily, 10 days, aimed at improving movements in the shoulder, elbow and wrist joints, as well as the actions of the daily activity of the hand and the whole hands, and functional training on the C-mill device 5 days a week for 20 minutes, a total of 10 days, aimed at improving walking skills.

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